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 Theivendren Panneer Selvam

Madasamy Palanivel

Joseph Coutinho

A INVESTIGATION OF VARICOSE VEINS TREATMENT

 Dr. T. PanneerSelvam M.Pharm., Ph.D
Is working as an Associate Professor in
Arulmigu Kalasalingam College of Pharmacy,
Krishnankoil, Tamilnadu. He received his PhD
degree in 2013 from Acharya Nagarjuna
University, Guntur, India and he earned
Young Faculty Award 2014 from EET CRS presents Academic
Brilliance Award-2014, Noida and has 08 years of teaching
experience, scientific research and development.
He has published17 Books, 50 scientific research and 02 review
articles in international and national journals. His research has
focused on the Design, Synthesis, and Analytical/Biological
Screening of Novel Heterocyclic Derivatives.
 Dr. M. Palanivelu M.Pharm., Ph.D
Is working as a Professor cum Principal in
Arulmigu Kalasalingam College of
Pharmacy, Krishnankoil, Tamilnadu. He
possesses over 22 years of teaching
experience in various levels as an
Lecturer, Professor and Principal and he is
teaching chemistry and analysis subject to the UG & PG
pharmacy students. He received his doctorate degree from Sri
Ramachandra University, Chennai. He has been performing as
Investigator and Co-Investigator for funding research projects in
different innervating titles. He published his research works in
valid and well reputed international and national level journals.
He is a Senateember (The TN DR. MGR Medical University,
Chennai) and Inspector (Pharmacy Council of India).
 Mr. Joseph Coutinho B.Pharm.,
Is currently a research student pursuing his
master’s degree in the field of Pharmaceutical
Chemistry at P.E.S’s Rajaram and Tarabai
Bandekar College of pharmacy at Ponda in
Goa. His area of research has focused on the
Design, Synthesis, and Analytical/Biological Screening of Novel
Heterocyclic Derivatives.
 Abstract
A varicose vein is a venous disorder and the word varicose
comes from the Latin word “varix” (meaning “twisted”). Up to 25
% of women and 18 % of men will suffer from varicose veins.
Nearly 50 % of untreated patients eventually experiences
chronic venous insufficiency. Varicose veins are more common
in women than men. Superficial veins of the leg are under high
pressure; hence this disorder is mostly seen in the leg. There
are several possible causes are known for varicose vein but the
exact cause of varicose veins is unknown. There is no cure for
the disease and way to restore the veins elasticity yet or to
repair their valves at any rate or the replacement of the veins,
but the management of the symptoms and any possible
infection from ulcers and the removal or the blocking of the
veins. In the treatment of varicose vein, the foam sclerotherapy
and laser ablation, clarivein, and sapheon glue system are
some of the new advancements in technology but the long term
effects of these treatments are not known. Out of various
treatment options, the cheaper ones sacrifice the decrease in
pain with cost but with not much difference in healing time and
recovery. There is no cure for varicose veins which means that
you have to treat and monitor them on a regular basis. Hence,
the better option for varicose vein is prevention than cure.
 Index
Content Page Number
Definition 1
Background / history of varicose 2-11
veins
Signs and symptoms of varicose 12-13
veins
Treatment of varicose veins 14-16
(based on medical intervention)
Surgical 17-29
Minimally invasive techniques 30-34
Non-surgical methods 35-66
Pharmacotherapy 67-77
Compression therapy 78-87
Combination therapy 88
Alternative Methods 89-127
Status 128-132
Conclusion 133
Reference 134-135

Definition
Varicose veins is a venous disorder where in the veins appear
to be dark blue, bulging or snake-like or are twisted and are
palpable under the skin due to their abnormal enlargement
(lengthening and widening) and twisting due to various reasons
(mostly due to weak walls of the veins and valves) and mostly
resulting in common symptoms such as itching, aching swelling,
etc. Such veins are termed as varicose. The term is mostly used
in reference to the superficial veins of the leg where the disorder
is mostly seen to occur as they are mostly under high pressure
although this disorder can occur in other veins of the body.
Varicose comes from the Latin word “varix” meaning “twisted”.

1

Background / history of varicose veins
Causes of varicose veins: The exact cause of varicose veins is
unknown. The possible causes may be as follows
• Weak vein valves
• Weak vein walls
• Hereditary conditions/Genetics
• gender
• Age
• Pregnancy
• Overweight
• Sitting or standing for long periods of time
• Lack of exercise
• Proteins
• Level of homocysteine in the body
• Hormones
• Leg injury
• Deep Vein thrombosis
• Smoking

2

In order to know about this disease we should first know about
the venous system.
The circulatory system is an organ system in the body that is
which has the function of transporting oxygen, water and
hormones, etc. to the cells of the body and carbon dioxide and
other waste materials from the cells of the body. It is made up of
two organ systems the:
• Cardiovascular system: Distributes blood.
• Lymphatic system: Circulates lymph.
The cardiovascular system is made up of
• Blood
• Heart and
• Blood vessels: These consist of
• Arteries: Carry oxygenated blood away from the heart
(except pulmonary artery) and are further divided into
capillaries. Have no valves.
• Capillaries: Responsible for the exchange of water and
nutrients (chemicals) between the blood and the tissues
of organs.
• Veins: They are responsible for the transfer of
deoxygenated blood back to the heart. They have
valves called leaflet valves that prevent the back flow of
blood in the veins.
• Classification of veins: They can be classified on
the basis of different criteria
• Size:

3

 • Large and
• Small
• Presence of oxygenated blood in them:
• Pulmonary: Carry oxygenated blood
from the lungs to the heart.
• Systemic: Carry deoxygenated blood to
the heart
• Location:
• Superficial: They are close to the exterior
surface of the body. They have no
corresponding arteries. Most commonly
associated with the condition especially
those veins located in the lower limbs .They
have no association with corresponding
arteries. They are responsible for 10% of
the venous return from the legs. Further
divided in the legs as:
• The Great Saphenous Vein: It starts
from inner side of the ankle and goes
upwards towards the groin where it
comes into contact with the deep
veins. At this point there is a valve
called the sapheno femoral valve. It is
a one way valve.
• The Short Saphenous Vein: This
starts from outer side of the ankle,

4

 and goes upwards to behind the knee
where it meets the deep vein. At this
point there is a valve called the
Sapheno Popliteal valve.
• Deep: They have connection with the
corresponding arteries. They are
responsible for 90% of the venous return.
• Connecting: Connect the above two veins
to one another. Also known as perforator
veins. They allow the blood to flow from the
superficial veins to the deep veins. At these
points also there are valves. Malfunction in
their valves is responsible for pigmentation
which appears at the region around the
ankles in patients having this condition.
• Weak valves: Veins return the deoxygenated blood back
to the heart except the pulmonary veins. They have valves
known as leaflet valves which prevent the backflow of
blood in them. The back flow is caused by the gravitation
pull on the blood in the veins. The veins of the lower limbs
return the blood back to the heart against the force of
gravity because of the of the pumping action of
• The skeletal muscle pump: It helps pump the
deoxygenated blood in the veins from the legs to the
pelvic region of the body, due to the contraction of

5

 muscles or movement, from where it is further
pumped to the heart by
• Respiration: Further pumps the deoxygenated blood
to the heart as it provides a thoracic pumping action.
Now in a normal person when the muscles around the
vein contract the valves open up. The contraction of the
muscles around the vein put pressure on the vein causing
it to squeeze the blood in it. Hence the blood is pushed
upwards. When the muscle relaxes the valves close and
prevent the backflow of blood in the vein to lower regions
of the same vein.
A vein is termed as competent when the valves in the vein
are working.
A vein is termed as incompetent when the valves in the
vein do not work.
In the case of a patient suffering from varicose veins, the
veins are incompetent and the valves in them are
defective (hereditary) or are injured or weak. Hence the
valves do not close on the relaxation of the muscle and
there is back flow of the blood, leading to pooling of blood
in the veins causing them to appear swollen, twisted and
enlarged under the skin.
Varicose veins can also be caused by the leakage of the
sapheno femoral valve or sapheno popliteal valve.

6

 • Weak vein walls: This can also be the cause of varicose
veins. It can also be the cause of weak vein valves. As
time passes on the veins lose their elasticity and hence
obtain an altered length and diameter of their lumen, that
is, they increase in their length and widen in the diameter
of their lumen. Hence they become enlarged in order that
they adjust to fit themselves in the same amount of space
as they previously occupied they become intricately
folded, twisted, or coiled and appear snake like under the
surface of the skin. When the veins lose their elasticity,
their lumen widens and they become enlarged and the
flaps of the valves in the vein do not meet or get
separated and because of this there is retrograde flow and

7

 pooling of blood in the vein which causes the vein to get
stretched even more. This in turn causes them to appear
even more swollen and become more enlarged .These
veins further twist to occupy the same space as they did
before they became stretched. The vein walls can also
become weak due to excess pressure on them.
• Hereditary conditions/genetics: Either or both of the
above two conditions can be hereditary in nature and
hence varicose veins can be hereditary. Those with a
family history of varicose veins are at a greater risk of
developing the disorder.
• Gender: Women are at a larger risk of developing
varicose veins on their legs than men due to hormonal
changes that occur during puberty, pregnancy menopause
and also due to the use of birth control medications.
• Age: As the age of an individual increases the elasticity of
the veins decreases and the veins get stretched causing
the valves in the veins to become weak. Hence there is a
more chance for the back flow of blood in the veins
resulting in the pooling of blood in the veins. This causes
the veins to enlarge and become varicose.
• Pregnancy: Varicose veins mostly occur in women when
they are pregnant. This can be the most likely period in
their lives when this disorder occurs. this can be due to

8

 • The increased pressure on the veins in the legs
and in the pelvic region which is exerted by the
growing uterus.
• Changes in the circulation: During pregnancy the
volume of blood in the body of the mother
increases. The flow of blood from the legs to the
pelvis decreases in order to support the foetal
growth. This can lead to the side effect of
developing varicose veins.
• Change in hormone balance in the body of the
mother: There are a lot of changes in the levels of
hormones in the body during pregnancy causing a
change in hormonal balance which can cause a
relaxation of blood vessel walls.
Varicose veins that occur during pregnancy usually get
better within 3 to 12 months after the delivery.
• Overweight: People who are overweight are at a higher
risk of developing varicose veins because of the increased
pressure on the veins.
• Sitting or standing for long periods of time and lack of
exercise: This is because staying in one position for a
long time may force your veins to work harder to pump
blood to your heart.
• Proteins: In 2011, researchers from Germany reported in
the printed October issue of The FASEB Journal that a
single protein that binds to DNA to control gene function

9

 (called "transcription factor AP-1") and causes the
subsequent production of a newly discovered set of
proteins. It is this set of proteins that significantly affect the
development of varicose veins.
• Level of homocysteine in the body: Hyper
homocysteinemia can be the cause of varicose veins. This
can cause the degradation and inhibition of development
of elastin, collagen and proteoglycans, all of which are the
main structural components of the artery. Homocysteine
affects function and structure of the artery by permanently
degrading cysteine disulphide bridges and lysine amino
acid residues in proteins. Homocysteine has a corrosive
effect on proteins like collagen, elastin and fibrillin.
• Hormonal changes: Hormonal changes during
pregnancy, puberty, menopause and also with use of birth
control medications increase the risk of the individual from
getting varicose veins.
• Leg injuries/damage: This can cause varicose veins as
this may cause damage to the valves in your veins which
increases the risk of the person getting varicose veins.
Leg traumas can also be in the form of previous blood
blots.
• Deep vein thrombosis: Deep veins which are
thrombosed cause an extra burden on the superficial
veins causing them to dilate leading to varicose veins.

10

 • Smoking: Smokers develop varicose veins faster as
compared to non-smokers as smoking is responsible for
the laxity of the walls of the vein.

