Varicose veins on the lower leg

Which treatments and therapies are recommended?

Varicose veins (varices in medical terminology) on the lower leg are almost always a symptom and first sign of a venous or vein disease, however do not constitute a disease in themselves.

In other words: in all cases there is a disease of another, usually larger vein (for example the main trunk vein) which causes the lower leg varicose vein.

If one would like to both treat and remove a lower leg varicose vein for the long term, one must also deal with the cause (meaning the diseased trunk veins) and not just the visible symptom in the form of the varicose vein in the lower leg.

The main cause of these varicose veins below the knee is a defective valve in the superficially located, long trunk vein, which is called the “greater saphenous vein” or, in medical terms, “vena saphena magna”.
This vein is normally about 3 millimetres wide and runs from the inner ankle (where it is usually visible in healthy patients) along the inner side of the lower leg and the knee and the upper leg until it reaches the groin, where it flows into the deep femoral vein system.
You have up to 20 venous valves (usually 15) through which the blood slowly “climbs”, rather like a ladder and its rungs, from valve to valve towards the heart.

If this vein is defective, meaning its valve can no longer flap closed, the blood cannot flow upwards, but rather pools in the vein below.

Usually this process begins with a defect of the top two venous valves, directly at the “junction” at the groin (“saphenofemoral triangle” in medical terms).
As the pressure that this causes builds up, the other venous valves also stop functioning from the top down the leg – a domino effect.

If this domino effect of defective valves from the groin downwards reaches the lower third of the lower leg, there is usually a build-up of varicose veins on the lower leg. These are caused by the increased pressure from the backlog of blood reaching small side veins, which then “blow up” and create non-functional, unsightly varicose veins.

To find a solution to this problem on a long-term basis, it is of course not sufficient to treat the varicose veins of the lower leg alone (regardless of the type of treatment being used). Instead, one must treat the cause of the vein disease, meaning the greater saphenous vein.

The accumulation of blood in these large veins can lead to various problems, such as a venous inflammation (“thrombophlebitis”), thrombosis, or even in the long term a leg ulcer. If this vein is removed, the visible varicose veins in the lower leg will usually slowly disappear by themselves.

This naturally has the advantage that one usually will not need additional treatments via incisions or injections around this vein area. The less medical treatment that the relatively thin tissue layers of the lower leg are exposed to, the better the long-term medical and cosmetic results.

Today, in order to treat the great saphenous vein, the options for treatment include a catheter process (using radiofrequency or, less commonly, a laser) or a conventional stripping operation.

There are also other – significantly rarer – causes for lower leg varicose veins, such as defective connective veins (“perforator veins”) which connect the superficial and deep vein system in several places on the leg.

When the cause of the problem has been treated properly, one should typically wait six months before taking further action: this is the time the body needs in order to return to its normal healthy function.

Then any “remaining” varicose veins can usually be atrophied with micro-foam injections without any problem.

Essential for planning the most appropriate therapy in each individual case are the most precise diagnostic tests.

The medical standard for diagnosing vein disease today is a two-dimensional “colour coded duplex sonography” - an ultrasound exam of the extremity, which uses sound waves to produce images of the veins in order to show the flow of blood in different colours (to see whether the blood is flowing upwards or downwards).
This exam must be performed very precisely by an experienced physician on an upright or very diagonally adjusted examination table and can take an hour or more.
Only by carrying out this exam can a precise image of the veins be made, which we call a “mapping”.

This exam can be combined with volume change measurements (for example a so-called “light reflection rheography" light sensor test or plethysmography test), thermography or by using a continuous wave Doppler as required.

During a Doppler exam, a hand-held ultrasonic probe is used to roughly transcribe the flow of blood through the veins into sound waves, effectively allowing the doctor to 'listen' to the flow of blood. Nowadays, however, the responsible medical societies no longer view the “Doppler exam” as a sufficient diagnostic test when used on its own.