11

Signs and symptoms of varicose veins
Commonly associated signs:
• Veins appear swollen, twisted, bulging and purple under
the skin.
• Discoloured skin in the region around the veins.
• Atrophie blanche: Whitened, irregular scar-like patches
can appear at the ankles.
• Telangiectasias: Clusters of red veins that are visible
under the surface of the skin.
Commonly associated symptoms:
• Heavy, aching or painful legs which cause a sense
of tiredness.
• Cramping, swelling and in the legs. Swelling also
occurs in the ankles.
• Itching and restless legs.
Complications: Occur rarely
• Dermatitis: It is an inflammation of the skin. It is an
itchy rash. It mostly occurs on the lower leg or ankle.
It causes a reddish brown area near the skin.
Scratching or a minor injury can result in the
development of ulcers which are difficult to heal or
bleeding. The ulcers may also bleed.
• Bleeding: Occurs if the skin is cut due to injury and
can be of great concern in geriatric patients.
• Venous ulcers: This occurs when the fluid from the
varicose vein leaks into the surrounding tissue.

12

 • Superficial thrombophlebitis: Here a blood clot is
formed in the in the superficial vein resulting in
inflammation of the vein due to decreased blood
flow through the vein. The affected region may look
red, feel warm and also become painful and may
also be associated with other related problems.
• Acute fat necrosis: Occurs mostly at the ankles.
Mostly in women.
• Development of sarcoma or carcinoma: Occurs in
longstanding venous ulcers.
• Lipodermatosclerosis: Here skin above the ankle
may shrink since the fat underneath the skin
becomes hard.
• Chronic venous insufficiency

13

Treatment of varicose veins
(Based on Medical Intervention)

• Active: These are medical procedures done to either

remove or close varicose veins
• Surgical:
• Standard:
• Vein stripping
• Vein ligation
• Ambulatory phlebectomy
• TIPP (Transilluminated Powered
Phlebectomy)
• Minimally invasive:
• Cryosurgery
• Subfacial Endoscopic Perforator Surgery
(SEPS)
• Non-surgical:
• Sclerotherapy
• Endovenous Ablation Therapy:
• Thermal methods:
• EVLT/EVLA
• Radiofrequency Therapy
• Non thermal methods:
• Clarivein
• Coil embolization
• The sapheon glue system

14

 • Pharmacotherapy:
• Flavonoids:
• Diosmin and hesperidin
• Diosmin
• Antibiotics
• Anti-inflammatory drugs/NSAIDs: Ibuprofen,
aspirin
• Other medications
• Compression therapy:
• Elastic compression:
• Compression stockings
• Elastic bandages
• Elastic wraps (not recommended any
more)
• Inelastic compression
• Intermittent pneumatic compression devices
• Elevating legs
• Combination therapy:
• Alternative therapy:
• Ayurveda
• Acupuncture and Acupressure
• Aromatherapy
• Color Therapy
• Diet and Supplements
• Chiropractic
• Herbal Therapies

15

 • Homeopathy
• Hydrotherapy
• Juice Therapy
• Exercise
• Massage
• Reflexology
• Schuessler Tissue Salts
• Yoga
• Folk remedies

16

 • Surgical: This method aims to remove as many of the
varicose veins as possible. The reasons for performing
surgery are:
• To halt recurrent bout of phlebitis.
• To reduce pain.
• Cosmetic option
• Standard:
•Vein stripping: It is the oldest method for the
treatment of varicose veins. This method consists
of removal of a part or the entire main trunk of the
great saphenous vein (great/long or lesser/short).
But, surgeons try to preserve this vein as it can be
used as a bypass graft in case of development of
coronary artery or peripheral artery disease. The
great saphenous vein collects blood from the skin.
Removal of these veins doesn’t hamper circulation,
if the deep veins are functioning properly.
In this technique there are two incisions made by
the physician
• One at the groin
• One at the ankle or knee.
The vein at each end is opened at each end. A
flexible wire called “a stripper” is passed through
the vein from the ankle or knee incision to groin
incision from where it is pulled out along with the
entire vein resulting in the stripping out of the vein.

17

 The leg is then bandaged and the patient has to
wear compression stockings throughout the
recovery period.
A number of small incisions in the skin are
sometimes needed along the vein in order to guide
the wire along the length of the entire vein.

For this treatment, general anaesthesia or an

epidural is prescribed as it is a lengthy procedure.
The patient may leave the hospital the same day or
may be required to remain in the hospital for a few
days. The recovery period for this procedure is 4 to
6 weeks. During this time the patient is made to:
• Walk for five minutes as the start out
time and slowly increase the duration
and the distance walked each day.

18

 • Wear compression stockings or
bandages.
• Elevate the legs while sleeping.
The stitches or bandages if any may be removed
after a weak after a re-visit to the hospital.
Advantages:
• Relieves the symptoms
• Prevents complications
Disadvantages:
• Leaves scars.
• Recurrence rate: up to 30 % at 5 years
after the procedure.
• Doesn’t prevent the recurrence of
varicose veins.
• No longer available for use as venous
bypass grafts in the future (coronary or
leg artery vital disease).
Complications:
• Pulmonary embolism
• Deep vein thrombosis
• Wound complications including infection
• Deep vein thrombosis

19

 •Vein ligation: This procedure consists of tying the
vein shut with the help of a suture (thread). Here
the surgeon first clamps the vein with the help of a
haemostat and then secures, with the help of a
suture, the vein before dividing the structure and
releasing the haemostat. The clamping is done
perpendicular to the axis of the vein. This
procedure is used along with stripping to treat

20

 varicose veins. When used along with stripping the
procedure is:
• Two incisions are made in the leg one at
the groin and one at the ankle or knee by
the surgeon.
• The surgeon then ligates the saphenous
vein and its branches at the groin
incision. He does this by first clamping
the vein the cutting it and stitching it at
both the cut ends at both the incision
sites.
• A thin and flexible wire called a “stripper”
is then passed through the vein from
either of the ends where the incisions
were made previously (usually from the
ankle end). It is then pulled out from the
other end along with the vein this is
called as stripping of the vein.
•Ambulatory phlebectomy: This procedure is done
so as to remove the varicose veins near the skin,
that is, the superficial varicose veins and the semi
circulatory varicose veins (side branch varicose
veins). It is a mini-surgical treatment and micro-
extraction procedure. By this procedure the
surgeon can remove varicose veins through
multiple incisions in the skin that lies over the

21

 varicose veins which are 2 to 3 mm deep and no
stitching is required. It is considered to be more
effective than sclerotherapy. This can be used
along with endovenous ablation therapy of the
greater saphenous vein.
Steps for this procedure:
• The patient is first made to stand.
• Then the veins are marked.
• The patient is positioned on the
operational table
• Local anaesthesia is then applied.
• Incisions are made using a surgical
blade along the skin overlying the
varicose veins.
• Then the veins are then extracted using
a phlebectomy hook (or a retractor) by
inserting it through an incision, hooking
the varicose vein, extracting it and
subsequently fixing it with a clamp.
• The next vein is then removed by
“wenching” or turning the exteriorized
part of the vein and moving the clamps
as the vein is pulled out further.
• Then the next incision is made 5 to 10
cm along the pre-operative markings

22

 depending on how much varicose vein
was removed
After the procedure the compression bandages or
stockings may be used for two weeks in order to
promote proper healing and reduce swelling and
discomfort.
Advantages:
• Quick procedure
• Office procedure
• Minimally invasive (micro-incisions or
pinholes only)
• Local anesthesia
• No stitches or scars
• No downtime
• Excellent cosmetic results
Complications: These are uncommon
• Paresthesia
• Bruising
• Haemorrhage
• Hematoma

23

 • TIPP (trans illuminated powered phlebectomy):
This procedure is suitable for the removal of clusters
of varicose veins and mostly for small varicosities. It
is performed under general, regional or local
anaesthesia. This technique is especially useful when
extensive phlebectomy is required and is an
alternative to the traditional phlebectomy technique
for symptomatic varicosities of the leg. It is an
adjuvant to surgical removal of the saphenous vein.
In this technique, the physician shines an intense light

24

 in your leg with the help of a device so that your veins
are visible on the surface of your skin and the
varicose veins can be located. The device which is
used to shine this light is called an endoscopic
transilluminator and is responsible for the trans-
illumination and visualization of the veins on the
surface of the skin.
General summary of the Procedure: This technique
can be done under administration of general, regional
and local anaesthesia.
• The clusters of the varicose veins are marked
superficially before the patient is placed in the
supine position.

• An incision is made in order to insert the

transilluminator.
• The transilluminator is inserted into the leg in
the subcutaneous tissue. If it is inserted into
the deeper tissues there is loss of trans-
illumination. The transilluminator is placed

25

 circumferentially around clusters of
varicosities.

• On trans-illumination, the veins can be seen

on the surface of the skin and the varicose
veins can be located.

• On location of the varicose veins, another

incision is made at the other end of the
varicose vein and the physician passes a
suction device having guarded blades though
it. This device is called a resector device and
cuts the varicosities and removes them out by
suction. The veins are avulsed under constant
aspiration. Resection is first done to those
veins which are further away from the

26

 physician and is slowly worked towards the
veins which are close to the physician.

• The trans illuminator also provides

tumescence anaesthesia, which hydro
dissects the veins and also causes veno
constriction which causes a decrease in
bleeding during resection.
• After the removal is complete, the second
stage anaesthetic is administered in order to
decrease bruising pain and haematoma. The
leg is repetitively compressed so as to remove
the blood and tumescence. The stab incisions
are closed using tape or steri-strips. The
compression should be of multiple layers
along the length of the ablated great
saphenous vein and the areas where
phlebectomy has taken place. The layers
(from inner to exterior):
• Absorbent pads.
• Short stretch bandages.
• Elastic stretch bandage (stretching from
the foot to the groin).

27

 Patients then come back after six to ten days
to confirm the ablation of the vein by duplex
ultrasound and also to identify subclinical
haematomas or fluid collections.
From compression bandages, the patients
can transferred or transitioned on to
compression stockings.
The resector can be inserted through the first
incision only so as to decrease the number of
incisions made during this procedure.
The resection has to be done in line with the
course of the vein.
If the resector handpiece is placed too
superficially, then there can be tearing of the
skin and if it is placed deeper than necessary,
then there can be an increase in
postoperative paresthesias.
Advantages:
• Lesser number of incisions and shorter
operative time
• Better cosmetic results than hook
phlebectomy
Disadvantages:
• Almost similar results in terms of amount
of pain felt by the patient

28

 • Not many advantages over the hook
phlebectomy to change in cosmetic
appearance by the traditional method
• More expensive than the traditional
method
Complications:
• Ankle paraesthesia
• Post-operative Haematomas
• Post-operative bruising (high occurrence)

29

 • Minimally invasive techniques:
• Cryosurgery: This procedure is a variant of
stripping.
In this technique,
• First a small incision is made.
• Saphneo femoral ligation is performed next.
• Then a cryoprobe is passed down along the
length of the great saphenous vein.
• The probe is then cooled to a temperature of
−85o with NO2 or CO2.This causes the vein to
get frozen.
• Once the vein is frozen to the probe it can be
can be retrogradely stripped after 5 seconds.
Advantages:
• There is no requirement of an additional distal
incision to remove the stripper.
• Safer than vein stripping.
• Lesser pain and discomfort than vein stripping.
• As compared to vein stripping the surgery
causes the formation of minimal number of
scars which are less visible than those
produced by vein stripping.
Disadvantages:
• Redness, swelling and blisters may occur at
the area where the procedure has taken place
and hence analgesics may be required to

30

 relieve the pain that may be caused after the
procedure.
Complications:
• Damage to the nearby health skin tissues
• Deep vein thrombosis
• Embolisms
• Infections and other wound infections
• SEPS (subfacial endoscopic perforator surgery):
It is a minimally invasive alternative to open
perforator ligature. This procedure is performed on
patients who have leg ulcers which are caused due
to incompetent perforator veins. Being an
endoscopic procedure, the physician can examine
the interior cavity of the body with the help of an
endoscope. This also provides the ability to
introduce instruments through the skin from tiny
incisions away from the site of skin changes or
affected areas and has a low rate of complications.
Hence by using tiny incisions and an operating
scope, perforator veins can be tied off or
disconnected. By doing this this, blood flow is
redirected to healthy veins. Hence the circulation is
improved and the ulcers are healed. This results in
the healing of ulcers in a majority of the patients.
SEPS provides excellent visualization of the
anatomy of the subfascial plane. Subfascial means

31

 under the fibrous tissue beneath the skin. It is a
treatment of choice in patients with chronic venous
insufficiency.
Procedure: SEPS is usually performed with two
points of entry into the leg.
• A special instrument is inserted deep to the
fascia of the leg and a large balloon is inflated
with water to create a working space.
• The balloon is then emptied and the space is
insufflated with air.
• The camera is inserted and the perforator
veins can be seen in the space passing from
superficial to deep layers.
• Another small incision is made in the calf for
passage of another instrument.
• The perforator veins are carefully dissected.
• Clips are applied and the veins are divided if
necessary.
• All trocars are then removed.
• The wounds are closed.
• The leg is then dressed with ACE wrap.
Perforating veins are divided by the use of
endoscopic scissors. Metal clips are placed on the
cut ends of the vein to avoid bleeding. Another
option to interrupt the vein is to use a harmonic
scalpel. A harmonic scalpel makes use of

32

 ultrasonic waves to seal the cut end of the vein and
hence prevent bleeding.
After surgery:
• The leg is kept elevated at 30 degrees for 3
hours, after which walking is allowed.
• Patients are discharged from the hospital either
on the same day or the morning after the
procedure.
• Patients may return to work. After ten days or
two weeks.
Recovery:
• The patient is usually discharged from the
hospital on the same day of the surgery or on
the next morning after the procedure.
• The ACE wrap can be removed in 48 hours.
• Recovery from this procedure is rapid with a
return to normal function within a week.
Walking is permitted throughout this recovery
period and pain associated with this procedure
is minimal.
• The reduction of venous pressure subjected to
the skin and ulcer area in those patients having
leg ulcers causes the accelerated healing of
these ulcers.
Advantages (over the conventional method):
• Decrease in healing time.

33

 • Ulcers heal rapidly. Half of the ulcers heal
within eight weeks.
• Lesser chance of complications occurring.
Wound complication rate is only 5%.
• After two years of the procedure, 80% of the
ulcers stay healed in patients who never had
blood clots in the leg but only 54% of those
who had blood clots in the leg veins before
surgery have no ulcers.
• Low recurrence rate.
• No long incisions required to ligate
incompetent perforator veins.
Disadvantages:
• Impaired healing and infection are possible as
the overlying is often atrophic, poorly
nourished and affected with skin necrosis.

34

 • Non-surgical methods:
•Sclerotherapy: It is a non-surgical, non-invasive
medical procedure used to improve the appearance
of the veins. It is used to treat varicose veins,
spider veins and haemorrhoids. Is mostly used to
treat small varicose veins. Here a chemical known
as a sclerosant is used in liquid form or foam and is
injected into the vein. This causes the irritation of
the inner lining of the vein and causes it to swell
and stick together causing the blood to clot. The
vein hence collapses or shrinks. In short they
cause sclerosis (they cause the thickening of the
blood vessel and seal off blood flow). The blood is
then re-rerouted to healthier veins in the body. The
collapsed vein is then converted into scar tissue
which is then absorbed into the local tissue and
eventually fades away. This may take a few weeks
to a month.

Sclerotherapy process

35

 Sclerotherapy is considered as a "gold standard"
and is preferred over laser treatments for
eliminating large spider veins (telangiectasiae) and
smaller varicose leg veins.

Injection of sclerosant into the leg vein

The solution or foam is injected through a very fine
needle using a syringe directly into the vein. At this
stage, there may be mild discomfort and cramping
for about one or two minutes. This is mostly seen
when larger veins are injected. The procedure itself
takes approximately 10 to 30 minutes and is hence
faster than surgery. The number of veins injected in
one session varies, and depends on the size and
location of the veins, as well as the general medical
condition of the patient. In some instances, several
sclerotherapy treatments may be needed and they
are spaced weeks apart to improve the appearance
of the legs.
When the sclerosant used is in the form of a foam
then this is called foam sclerotherapy. The foam is
created by combining the sclerosant with a gas (air

36

 or oxygen or carbon dioxide) by rapid mixing and
agitation. The drugs are called foam sclerosant
drugs. The foam is used as it will have a greater
surface area for acting along the lining of the
vessel. Hence it causes a severe spasm of the vein
and can also be used to treat larger veins which
would not normally be treated by the conventional
method. It also has the added advantage that a
greater volume can be injected although little of the
sclerosant can be used. It does not mix with the
blood in the vessel and in fact displaces it, thus
avoiding dilution of the drug and causing maximal
sclerosant action.
These methods can be used in along with
radiofrequency and laser ablation and also along
with surgery to treat spider veins and sometimes
varicose veins and other venous malformations.
Sclerotherapy is used usually after the venous
abnormality has been diagnosed under duplex
ultrasound. It is then used along with the guidance
of ultrasound to treat the condition. The ultrasound
helps visualize the vein and also helps the
physician to deliver and allow him to monitor the
injection in real time. The ultrasound can also be
used to confirm closure of the treated veins and
also for the identification and treatment of the
residual varicose veins. After treatment the patient

37

 has to use compression stockings for about two
weeks and is also advised to walk regularly during
this time.

Ultrasound guided foam sclerotherapy

Sclerotherapy under ultrasound guidance and
using micro-foam sclerosants has been shown to
be effective in controlling reflux from the sapheno
femoral and sapheno popliteal junctions.
Sclerotherapy can also be performed using micro-
foam sclerosants under ultrasound guidance to
treat larger varicose veins, including the great and
small saphenous veins. Sclerotherapy can also be
performed using micro-foam sclerosants under

38

 ultrasound guidance to treat larger varicose veins,
including the great and small saphenous veins.
Sclerosants used: Different concentrations of the
sclerosant are used depending upon the size of the
vein.
Commonly used sclerosants are:
• Sodium tetradecyl sulphate (STD)/(STD)
• Polidocanol (POL)
• Sclerodex
• Hypertonic saline
• Glycerin
• Chromated glycerin
• Morrhuate sodium
• Sodium salicylate
• Ethanolamine oleate

39

 • Sodium tetradecyl sulphate (STD)/(STD):

Trade name: Sotradecol, Fibro-Vein (Australia,

Italy, Ireland, South Africa, New Zealand, U.K)
It is an anionic surfactant used as Sclerosant drug.
It is a detergent-based chemical.
Mechanism of action: It acts on the lipid molecules
in the cells of the vein wall and causes
inflammatory destruction of the internal lining of the
vein and also thrombus formation which results in
the sclerosis of the vein. They exert their effect
unless diluted by or inactivated by serum
sclerosant.
Concentrations for use: 0.1% to 0.3%.
Preparations: 0.2%, 0.5%, 1.0%, and 3%.
• Polidocanol (POL):

Trade name: Asclera, aethoxysklerol

Mechanism of action: It causes fibrosis inside
varicose veins resulting in the occlusion of the
lumen of the vein and reduces the appearance of
the varicosity.

40

 It damages the cell lining of blood vessels and
hence causes them to close and gradually be
replaced by other types of tissue.
Use: Sclerosant, local anaesthetic and antipruritic
component of ointments and bath additives.
• Sclerodex (Canada):
It consists of Dextrose USP 250 mg/mL
Sodium Chloride USP 100 mg/mL
It is a weak sclerosant.
It is used for the local treatment of varicose
veins, mostly small vessels and
communicating veins of the superficial venous
system.
Dosage: Depends on the length and size of
the vein to be sclerosed. Do not inject more
than 10 mL per visit, at the rate of 0.1 to 1 mL
maximum per injection site; keep a 5 cm space
between injection sites.
• Hypertonic Saline: Most commonly used
osmotic agent. It is a sclerosant and an
osmotic agent.
Mechanism of action: It is a hypertonic
solution. It exerts its effects by dehydrating the
endothelial cells through osmosis which results
in their destruction.

41

 As they are rapidly diluted in the blood stream
they lose their potency within a short distance
of injection and are hence are less effective in
the treatment of veins larger than 3 to 4mm in
diameter and hence are no longer commonly
used. It is very painful when injected an also
causes a burning sensation at the place where
it is injected. To help ease the pain, physicians
sometimes mix lidocaine in the solution or give
their patients valium or a pain reliever. But, this
rarely makes the burning go away entirely.
Furthermore, there are risks. If the physician
misses the vein, the saline can cause severe
pain and even ulceration at the injection site.
• Glycerin: It is a chemical irritant. The
concentration depends upon the size of the
vein. The concentration of glycerine used as a
sclerosant is 72%. Small spider veins may be
treated with a combination of glycerin,
lidocaine, and epinephrine. This solution is
prepared in the doctor’s office by mixing 2
parts glycerin 72% with 1 part 1% lidocaine
with epinephrine.
Mechanism of action:
• Chemical irritant: Act as corrosives and
injure cells.

42

 • Osmotic action: Shown only by plain
glycerine. It is extremely hygroscopic in
nature and hence a highly concentrated
solution of glycerine can act as a
dehydrating agent. This dehydrating action
is irritating to the tissue or inner lining of
the blood vessel when injected into it
which results in its collapse and hence
disappearance after being eventually
absorbed into the body.
• Chromated glycerine: It is a chemical irritant.
72% solution has been used as a sclerosant.
25% as well as 100% concentrations have
also been used as sclerosants. Its action is
dose dependant. The recommended maximum
amount used per injection session is 10ml of
pure solution. The chromium alum component
of Chromatin Glycerine is a potent coagulating
factor that increases the sclerosing power of
glycerin. It also prevents the mild hematuria
induced through the use of glycerin alone. The
cauterization effect is due to the associated
heavy metal.

43

 • Morrhuate Sodium: It is a mixture of the
sodium salts of the unsaturated and saturated
fatty acids of Cod Liver Oil. Prepared by the
saponification of selected Cod Liver Oils. It is a
detergent sclerosant. It is available as a 5%
solution which can be diluted with normal
saline to the required appropriate
concentration.
• Sodium salicylate: It is an osmotic agent. It
should be diluted with 1% lidocaine without
epinephrine as it is painful on injection,
especially if the drug is injected extravascularly
or even if it diffuses extravascularly.
Mechanism of action: Produces necrosis on
extravasation in a concentration-dependent
manner.
The maximum amount that can be used in a
day 8-10 mL
• Ethanolamine oleate: It is a synthetic mixture
of ethanolamine and oleic acid.
Trade name:Ethamolin.
Mechanism of action: It diffuses through the
venous wall and causes an extravascular
inflammatory reaction.
Oleic acid produces the inflammation and
may release of tissue factors and Hageman

44

 factor XII and hence be responsible for
activation of coagulation in vitro.
Advantages of sclerotherapy:
• Minimally invasive manner
• Relatively painless: The patient may experience
some mild discomfort as a result of the injections but
this is short lived.
• It is a safe form of treatment.
• Effective for a short term.
Disadvantages of sclerotherapy:
• The long term effects of foam sclerotherapy are still
unknown.
• Several sessions needed before the vein
disappears.
• There is always a risk of reoccurrence.
• Formation of blood clots in other veins
Complications:
• Superficial thrombophlebitis
• Brown pigmentation of the skin
• Deep venous thrombosis (DVT)
• Skin ulceration
• Allergic reaction
• Visual disturbances(temporary)
• Stroke/ fainting
Before the patient can undergo sclerotherapy it has to be
found out if the patient is fit to be a candidate for this

45

 procedure. Most people usually are but those who cannot
be candidates are as follows:
• Patients who also have uncontrolled diabetes.
• Patients with skin infections.
• Patients who have experienced deep vein
thrombosis.
• Women who are pregnant or breastfeeding.
• People taking certain medications such as anti-
coagulants or corticosteroids.
Microsclerotherapy: Is used to treat spider veins and
other very small varicose veins. Here a small amount of
the chemical is used and is injected in the vein using a
very fine needle.

46

 • Endoveneous ablation therapy:
Endovenous ablation therapy is used to close off a
varicose vein.
• Thermal methods (thermoablation): These methods
make use of lasers or radiowaves to create heat to
close of the varicose veins.
The physician makes a tiny incision on the skin near
the varicose vein and then inserts a small tube called a
catheter into the vein. There is a device at the tip of the
catheter which heats up the inside of the vein closing it
off.
• Endovenous laser therapy: It is a minimally
invasive alternative to traditional vein stripping. It is
quicker than the traditional procedure for the
stripping of veins. It leaves no scarring and is
performed under local anaesthesia in a doctor's
office. The recovery time from this procedure is also
short and the procedure is almost pain free. Before
treatment, an ultrasound machine is used to map out
the vein which is to be treated. The entire procedure
takes less than an hour.
Principle: The thin laser fibre is inserted into the
varicose vein using a special tube called a sheath.
Then the fibre is positioned properly. Laser energy
in the form of light usually in the infra-red spectrum,
is applied as the physician slowly pulls the fibre

47

 through the length of the vein. The laser energy is
delivered in short pulses and this heats the vein
from within causing it to shrink, collapse and get
sealed shut. Blood is then rerouted through healthier
veins to the heart. During this procedure, Local
anaesthetic is administered to the patient at the area
which is supposed to be treated.
The patient can return to normal daily activities
immediately.
EVLT and ELT mean the same, that is, they work on
the same principle and have the same procedure,
except that EVLT is the trademark name owned by
a company called Diomed and this is the name used
for their 910nm laser treatment unit for performing
endovenous laser therapy. The original laser fibre
was the 810nm laser and was pioneered by Dr.
Robert Min of New York, USA. There are various
other fibres with different wavelengths that are
available as the varying wavelengths each aim to
maximize local damage to a component of the
varicose vein or the blood contained in it while
minimizing damage to adjacent tissues.

48

 Procedure:
• An incision is made
• Catheter is inserted into the great saphenous
vein or small saphenous vein under ultrasound
guidance. The catheter has a laser fibre.

• The catheter is then advanced with the aide of

ultrasound guidance to the level of the groin or
knee crease.

• Dilute local anaesthesia is administered to the

patient in the region around the vein and along
the vein. The anaesthesia to be administered
in the region around the vein is done so with

49

 the aide of ultrasound imaging in the sub-facial
compartment. This technique is derived from
the tumescent local anaesthesia (TLA)
method.

• As the laser fibre is pulled back the laser is

activated and hence there is shrinking,
collapse and closure of the varicose vein
along its entire length.

50

 • The treatment without sedation takes about
one to two hours after which the patient can
immediately resume walking.
• After the procedure the patient has to wear
compression stocking or bandages for up to 3
weeks, is encouraged to walk and avoid
performing any strenuous activities.
Taking over-the-counter pain relievers or walking
can help relieve any remaining discomfort as the
patient may experience some soreness or bruising
for 3 to 5 days after the procedure
Advantages:
• It is performed under local anaesthetic.
• It is a minimally invasive procedure and hence
there is lesser chance of scarring and
postoperative infection.

51

 • Less than an hour is required for examination
and treatment time.
• Rapid recovery.
• The patient can resume his normal acivities
immediately.
Disadvantages:
• There can be numbness in area which was
treated.
• The skin can become sore or appear red on
the affected region.
• Bruising.
• There is a small chance of recurrence
• Infection (very rare)
• Deep vein thrombosis (very rare)
• Burns or brown marks (hyperpigmentation)
on the skin (very rare).
• Perforated vein (very rare)
• Allergic reaction to the local anaesthetic
(very rare)
Complications:
• Minor:
• Bruising
• Hematoma(temporary)
• Numbness
• Phlebitis
• Induration

52

 • Sensation of tightness
• Severe:
• Skin burns
• Deep venous thrombosis
• Pulmonary embolism
• Nerve injury

• RFA (radiofrequency ablation): This is a medical

procedure where ablation of the varicose vein is
done using heat which is generated from
Radiofrequency energy. The radiofrequency energy
is generated by passing alternating current between
the different electrodes in the catheter that has been
inserted in the vein, at radiofrequency rates or at
very high frequency (350-500 kHz) through the vein
wall which is sufficient to produce heat. Due to the
heating the vein wall dies and the collagen in the
wall shrinks and the vein closes at the targeted area.
This can be done along the entire course of the

53

 target vein to treat it completely. Hence there is
collapse and the sealing of the targeted vein.
This procedure is a minimally invasive one. It is an
alternative to the traditional vein stripping procedure.
Radiofrequency ablation is used to treat
• The great saphenous vein.
• The small saphenous vein.
• The perforator veins.
The treatment is mostly for these veins as
radiofrequency ablation catheters cannot be easily
passed along a tortuous superficial vein.
But bipolar radiofrequency devices such as VNUS
RFS or RFiTT can be used in small sections of other
veins that are straight enough to allow the catheter
to be inserted in and passed with the aid of
ultrasound guidance.
After this, branch varicose veins are treated by
minimally invasive procedures such as
• ambulatory phlebectomy
• sclerotherapy or foam sclerotherapy.
General overview of the Procedure:
• Duplex ultrasound is used to find and confirm
the diseased vein.
• The sapheno femoral junction or target
location in the diseased vein, the vein and the
point of entry are marked. The point of entry is

54

 chosen at a region just below or above the
knee which permits cannulisation of the vessel
• The incision is made.

• The physician inserts the catheter with the

radio frequency device into the vein and
guides it to the sapheo phemoral junction or
the target location in the diseased vein. The
catheter is guided through the course of the
diseased vein and properly positioned at the
target site with the aid of ultrasonography.
• Now with the aid of ultrasound a local
anaesthetic is administered to the patient in
the tissues surrounding target vein above and
within its fascial sheath. The anaesthesia is
administered along the course of the vein from
the target location to the site of insertion. The
anaesthesia is given in order to anesthetize
and compress the vessel. The anaesthetic
agent should be delivered at the correct
intrafascial location and in a volume that is

55

 sufficient to compress the vein and also
dissect it away from other structures along its
entire length like nerves. The anaesthesia also
acts as a heat sink and absorbs any heat
which might be created by the device which
reduces the risk of skin burns during the
procedure. 200-400mL of 0.1%Lidocaine is
given usually given and is also sufficient to
produce the above desired effects. The patient
should not feel a sudden heat sensation.
Hence tumescent anaesthesia should be
administered properly. If the patient gets such
a sensation more anaesthesia is given.
• The console is turned on and the alternating
current is transferred between the electrodes
of the catheter through the vein wall at
radiofrequency rates. Heat is generated
through radio frequency energy.

• The vein wall gets heated by the

radiofrequency energy to a certain

56

 temperature such that the collagen in the vein
shrinks and the vein wall collapses at the
target area and the catheter is slowly pulled
back closing the vein.

• The catheter is slowly pulled back a certain

distance from the previously treated part of the
target vein and the process is repeated.

• In this way, the entire vein is treated in

segments up till the point of incision such that
entire vein is ablated.
If a set amount of power is used and maintained and
the catheter heating element is pulled back at a set
rate then we can make sure that the temperature

57

 generated inside the vein is sufficient to heat it
without burning it too much.
If the heat supplied by the catheter is less or too little
we will have insufficient death of the vein, that is,
only the inside of the vein will be killed and there will
be formation of blood clots and the vein will open
after months or years.
If we heat the vein too much then it can get
vaporized which can be painful.
There are different types of catheters to perform this
procedure, each with their advantages and
disadvantages. But the Closure catheters
manufactured by VNUS Medical Technologies are
the only commercially available radiofrequency
ablation system designed for venous ablation.
The first technique was the VNUS Closure technique
which had small electrodes and it took a long time to
treat the vein.
The RFiTT device uses this same principle but with
larger electrodes. Hence it can produce more energy
and is therefore able to treat veins much quicker.
This device is a bipolar radiofrequency ablation
device. The tip of this device doesn’t get hot. It can
treat small sections of the veins and also perforator
vein which is not possible with the Closure Fast
technique. Hence this device is versatile and can be
used for all veins. This device had some teething

58

 problems but due to research at the whitely clinic in
the U.K they designed protocol which shows that the
RFiTT can be used as a reliable technique for
successfully closing the Great Saphenous Vein
(GSV) in every treated vein. Further studies from
this same clinic have shown that the RFiTT device
can also be used to close incompetent perforating
veins by using the TRLOP technique.
The Closure Fast device manufactured by VNUS
technologies is designed to speed up the treatment
and decrease the time of treatment. This type of
device has a 7 cm end which gets heated up to the
tip. Using this device the physician can treat 7cm of
a long vein at once and hence the entire length of
the vein can be treated in a short time in 7 cm
segments.
But there are some disadvantages to this technique:
• The tip of this device gets heated also and
hence if it is placed in the wrong position then
it can heat blood, skin or subcutaneous fat.
• The device heats by conduction hence it heats
anything it comes in contact with.
• The device itself gets heated and can heat
vein tissue.
• It can’t be used to treat perforator veins or
recurrent varicose veins

59

 To overcome these drawbacks VNUS has produced
another device called VENEFIT which is 3 cm
version of the above device.
The VNUS Closure RFS device is the only device
which has been approved by the FDA for
endovenous ablation of perforator veins.
RFA is generally conducted in the outpatient setting,
using either local anaesthetics or conscious sedation
anaesthesia.
After the procedure, a bandage is placed over the
area where the catheter was inserted and the leg is
wrapped for a day to aid in healing.
The physician confirms the sealing of the treated
vein by ultrasound.
For a speedy recovery,the patient may be asked to:
• Walk.
• Wear compression stockings.
• Avoid standing for long periods of time
Patients may resume their daily activities within one
to two days.
Advantages:
• The recovery time is short. The patients can
resume their normal day to day activities within
one to two days.
• Procedure is quick to perform.

60

 • Local or regional anaesthesia is administered
to the patient.
• There are no visible scars hence there are
good cosmetic outcomes.
Disadvantages:
• For the procedure to work there has to be
good contact between the elctrodes of the
catheter and the wall of the vein.
Complications:
• Mild burns on the skin
• Deep vein thrombosis
• Bleeding
• Infection

61

 • Non thermal methods:
• Clarivein: It is a non-thermal vein ablation therapy.
In this technique sclerotherapy is combined with a
rotating device which abrades and irritates the intima
of the vein resulting in the mechanical disruption of
the vein and a mechanical disruption of the inner
vein wall by a rotating device. The combination of
these two effects causes the collapse and closure of
the varicose vein.
It is the latest technique for the treatment of varicose
veins.
The procedure is almost painless to the patient as
no heat is generated by the procedure. This method
does not require injections, other than the initial prick
when the catheter is inserted with the aid of
ultrasound guidance percutaneously into the vein.
The catheter is positioned at the sapheno femoral
junction. The procedure is completely painless and
hence there is no need for pain relief but xylocaine
may be used when the physician enters the vein. A
rotating catheter is inserted into the vein, together
with a drug called Fibro-Vein or STD, which causes
the vein to collapse. The drug is spread throughout
the vein by the rotating motion of the catheter. The
rotating motion of the catheter creates vessel spasm
during pullback of the catheter to block forward flow

62

 and concentrate the liquid sclerosant. The
scleroscant is sprayed on the pull back to obtain
maximum efficiency of the procedure.
Advantages:
• Painless to perform
• Candidates can be similar or same type as
those in other ablation procedures.
• No damage to the nerve as there is no thermal
energy used.
• No injection into the thigh is needed.
• Takes a maximum of 20 minutes. It requires
lesser time than other ablation procedures
since no tumescent anaesthesia required.
Disadvantages:
• Not suitable for large veins or large legs, since
the tip of the instrument is around 8mm. Hence
it is difficult to get the catherter to reach the
entire inside of the veins larger than this
diameter.
• Coil embolization: In this technique a catheter is inserted
into the affected vein with the aid of x-rays and ultra
sound. The catheter has a small coil made up of platinum.
The catheter is inserted in the varicose vein in the back of
the calf muscle or leg. A small amount of alcohol is
injected into the vein at the same time the catheter is
removed. The alcohol is a chemical irritant and irritates

63

 the inner lining of the vein causing sclerosis of the vein
and its ultimate collapse and closure. This closure results
in a scar. The collapsed vein is then converted into scar
tissue which is then absorbed into the local tissue and
eventually fades away.
Advantages:
• Minimally invasive procedure
• No risk of infection or scaring on the outside of the
body. Scarring only occurs within the affected vein.
• No general anaesthesia required.
• Recovery time is short.
Disadvantages:
• This technique cannot be applied every case of
varicose veins.
• There can be a small chance for bruising to occur
around the region where the catheter is inserted.
• There is always a possibility of recurrence.
• The sapheon glue system: This procedure is called
VenasealTM or superglue therapy and was developed by
the company Sapheon Inc. and is a non-surgical
procedure. It is not yet approved in the U.S but is has a
licence in the E.U. This technique seals the inner walls of
the vein shut by the use of a medical superglue or adhesive
called cyanoacrylate and with the aid of compression from
the surface above the vein by the physician. As these veins
are closed the blood is rerouted to healthier veins in the

64

 body. The vein is then absorbed by the body’s natural
processes. The sapheon system is a potential step forward
in the stitching of the veins together.
Procedure:
• An incision is made.
• The catheter is inserted into the varicose vein with
the aide of local anaesthesia.
• The catheter is then positioned near the saphneo
femoral position with the guidance of ultrasound.
• Compression is applied with the ultrasound
transducer above the catheter so that the vein can
be collapsed.
• The first injection is precisely administered
• The catheter is moved back one centimetre and
another injection is made.
• And the catheter is pulled back three centimetres.
• Gentle pressure is also applied by the physician
using his free hand along with the transducer.
• The tip of the catheter is located once again with
the help of the ultrasound transducer and the
transducer is positioned to be above this tip.
• Compression is applied and an injection is again
administered and the catheter is pulled back three
centimetres.
• Compression is applied by the physician using his
free hand.

65

 • This routine is repeated along the whole course of
the vein diseased varicose vein
• The catheter is then removed and only a band aid is
placed at the incision site.
• The patient suitability for the procedure is
determined after a full consultation and duplex
ultrasound scan.
Advantages:
• Time required 20 minutes.
• Only one local anaesthetic injection is used, that is,
at the starting of the procedure. No other injections
are needed.
• Patients do not need to wear compression
stockings after the procedure.
• No use of heat energy.
Disadvantages:
• Some people find these inconvenient in terms of
appearance
• They can cause dry or itchy skin.
• There is discomfort if the weather is warm.
• Treatment is at the early stage we do not know how
effective it will be.

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 • Pharmacotherapy:
• Flavonoids:
• Diosmin and hesperidine: These are both
flavonoid compounds. Diosmin is a flavone and
is the synthetic derivative of hesperidin which is a
flavanone. Diosmin consist of an aglycone called
diosmetin. Diosmin is obtained from
Teucriumgnaphalodes, a plant endemic to the
Iberian Peninsula while hesperidin is obtained
from citrus fruits. They are both capillary
stabilizing agents.
Mechanism of action: When used together or in
combination they
• Prolong the vasoconstrictor effect of
noradrenaline on the venous wall. Hence
this results in:
• Increase in venous return and
• Reduction of venous hyper pressure that
is present in patients with chronic venous
disease.
• Improve lymphatic drainage
• Protect the microcirculation from
inflammation.
Use:
• Chronic venous disease
• Haemorrhoidal disease

67

 Dosage: The combination is given by oral route.
Dosage form: Tablet
Each tablet contains:
• Diosmin- 450mg
• Hesperidin- 50mg
• Chronic venous disease
Adult: 2 tablets daily
• Haemorrhoids
• Adult:
• Acute attack:
First four days: 6 tablets daily
Next three days: 4 tablets daily
• Chronic haemorrhoids: 2 tablets daily
Contra indication: During lactation
Adverse Drug Reaction: Gastro Intestinal
discomfort.
Drug Interactions: The metabolism of
metronidazole may be decreased on concurrent
administration of diosmin. This has the potential t
turn into a fatal condition.
The formulation DAFLON produced the
manufacturer Serida. It is a micronized purified
flavonoid fraction of rutaceae. It consists of 90%
of diosmin and 10% of other flavonoids
expressed as hesperidin. It is a vasculoprotector
and a venotonic.

68

 Indications:
• Chronic venous insufficiency (organic &
functional) of the lower limbs which is
accompanied by the symptoms of heavy
legs, pain, nocturnal cramps & oedema
• Varicose veins
• phlebitis
• Haemorrhoids & acute haemorrhoidal
attacks
• DUB/IUCD induced bleeding
Dosage:
• General dose: 1 tablet twice a day with
meals.
• Haemorrhoids
• Acute attack:
• First four days:6 tabets daily
• Next three days:4 tablets daily
• Maintenance dose: 2 tablets daily
• Diosmin: It is also available solely in its synthetic
form in the form of tablets, e.g., VENEX
manufactured by Elder. Diosmin is safe when
used for short-term of up to three months.
Dosage:
• 600-1200 mg daily after meals.
• Acute disorders (eg. haemorrhoids): 4 tabs
thrice a day for 2-3 days.

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 Indications:
• Haemorrhoids
• Varicose veins
• Menorrhagia
• IUD intolerance
• Functional venous disorders
Side effects of diosmin:
• Stomach and abdominal pain,
• Diarrhoea
• Headache.
• Antibiotics:
When a patient suffering from varicose veins
develops ulcers then there is a high possibility of
these ulcers getting infected by various bacteria.
Signs of possible infection of the ulcer are:
• When the ulcer produces more pus.
• When the ulcer becomes more painful.
• Redness around the ulcer.
This contributes to poor healing of the wound.
Antibiotics are given in order to treat and heal these
infections. The course of the antibiotic is usually for
seven days. But a Cochrane review of 22
randomized controlled trials of topical and systemic
antibiotics and antiseptics for the treatment of
venous ulcers found no evidence that the routine
use of oral antibiotics improves healing rates.

70

 Oral antibiotics are recommended to treat venous
ulcers only when there are cases of suspected
cellulitis. When osteomyelitis is suspected then it is
necessary to perform an evaluation of arterial
disease and the physician has to consider the
treatment of this infection with intravenous
antibiotics.
• Anti-inflammatory drugs/NSAIDs:
They are prescribed by the physician. They are
effective in preventing inflammation as they are COX
inhibitors. There are various agents e.g. Ibuprofen,
paracetamol, etc. but they may be contraindicated in
some individuals and have to be replaced by a
suitable alternative.
Use:
• To prevent inflammation in superficial
thrombophlebitis: Agents like Ibuprofen are highly
effective in preventing inflammation but cannot be
used in case of patients who are pregnant. In such
cases paracetamol may be used as an alternative.
They may also be useful in preventing the
recurrence and enlargement of varicose veins due
to superficial thrombophlebitis. But more studies are
needed to confirm this.
Anti-inflammatory gels or creams: (e.g. Ibuprofen
gel) Are alternatives used to the other formulations

71

 of these drugs if superficial thrombophlebitis is mild
and only affects a small area of vein. They tend to
produce fewer side-effects than when these drugs
are taken orally.
• Prevent inflammation in painful ulcers (especially
when compression bandages are applied for the first
time to an ulcer that is unhealthy): In this case a
suitable agent may be prescribed.eg paracetamol.
• To treat ulcers:

Aspirin (300 mg) combined with compression

therapy has shown to decrease ulcer size and
increase ulcer healing time as compared to using
only compression therapy. Aspirin is recommended
in the treatment of venous ulcers whenever it is not
contraindicated.

72

 • Other medications:
• Pentoxifylline:

Trade name: Trental

It is a xanthine derivative and belongs to a group
of vasoactive drugs which increase the
peripheral tissue oxygenation by improving the
peripheral blood flow. It is used to treat venous
ulcers.
Mechanism of action: The exact mechanism of
action is not known. It improves blood flow
properties by decreasing the viscosity of the
blood. This is in turn causes an increase in the
blood flow to the affected microcirculation
resulting in enhancement of tissue oxygenation.
It is able to decrease the viscosity of the blood
by:
• Platelet deaggregation
• Haemorheologic action: It improves the
deformity or flexibility of red blood cells which

73

 probably contributes to the improvement of the
ability of blood to flow through peripheral
vessels.
It is also shown to improve the flexibility of
leukocyte deformability and to inhibit neutrophil
adhesion and activation.
Indication: To treat the symptoms of
• Intermittent claudication caused by peripheral
artery disease.
• Of chronic occlusive peripheral vascular
disorders of the extremities
It improves symptoms and function but is cannot
replace more definitive therapy for the treatment
of peripheral vascular disease like:
• Surgical bypass
• Removal of arterial obstructions.
Dosage:
• Peripheral vascular disease
• For adult
• Usual dose: 400mg two or three times a
day (for at least 8 weeks).
• Recommended starting dose: 400 mg
twice daily after meals. This is
because sometimes if 400mg is taken
three times a day there can
manifestation of Gastrointestinal and

74

 Central nervous System side effects in
the patient.
It may take up to 2 months to obtain the full
results.
Pentoxifylline (400 mg three times per day) has
shown to be an effective adjunctive treatment for
venous ulcers combined with compression
therapy.
For patients who are unable to tolerate
compression bandaging it can be used as a
monotherapy.
Adverse effects (by frequency):
Common (frequency: 1-10%):
• Flushing
• Dizziness
• Headache
• Vomiting
• Indigestion
• Nausea
Uncommon (frequency: 0.1-1%):
• Palpitations
• Angina
Rare (frequency : <0.1%):
• Itchiness
• Hives
• Bleeding

75

 • Hallucinations
• Arrhythmias
• Hypersensitivity
• Rash
• Aseptic meningitis
Contraindications:
• Patients who have allergy to xanthine and
related xanthine based products.
• Patients with recent retinal haemorrhage.
• Patients with recent cerebral haemorrhage.
Drug interactions: They can be potentially fatal.
• Concurrent administration with ciprofloxacin
may cause an increase the adverse effect
of pentoxifylline.
• Concurrent use may increase serum levels
of theophylline derivatives.
Special indication:
• Pregnancy: It is a category C Drug for
pregnancy.

76

 Iloprost:

+2

+
+

+2 2+

It is a synthetic prostacyclin.
Action:
• Vasodilator
• Inhibits platelet aggregation.
It was shown in a study that intravenous iloprost
along with elastic compression therapy
decreased the healing time of the ulcer as
compared to the use of a placebo. Intravenous
iloprost is not available in the United States. But,
the medication is very costly and there is not
sufficient data to recommend its use.

77

 • Compression therapy
• Elastic compression therapy: They conform to
changes in leg size and sustain compression during
both rest and activity.
Materials:
• Stockings
• Bandages
• Elastic wraps (not recommended as they
do not provide enough pressure)
• Compression stockings:

78

 They are tight stocking that squeeze or compress
the leg muscles and are usually recommended
by the doctor.
They don’t cure the condition but they slow the
progress of the disease and slow down the
worsening of the condition.
They squeeze the muscles in the affected leg
and helps in the pumping of blood. They are
graded as they create a gentle and gradual
pressure up the leg as they slowly decrease the
pressure on the leg applied by them from the
ankle upwards toward the upper parts of the legs
(knee and thigh), that is, they are tighter at the
ankle and become looser on moving upward the
leg. This keeps the blood from pooling and helps

79

 in the pumping of the blood to the heart and also
decreases the swelling in the effected leg.

The minimum pressure provided should be 20 to

30 mmHg
The preferred pressure provided should be 30 to
44 mmHg
Types of compression stockings:
• Support pantyhose: Offer the least
amount of pressure.

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 • Over-the-counter compression hose:
They give a little more pressure than
support pantyhose. Sold in medical
supply stores and pharmacies.
• Prescription-strength compression hose:
They offer the greatest amount of
pressure. Sold in medical supply stores
and pharmacies.
You have to get them fitted by a trained person
before you buy them.The material used depends
upon the manufacturer but they are made in
such way that they are graded. They come in
different sizes and colours and are of different
brands and the type to be worn by the patient
depends upon the practitioner.
The wearing of graduated compression stockings
with variable pressure gradients (Class II or III)
• Corrects:
• The swelling
• Nutritional exchange
• Improves the microcirculation in legs affected
by varicose veins
Advantages:
• Reduces oedema
• Decreases heaviness caused by varicose
veins.

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 • Improves venous reflux
• Enhances healing of ulcers and
• Reduces pain
• Reduce the risk of deep vein thrombosis
• Maintenance helps prevent recurrence of
ulcer.
Success rates:
• After 24 weeks: 30-60%
• After 1 year: 70-85%
After an ulcer has healed, lifelong maintenance
of compression therapy may reduce the risk of
recurrence.
Disadvantages:
• Pain
• Drainage
• Application difficulty
• Physical limitations:
• Obesity
• Contact dermatitis
• Uncomfortable in warm weather
• They do not prevent recurrence of varicose
veins.
Contraindication:
• Diabetics
• Smokers

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 • Patients with significant arterial disease and
uncompensated heart failure
Instructions:
• To be removed at night.
• Replace the pair ever six months as there
is loss of pressure on washing
• Follow washing instructions as per
manufacturer.
• Follow the manufacturer’s instructions on
how to put on the stocking.
• After removal raise your legs so that the
blood flows towards your heart with the
help of gravity and promotes normal
circulation.
• Apply moisturising cream in order to
prevent the skin from becoming flaky and
thin especially in the affected area.
• Elastic bandages: Less preferred to compression
stockings. They are alternatives to compression
stockings. High compression has been proven to be
more effective low compression. Multilayer
bandages are more effective than single layer.
Disadvantage:
• Have to be skilfully applied

83

 • Have to be applied about 2 times a week in
the doctor’s office. The number of times they
are applied depends upon drainage.
• Inelastic compression: Less effective as compared
to elastic compression. They have no resting
pressure but provide high pressure during muscle
contraction and ambulation
Disadvantages:
• Difficult to wear
• Do not conform to leg size
• Requires frequent replacement as may smell
due to accumulation of exudate from
varicose ulcers.
• Common method:
• Unna boot: It is a zinc oxide impregnated, moist
bandage. It hardens after application. It hardens
after application.
• Intermittent Pneumatic Compression devices:

Use: To treat varicose ulcers.

84

 It is a second line therapy for venous ulcers and is
used in immobile patients
They consist of a pump that delivers air into
inflatable and deflectable sleeves. These sleeves
embrace the extremities and provide intermittent
compression. They can be single or multi
chambered and are applied to the limb.
They inflate and deflate in a sequence such that
simulate venous foot and calf muscle action and
normal circulatory action.
Advantages:
• Aid venous return
• Reduces oedema
• Useful in immobile patient and those who
cannot tolerate compression bandaging
• Useful in patients who cannot control limb
oedema
• Patients with limited mobility in the ankle
• Patient with reduced calf function
The benefits of this method are not clear as
compared to standard continuous compression.
Disadvantages:
• Expensive
• Immobilization of the patient is required.
• Bulky equipment

85

 • Some can only run on electricity but now more
portable versions with rechargeable batteries
are being developed.
Hence, they are only reserved for bed ridden
patients who cannot tolerate continuous
compression therapy.
• Leg elevation:

It is considered as a standard of care when used with

compression therapy and has been recommended by
doctors for a long time.
Here the patient has to raise his or her legs above the
level of the heart. Ideally the affected legs toes and the
eyes should be at the same level. The patient can
even sleep with a pillow under the feet or if the patient
can’t sleep then by sitting on a chair he or she should
elevate their legs by putting them on the head of
another chair. But do not sit for too long.
This is especially useful for those having chronic
swelling in their legs and those with mild to moderate
varicose veins.

86

 Advantages:
• Reduces oedema in the ankles caused due to
fluid build up
• Improves microcirculation and delivery of oxygen
• It hastens ulcer healing.
• Help move blood from the feet to the heart by
gravity
• Can be done at home and is easy to perform
In a small study it was shown that the laser Doppler
flux (the flow within the veins) was increased by 45%
by leg elevation.
This technique is most effective when performed 3 or 4
times per day for 30 minutes. But the allotment of time
for such exercises by the patient in his or her daily
routine may be difficult.

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 • Combination therapy:
Here several treatment options are used in one session in
order to obtain the combination therapy involves the use
of several vein treatment options in one session to give
the best possible the best results. E.g. laser or ultrasound
guided foam sclerotherapy or VNUS closure can be used
to treat superficial vein reflux and then phlebectomy can
be used to treat the varicose veins.
Advantages of using of several minimally invasive
treatment options together in one session:
• Good cosmetic results
• Rapid recovery
• Low recurrence rate
• Treatment of extensive veins in one session
• Rapid removal of varicose veins

88

 • Alternative Methods:
• Ayurveda:
Ayurvedic medicine considers the holistic treatment of
the disease and the uniqueness of every individual
patient. The treatments prescribed to a patient by the
ayurvedic practitioner can differ from patient to patient
along with some yoga exercises.
Under ayurveda, varicose veins are dealt as ‘Siraja
grandhi’ and considered to be due to ‘Srotavarodham’.
‘Srotus’ “SravanamSrotamsi” meaning the channels
through which there is flow in the body like arteries,
veins etc. ‘Avarodham’ refers to the obstruction in
these channels. Under normal healthy condition
‘Srotus’ gives and protects health but when vitiated or
altered it causes disease.
Treatment for Varicose veins according to Ayurveda is
done by means of speciality treatments called
"PanchakarmaChikitsa." to correct the essential
balance of ‘tridosha’ in the body and to get to the root
cause of the problem.
Panchakarma is a Sanskrit word which means "five
actions" or "five treatments”.
If the Doshas are vitiated beyond a particular level,
they give rise to various endotoxins, which get
accumulated in the body in the minute channels. If

89

 these endotoxins cannot be pacified or controlled then
they need to be eliminated from the body.
In such cases Ayurveda indicates the uses ofcleansing
therapy called, Shodhan Chikitsais. Since it consists of
five types of main therapies, it is known as the
Panchakarma Chikitsa and in case of varicose veins
these treatments aim to decrease the pressure in the
veins of the lower limbs.
It goes through several stages which are:
• Abhayangam (oil massage)

• Swedanam (steam procedures/fomentation)

90

 • Elakizhi (leaf bundle massage)

• Pizhichil (oil bath with 3 litres of oil)

• Vasti Karma (enemas which include Matra Vasthi

,Kashaya Vasthi, Anuvasana Vasthi, etc.)

91

 Matra Vasthi

Kashaya Vasthi

• Virechanam (purgation)
• RakthaMokshanam (bloodletting) etc.

92

 Some recommendations in this type of therapy are:
• Diet:
• Fresh fruits: Amla and citrus fruits, make sure
to chew on the inside of the rinds,
• Whole grains: Mostly wheat and millet. To
disperse build-up of a protein that makes skin
near varicose veins hard and lumpy, try eating
more onion, ginger and garlic.
• Pineapple: Contains the enzyme bromelain
which promotes the breaking up of fibrin.
• Fish(plenty)
• Avoid red meat
• Bioflavonoids: Should be incorporated in your
diet in your diet by taking
• Supplements or
• Fruits:
• Oranges
• Apricots
• Blueberries
• Blackberries
• Cherries
• Rosehips
• Buckwheat
• To stimulate circulation in the legs alternate
between hot and cold baths.

93

 • Do not wear any tight clothing, especially if
they constrict the waist area.
• Avoid the use of high heels: They affect
circulation as they stop normal muscle
contraction of the lower leg.
• Elevate legs in the night: This helps maintain
good blood circulation and also relieves the
patient from swelling or oedema.
• Exercise regularly: It improves muscle tone,
stimulates circulation and helps prevent
varicosities. Brisk walking, cycling and
swimming, performing stretching exercises for
the legs are all recommended for those having
moderate varicose veins.
• Use a rocking chair while watching television.
• Perform yoga: Certain yogaasanas such as
the Sarvangaasana, Halaasana, and
Pawanmuktaasana series promote circulation
and the drainage of blood from the legs.
• Stop smoking: It may contribute to high blood
pressure, this can worsen varicosity.
• Do not use contraceptive pills.
• Pregnant patients should sleep on their left
side rather than on their backs as this
minimises pressure from the uterus on the

94

 veins in the pelvic area. There is also
improvement in blood flow to the foetus.
• Herbs: Arjuna and Guggul are highly
recommended. They reduce inflammation and
improve blood circulation.
• Ayurvedic remedies:
• Brahmi (Bacopa monnieri): It is a tropical
creeper.
Use: In patients with venous insufficiency.
Benefits are seen after four weeks of
treatment.
Dose: 10 - 20 ml, 2 times a day.
• Zinc: It is given in the form of Jasad bhasma. It
has the following medicinal properties:
• Assists in healing.
• Assists in collagen formation.
• Helps maintain proper concentration of
vitamin E in blood.
• Garlic (Allium sativum): It has the following
medicinal properties:
• Supplies protein to the lower limb region,
as it breaks down the protein content in
the body and supplies it evenly.
• Eases the blood clots.
• Normalises the blood circulation.

95

 • Onion (Allium cepa): It has the following
medicinal properties:
• Helps in the proper assimilation and
distribution of protein in the body.
• It gives inner strength.
Eating an uncooked medium sized onion daily
is recommended as it is believed to solve the
problem.
• Ginger (Zingiber officinale):
Action:
• Supplies protein to the lower limb region
as breaks down the protein content in the
body and supplies it evenly.
• Guggul (Commifera mukul): It is a herb.
Active ingredients: They are natural plant
sterols. Guggulsterones is the most important
plant sterols of guggul. They are important for
fat metabolism properties of guggul and
cholesterol support. Other sterols have a
synergistic action to the actions of these.
Properties:
• Improves blood circulation
• Reduces swelling
• Maintains normal cholesterol and
triglyceride levels and HDL-LDL ratio.

96

 • Helps to lose weight and maintain
normal weight
• Best herb for cholesterol support.
• Supports normal metabolism.
• Supports normal function of joints and
connective tissues.
• Supports immune system function.
• Arjuna (Terminalia arjuna): It is a tree called
nadisarjja in Sanskrit and its bark is used for
medicinal purposes.
Medicinal properties of the bark:
• Cardiotonic
• Aphrodisiac
• Urinary astringent
• Expectorant
Active ingredients:
• Bark
• Tannins
• Triterpenoid saponins:
• Arjunic acid
• Arjunolic acid
• Arjungenin
• Arjunglycosides
• Flavonoids:
• Arjunone
• Arjunolone,

97

 • Luteolin
• Gallic acid
• Ellagic acid
• Oligomeric proanthocyanidins (OPCs)
• Phytosterols (b-sitosterol)
• Minerals: Calcium, copper,
magnesium and zinc.
• Bark powder:
• Arjunone
• Arjunolone
• Leteilin
• Gallic acid
• Ellagic acid
• Phytosterols
• Minerals: Calcium, copper,
magnesium and zinc
• Triterpine glycosides:
• Arjunetosides I,
• Arjunetosides II,
• Arjunetosides III,
• Arjunetosides IV,
• Arjunine,
• Arjunetein
Principle constituents:
• §-sitosterol,
• Ellagic acid

98

 • Arjunic acid.
Medicinal properties:
• Heart tonic:
• Helps maintain healthy
cardiovascular functions,
• Strengthens heat muscles,
• Promotes normal cholesterol and
homocysteine levels
• Helps maintain normal blood pressure
and blood flow
• Arjuna bark powder contains the co-
enzyme Q-10:
• It is beneficial for strong heart
muscles as it assupports
• The heart's energy output
• Enhances overall energy levels,
cellular health immunity, stamina
and cellular health.
• Tree turmeric (Berberi saristata): It is a
herb.
Medicinal properties: Helps in reducing
• Bleeding
• Pruritis
• Swelling
• Neem (Azadirachta Indica):
Bitter Active principle: Nibin and nimbidin
Medicinal properties:

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 All the parts of the tree are useful.
• Has a cleansing and purifying effect on
the skin and blood.
• It detoxifies blood, digestive, urinary
and respiratory system.
• Supports normal function of the
circulatory and dermal systems.
• Supports normal blood flow to the
organs.
• Helps control bleeding, bacteria,
itching and is has a soothing effect on
application.
Leaf:
• Used for balancing Vata disorders.
• It removes ama and other toxins from
the body.
• Purifies the blood.
• Neutralizes damaging free radicals.
Bark:
• Cooling
• Bitter
• Astringent
• Used to treat tiredness and
Kaphadosha imbalance.

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 • Triphala: It means 3 fruits and is an ayurvedic
combination of :
• Amalaki (Emblica officinalis),
• Haritaki (Terminalia chebula)
• Vibhitaki (Terminalia bellirica)
Medicinal properties:
• Gentle laxative: Doesn’t cause cramps
or irritation. Corrects occasional
constipation.
• Detoxifier and cleanser.
• Improves digestion and assimilation.
• Blood purifier: Detoxifies the liver by
causing bile secretion.
• Promotes normal serum cholesterol and
lipid levels throughout body.
• Helps reduce weight: When consumed
for a long time.
• Rejuvenates membrane lining of gastric
tract.

101

 • Effectively cleanses the colon:
Stimulates the intestinal walls gently
(stimulates peristalsis) and restores tone
to the colon, which helps in the
elimination process, providing a colon
cleansing effect.
• Helps maintain good eyesight.
• Anti-oxidant activity (in-vitro).
• Prevents haemolysis of the red blood
cells which is induced by superoxide.
• Prevents lipid peroxidation which is
caused by Fe+3/ADP/Ascorbate system
in liver mitochondria.
• Promotes normal blood pressure and
blood circulation
• Promotes liver health: stimulates bile-
flow
• Prevents aging
• Imparts immunity
• Improves mental faculties.



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 • Indian laburnum (Cassia fistula): When used in
combination with Haritaki and Amalaki it helps
in reducing bleeding and easy motion of stool.
• Orchid tree (Bauhinia variegate): Very
effective in reduction of swelling when used
with guggul.
• Oils: The ones used are
• Chandana Bala Lakshadi oil
• Prasarini oil:
These oils must be used for regular massage
but they are never massaged directly on the
varicose vein as this would increase the
pressure on them.
• Marigold: Wash and crush the petals and
make a paste and apply it overnight.
• Fuller’s earth: Make a paste with one cup of
water and apply it to the affected area and
leave it overnight. Then wash it with warm
water in the morning.
• Chamomile powder: Make a paste with water
apply the paste.
• Consume a mixture of carrot and spinach juice
daily. This will solve the deficiency of vitamins
in the leg.

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 • Acupuncture and Acupressure:
• Only prevents the worsening of the situation but
does not provide any aesthetic benefit.
• Press the following for ten minutes daily: (usually the
Points on the legs along the spleen channel are
targeted)
• SP 5
• SP II
• BL 38
• ST 32
• ST 36
• CV 1
• Aromatherapy:
• Add 12 drops each of cypress essential oil and 12
drops geranium essential oils in four ounces of a
carrier oil (e.g. soy, almond or sunflower).
Apply the mixture to the legs gently and stroke
upwards, in the direction of the heart.
Instructions for application: Do not massage directly
on the veins but massage in such a way such that
you apply the mixture to the surrounding area and
gently stroke the oil over the veins.
• Oil of rosemary (Rosmarinus officinalis): Gently
massage the affected area with this as it may cause
capillaries to dilate and stimulate circulation.

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 • Oils of cypress and chamomile (Matricaria recutita):
These may sooth swelling and provide relief from
pain when applied to the affected area.
• Colour therapy: Use red and yellow all over the
affected area for thirty minutes once per day. In cases
of ulcers in the legs use blue light radiation for thirty
minutes followed by ultraviolet for forty-five minutes,
every day for ten to sixty days.
• Diet and Supplements:
• High fibre diet: Switching to or the incorporation of a
high-fibre is recommended in patients with varicose
veins as this prevents straining of the stool which
causes the building up of pressure which can
worsen the varicose veins in patients who already
have them. The recommended amount of fibre to be
consumed per day is 30g.
• Foods:
• Whole grains
• Legumes
• Fruits
• Vegetables
• Also eating plenty of blackberries and
cherries is recommended as they contain
large amounts of compounds that may
prevent varicose veins or lessen the
discomfort they cause.

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 • Vitamin A: This is taken in the form of beta carotene
as it helps maintain the skin integrity and also aids in
the quick healing of the varicose ulcer.
• B complex vitamins: In order to help maintain strong
blood vessels, take tablespoon of brewer's yeast
and one comprehensive tablet daily.
• Bioflavonoids (0.1-1g) and vitamin C (1-5g): Should
be taken daily in divided doses.
Use:
• Aids circulation.
• Promotes the healing of sores.
• Strengthens vein walls to prevent dilation.
Rutin is a bioflavonoid present in many foods and is
used routinely in the treatment of varicose veins.
Rutin containing foods:
• Cherries
• Rose hips
• Citrus fruits
• Apricots
• Blackberries
• Blueberries
• Buckwheat
• Vitamin E: On usage, its dose should be gradually
increased.
Use:

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 • improves circulation
• Reduces susceptibility to varicose veins
• Relieves pain
• Correct varicosities
• Relieves localized irritation(topical application)
• Speeds the healing of varicose ulcers(topical
application)
Dose: 30,300-800 IU
Contraindication: Patients suffering from moderate
coagulation factor deficiency as it can cause
bleeding.
• Lecithin: To emulsify fats and aid circulation take
one tablespoon of granules daily.
• Tissue Salts: of
• 6XCalc.Fluor: Two tablets to be used each morning
and evening in order to improve the elasticity of the
walls of the blood vessel.
• Zinc:
Use:
• Assists in collagen formation.
• Assists in healing and collagen
• Helps maintain proper concentration of vitamin E
in the blood
Dose: 50mg daily
• Preferred Foods:
• Fresh fruits

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 • Berries and cherries
• Citrus fruit
• Whole grains
• Garlic
• Onions
• Ginger
• Cayenne pepper
• Fish
• Foods to avoid:
• Salt
• Fried foods
• Processed and refined foods
• Animal protein
• Cheese
• Sugar
• Alcohol
• Red meat
• Ice cream
• Chiropractic: This type of therapy involves physically
manipulatingthe skeletal system in combination with
modifications to the diet and the lifestyle of the
patient to control varicose veins. To improve the
blood flow and flow of other fluids through the body
the chiropractor manipulates the skeletal system of
the patient in such a manner so that there is less
strain on the pelvis.

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 • Herbal Therapies:
• Witch hazel:

It is a herb. The ointment is applied 2 to 3 times a

day. Results are seen after two or more after
application of ointment weeks. Application of a
witch hazel ointment three or more times is
necessary for two or more weeks before results
can be expected. Herb not for internal use .It can
be made into a strong decoction for use as a
compress or can be taken internally as a tea.
May cause irritation in some patients, when
applied topically.
Use:
• Reduces pain and swelling(in haemorrhoids)
• Reduces inflammation
• Tightens and soothes aching varicose veins

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 • Horse chestnut:

Used internally for externally for the treatment of

venous circulation problems, like varicose veins.
The seeds and leaves are used to treat varicose
veins.
Adverse effects: allergic skin reactions (rare)
Contraindications:
• Patients with liver disease or kidney disease
• Pregnancy
• Lactation
Indication:chronic venous insufficiency (short term
treatment)
Use of seed extract which is diluted to 20%
aescin:
• Venotonic effect

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 • Vascular protection
• Anti-inflammatory action
• Free radical scavenging properties.
• Bilberries:

They help prevent varicose veins by

• Supporting normal formation of connective tissue.
• Strengthening the capillaries in the body.
• Butcher's broom:

Can be prepared as a tea or may be used as a

compress externally. It is used in the treatment of

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 varicose veins as it tightens blood vessels and
capillaries. It has compounds called ruscogenins
which decrease inflammation while constricting the
vein.
100g of ruscogenins taken internally as whole herb
extract is beneficial.
Use:
• Tones veins
• Reduces inflammation
• Enhances blood flow to the legs, brain and hands
• Relieves water retention
• Improves circulation
• Herbal remedies to strengthen blood vessels and
improve peripheral circulation:
• Gotu Kola

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 • Ginkgo (Ginkgo Biloba)

• Hawthorn (Crataegus laevigata)

• Herbal remedies that break down fibrin along with

the blood: They help maintain the normal function of
blood vessels which fibrin disrupts.
• Cayenne (Capsicum frutescens)

• Garlic (Allium sativum)

• Onion

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 • Ginger (Zingiber officinale),
• Pineapple contains an enzyme called bromelain
promotes breakup of fibrin.
• Herbal Tea
Ingredients:
• Ginger ……………………..1 part
• Horse chestnut………….. 3 parts
• Hawthorn berries……….. 3 parts
• Prickly ash bark………… 2 parts
• Yarrow…………………… 2 parts
Instructions: Infuse two teaspoons of the mixture for
15 minutes.
Indications: 3 times a day daily.
• Aloe vera gel: Used to soothe irritated or itchy
varicosities.
• St. John's wort:

Use:
• Internally: As an infusion. It provides compounds
that will nourish the stressed vein.
• Externally: As oils, tinctures, etc. and is applied by
rubbing on the affected area

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 Uses:
• Reduces inflammation
The herb should be used fresh or should be freeze
dried otherwise it will lose its properties.
• Homeopathy:
This type of system uses the body’s own healing ability
to treat the disease. Homeopathy works well for mild
and moderate cases of varicose veins. There are
many homeopathic preparations which give relief to
the patients suffering from varicose veins. These
mainly provide relief. The choice of these preparations
and the relief required depends on the experience and
judgement of the practitioner.
Some of these are:
• Fluoric acid:
Use:
• Bluish varicose veins
• Collection of veins in small spots
• Varicose ulcers
• Lycopodium clavatum:
Use:
• Veins which are swollen or enlarged, especially
those which are which have imperfect valves as in
legs, especially the right one.
• During pregnancy, varicose of genital organs of
labia.

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 • Pulsatilla nigricans:
Potency used: 3X
Use:
• In case of disturbance of venous circulation.
• Varicose veins in legs and about testicles of bluish
hue with soreness and stinging pain.
• In case of Passive haemorrhage.
• Calc. Flour:
Use:
• Varicose veins and their ulceration
• Vascular tumours with dilated blood vessels.
• Ferrum phos:
Use:
• Varicose veins
• Haemorrhoids in young people
• Hard stools
• Hamamelis (Tincture or lotion):
Use:
• Varicose veins
Instructions:
• May be applied locally at night.
• Hamamelis 3X should be taken every 3 hours
• Carbo vegetabilis:
Use:
• For constipated with poor circulation.
• Ulcers of varicose veins.

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 • Belladonna:
Use:
• Varicose veins which are tender, swollen and red.
Potency used: 12X or 12c
Instruction: To be used four times a day,
• Ferrum metallicum:
Use:
• If your legs look pale but redden easily.
• Weak, achy feeling is relieved by walking slowly.
• Arnica:
Potency used: 30c.
• Aconite napellus:
Potency used: 6c
• Pyrogeniunm
• Atropha Belladona Glonoinum
• Arsenicum album
• Formica rufa
• Fluoricum acidum
• Nux vomica
• Vipera
• Magnetis - Polus - Australis
• Sulphur
• Lachesis mutus
• Millifolium
• Mercurius sol:

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 • Hydrotherapy: Circulation of blood is believed to be
stimulated by alternating between hot and cold baths.
Procedure:
• Take 2 buckets
• Fill with hot water (not too hot but warm enough to
be comfortable) and the other with cold water. They
should be filled just enough that you can submerge
you’re your legs up till your knees. At this stage you
can add
•Epsom salts (2 tablespoons per quart of water) or
•Oil(s) used in aromatherapy to the water.
• First, soak your legs in the bucket of the hot water
for about three to five minutes,
• Then, immerse them in the bucket of cold water for
about 15 to 30 seconds.
• Repeat the procedure three times such that you
finish with the cold soak.
This treatment should be performed once a day for
one month.
Caution: In case of diabetics, use warm (not hot)
water.
Use:
• To improve circulation
• To relieve pain caused due to varicose veins

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 Aches and pain from superficial varicose veins can be
relieved by spraying or sponging the legs with cold
water.
• Juice Therapy: Juices of dark-coloured berries
(blackberries, blueberries, etc.)contain anthocyanins
proanthocyanidins and pigments that tone and
strengthen the walls of the veins. Pineapples are rich in
an enzyme called bromelain, which helps prevent blood
clots, complication of varicose veins. When a juice is
made of such fruits and berries then the concentrations
of these useful compounds are increased as compared
to eating the fruit alone. For maximum benefit, eight
ounces of juice (of a single fruit or diluted with the juice
of another fruit) once or twice a day.
Good combinations of fresh fruit or vegetable juices are
any combination of apple, beet, carrot, celery, citrus,
parsley, or pineapple and dietary supplements may be
helpful in preventing and treating varicosities.
• Exercise:
Maintaining overall fitness is essential for preventing
varicose veins as well as preventing the condition from
worsening developing. Hence regular exercise is
necessary.
Benefits:
• Stimulates circulation: Contraction helps move the
blood upwards out of the veins.

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 • Improves muscle tone.
• Helps prevent varicosities
Recommended exercises:
• Brisk walking (not jogging).
• Cycling (not strenuous).
• Swimming
• Calve raises:
• Stand up straight, grasping a chair or wall
for balance.
• Position your feet hip-width apart.
• Slowly raise your heels until you're on your
tiptoes. Balance your body weight on the
balls of your feet.
• Pause for a minute and then slowly lower
yourself.
• Repeat.

• Heel slips: With your knees bent, slide your heels

back and forth.

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 • The ankle pump: Flex your foot up and down as you
would when you pump a piano pedal or gas pedal.
You can control varicose veins with a program of
specially designed exercises, under the guidance of a
trained exercise therapist who knows about the
condition and its needs.
• Massage: Regular massage can significantly alleviate
the discomfort associated with varicose veins. It should
be done daily for five minutes on each leg. Trained
massage therapists start at the feet, then massages
the legs and moves up to the hips and then along the
lymphatic system in order to mobilize the congested
body tissues.
Use:
• Massage reduces swelling in the legs.
Caution: You can perform it on your own but make
sure not to touch the varicose veins as this may
increase the pressure in them.
• Reflexology:
Reflexology may relieve the pain of varicose veins
Working your hands or feet may help with varicose
veins. Massage the whole feet or hands and press the
following points three times per day for five minutes
each point after massaging the whole feet: 18, 19, 24,
25, 21, 22, 34, 26 (adrenal and parathyroid gland,

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 digestive system (especially the liver), spine, heart and
sciatic nerve.)
• Schuessler tissue salts:
• Calcarea fluorica:
Potency: 6X
Use:
• Dilated veins
• Varicose ulcerations
• Bluish discoloration of the tissues
• Muscular weakness.
• Ferrum phosphorica:
Potency used: 6X
Use:
• Inflammation of the veins
• For red streaks following the course of vein
• Throbbing pain along a vein.
• Alternative to calcarea fluorica.
• Magnesium phosphorica:
Potency used: 6X
Use:
• For severe, acute and spasmodic pains.
• For those suffering from flatulence or neuralgia

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 • Yoga:
Recommended and beneficial for mild and moderate
cases of varicose veins. A number of asanas and
practices in yoga provide relief from the discomfort
caused by varicose veins.
Positions which promote circulation and drainage of
blood from the legs: such as the
• Halasana (Plow pose)

• Savasana (Corpse pose)

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 • Ardha Sarvangasana (Half Shoulder pose)

Yoga asanas that place your head down and legs

above can for a temporary period reverse the blood
pooling that is related to varicose veins.
Deep-breathing exercises get more oxygen into the
blood stream and may decrease the discomfort caused
in varicose veins:
• Lie with your back on the floor.
• Keep your arms at your sides.
• Rest your feet above on a chair.
• Breathe deeply through your nose using the belly
breath.
This exercise has the following benefits:
• Gravity helps pull blood from your legs.
• The deep breathing creates a pull in your chest
cavity that also draws blood from the legs.
• This eases pain as fresh blood enters in the veins.

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 This exercise has to be done once a day for ten
minutes.
Viparita Karani: It is an exercise for varicose veins

•
•
•
•
•
•
• Lie with your back on the floor
• Raise your legs high against a wall.
The blood gets pushed to the heart with the help of
gravity. It should be done twice daily twice daily. Those
having back problems should check with their
practitioner before doing this exercise.
Other asanas for varicose veins: include the
Gomukhasana (Cow Face Pose)

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 Sirhasana (Head Stand Pose)

Pilates for varicose veins should also be done in

addition to yoga for added benefits.
Tips to help you relieve varicose veins:
• Avoid sitting (especially with your legs-crossed)
and standing for long periods of time as this can
worsen the symptoms of varicose veins.
• Folk remedies:
• Take a cloth and saturate it with apple cider vinegar.
Apply this to the varicose veins. This should be done
for 30 minutes twice a day. This should be followed
by drinking glass of water mixed with two teaspoons
of apple cider vinegar.
• Take 2 cups of chopped calendula stems, leaves
and flowers. Add this to an equal amount of melted
lard and stir .let this mixture stand for 24 hours.

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 Reheat and strain. Coat this mixture over varicose
veins and let it stand overnight.
• Take Marigold petals and boil it in water. Make
compresses of this liquid. Consume a few petals of
marigold daily. This therapy is believed to nourish
the veins and shrink the varicosities.
• Prepare a poultice of bruised cabbage leaves, rotten
apples, chopped brown onions, or a half-and-half
blend of cod liver oil and raw honey. Apply this
overnight. This is believed to heal varicose sores.
• Take 3 tablespoons of sugar and apple cider vinegar
and add them to a pint of warm water. Consume 2
ounces of this daily.
• Rub your legs with vinegar (full strength).then to
honey add two tablespoons of vinegar and mix it.

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Status
• General statistics of the disease:
• Up to 25% of women and 18% of men will suffer from
varicose veins.
• If both parents have varicose veins, your chances to
develop the disease are close to 90%.
• If one parent is affected, daughters have a 60%
chance while sons have a 25% chance of developing
the disease.
• 60% of leg ulcers are due to varicose veins.
• Left untreated, nearly 50% of patients will eventually
experience chronic venous insufficiency
• With leg exercise, almost 90% of venous blood in the
leg is pumped through the deep veins. Therefore,
exercise significantly helps
• 12% of patients will end up with long-term stockings
• International: There are many specialty clinics for this in the
developed countries. As far as research is concerned. In
2011, researchers from Germany reported in the printed
October issue of The FASEB Journal that a single protein
that binds to DNA to control gene function (called
"transcription factor AP-1") and causes the subsequent
production of a newly discovered set of proteins. It is this
set of proteins that significantly affect the development of
varicose veins. In the U.S.A, one in every 22 people suffers

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 and is like to be suffering from varicose veins. Women are
more likely to be affected than men.
According to the World Health Organization statistical
information system nearly 177 deaths per year occurred in
US, 152 deaths per year in Germany due to varicose veins.
According to W H O approximately 2% of western
population have primary varicose vein, women having 3 to
4 times more than men. The world prevalence of varicose
veins usually means the estimated population of people
who are managing varicose veins at a given time. Statistics
by country for prevalence of varicose veins is 45 per 1000.
It is approximated that 1 in 22 people or 12.2 million people
in U S A suffer from this disorder.
• National: In India varicose vein affect one out of 4 people
over age of 50. Varicose veins are more common in women
than men. According to one estimate, 15 to 20 per cent of
the population in India is suffering from Varicose vein
disease these days.
The list of of General Surgery Hospitals in India is as
follows :
• Apollo Hospitals Bangalore Apollo Hospitals, Bangalore,
India
• Apollo Hospital Chennai Apollo Hospital, Chennai,
India
• Apollo Hospitals Hyderabad Apollo Hospitals,
Hyderabad, India

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 • Apollo Hospitals Delhi Indra prastha Apollo
Hospital, Delhi, India
• Apollo Hospitals Kolkata Apollo Gleneagles Hospital,
Kolkata, India
• Apollo Hospital, Goa, India Apollo Hospital, Goa, India
• Wockhardt Hospital Bangalore India
• Wockhardt Hospital hyderabad, India
• Wockhardt Hospital Mumbai, India
• Wockhardt Hospital and Kidney Institute, Kolkata, India
• Fortis Hospital, Delhi, India Fortis Hospital, Delhi, India
• Fortis Hospital Mohali, India Fortis Hospital, Mohali, India
• Fortis Hospital Noida, India Fortis Hospital, Noida, India
• Manipal Hospital, Bangalore, India
• MIOT Hospital, Chennai, India
• Sparsh Hospital, Bangalore, India
• Narayana Cancer Hospital, Bangalore, India
• Artemis Hospital, Gurgaon ( Delhi ) , India Artemis
Hospital, Gurgaon ( Delhi ) , India
• Max Super Specialty hospital, Delhi, India Max Super
Specialty hospital, Delhi, India
• BGS Global Hospital Bangalore, India
• BGS Global Hospital Chennai, India
• BGS Global Hospital Hyderabad, India
These hospitals provide varicose ulcer treatment surgery and
varicose vein removal surgery.

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India also has various other alternative therapies like ayurveda,
yoga, etc. to treat the disease.
Research carried out:
Variants of a gene that leads to cells in blood vessels producing
too much of a protein heighten the risk of developing varicose
veins, according to a study carried out by a group of Indian
researchers.
An analysis of 6,350 hospital patients with varicose veins in
Kerala too showed that 85 per cent of them had a family history
for the condition.
The researchers decided to look at whether a gene known as
‘human forkhead box C2’ (FoxC2) could be involved. Why
because this gene is known to be important for blood vessel
development. Moreover, variants of this gene have been
implicated in another condition where many sufferers went on to
develop varicose veins.
For their study, the scientists examined blood and venous tissue
samples from those had varicose veins and compared it to
similar samples taken from people without the condition. They
found that cells from those with varicose veins showed changes
in the FoxC2 gene.
Changes that occurred at four places in the gene were found to
be significantly associated with the condition. Furthermore,
individuals carrying two or more of those changes in their
FoxC2 gene had a seven-fold greater risk than those with just
one change in that gene.

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Tests showed that FoxC2 protein levels were greatly elevated in
cells from varicosed veins. In another experiment, when
cultured venous cells were coaxed into producing excess
FoxC2 protein, genes associated with arterial development got
activated. Activation of these genes could be disrupting the
normal structure of veins, leading to changes characteristic of
varicose veins.
When a person with a high-risk variant of the FoxC2 gene was
faced with having to stand for lengthy periods, the vein in their
legs might not be able to adapt to the stress, leading instead to
changes that produced varicosity.

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Conclusion
There is no complete and proper understanding of cause
of the disease. There is no cure for the disease and way
to restore the veins elasticity yet or to repair their valves at
any rate or the replacement of the veins, but the
management of the symptoms and any possible infection
from ulcers and the removal or the blocking of the veins.
They have been new advancements in technology for
their treatment like the foam sclerotherapy and laser
ablation, clarivein, and sapheon glue system but the long
term effects of these treatments are not known. The best
option is still prevention is better than cure. The new
procedures are advancing more towards minimizing the
invasiveness of the procedure along with proper its
monitoring and visualization. Many treatment options often
the cheaper ones sacrifice the decrease in pain with cost
but with not much difference in healing time and recovery.
There is no cure for varicose veins which means that you
have to treat and monitor them on a regular basis. There
is always a chance that they will come back even in spite
of the newer forms of treatment such as endovenous laser
ablation.

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