What are surface blood clots?

The current term for surface blood clots is superficial vein thrombosis (SVT). The terms phlebitis or superficial thrombophlebitis are also common. Surface blood clots are a common condition affecting up to 57% of patients with varicose veins. They may also affect some patients without varicose veins but prone to blood clots and those with cancer or having had recent surgery. SVT often develops and appears as an inflamed and painful area on the skin.

When SVT affects the main surface veins of the leg, rather than a small side-branch, it can be serious, with a higher risk of deep vein thrombosis (DVT). Blood clots caused by a DVT may break off and travel to the lungs, resulting in a life-threatening (pulmonary embolism, PE). Diagnosis of a serious SVT increases the risk of DVT and PE.

 

 

Investigation of surface blood clots

Ultrasound scan of the area affected by the SVT will confirm the diagnosis, determining whether the blood clot has extended to the deep veins as a DVT. When the blood clot is in the thigh portion of the main surface veins, and greater than 5cm in length, there is a higher risk of developing a DVT and PE. This risk may be as high as 20% if left untreated. Further attacks of SVT may occur in up to 10% of people, making treatment of the underlying condition, such as varicose veins, important. 1

 

 

 

Treatments

 

Blood thinners

Treatment of serious SVT has changed over the years. From simple pain relief, to urgent surgery and now the use of blood thinners. Blood thinners, such as Warfarin, Clexane, Pradaxa and Rivaroxaban, reduce the risk of blood clots progressing and DVT, PE and SVT from recurring. Each of the blood thinners has specific benefits and disadvantages. A patient’s general practitioner (GP) will usually prescribe a blood thinner, selecting the one most suited to the patient. In general, the course length of blood thinners for SVT is 4 to 6 weeks.

In New Zealand, Rivaroxaban is now one of the most commonly used tablet blood thinners. Patients with kidney impairment, those who are pregnant or breast feeding and some other groups of patients, cannot take Rivaroxaban and will need an alternative. A patient’s GP will recommend a suitable alternative.

 

 

Anti-inflammatories for surface blood clots

SVT causes painful inflammation within the affected vein, and as such, patients may get significant benefit from regular use of anti-inflammatories, such as Ibuprofen (Neurofen). Some patients cannot take anti-inflammatories because they can affect kidney function or interfere with other medications. A patient’s GP will advise on alternative medications.

Topical anti-inflammatory creams or Hirudoid cream, can also provide some symptom relief.

 

 

Compression stockings

Following an SVT, compression stockings are important to support the affected leg and reduce the risk of further blood clots. Medical-grade stockings, fitted by someone trained in correct sizing, are best. Over-the-counter or sports compression stockings may not have adequate compression, as they are often designed for sport.

A follow-up ultrasound scan is usually done after the blood thinners stop and as a result of this update, the status of the blood clot and remaining veins becomes clear, allowing for planning of definitive varicose veins treatment.

 

 

Varicose veins treatment

 

 

Following a surface blood clot, any remaining varicose veins need treatment to stop recurrent blood clots. Standard minimally invasive treatments for varicose veins result in minimal discomfort and down time following treatment.

 

 

Current varicose vein treatments – Venaseal vs laser

Varicose vein treatments are now minimally invasive, leading to excellent outcomes when compared to surgical stripping. Patients can expect safer treatments, resulting in less discomfort, and importantly, a quicker return to work or other normal activities. 1

There are two types of minimally invasive treatments, comprising heating or non-heating methods. Laser (EVLT) and radio frequency (RFA) are examples of heating methods and Venaseal is an example of a non-heating method. In general, the heating treatments require numbing to protect the skin and surrounding nerves from heat damage, and the non-heating treatments do not require numbing, leading to improved comfort.

 

Varicose vein treatments: Venaseal vs laser

VenaSeal is a non-heating treatment that eliminates the risk of damage to skin and nerves in the vicinity of the varicose veins. It is safe and effective when compared to the heating methods of treatment.

VenaSeal uses small quantities of medical-grade sealant to seal the abnormal veins that give rise to the varicose veins.  The specialist monitors application of the sealant along the vein with ultrasound. As the vein being treated is abnormal, it serves no useful purpose and sealing it off is safe. Blood automatically re-routes to healthy veins.

 

Click here to see the Venaseal non-heat closure system in action.

Recent studies show that VenaSeal treatment is highly effective, with improved quality of life scores and durability. This minimally invasive treatment allows patients to return to normal activities more quickly. In addition, patients can walk immediately after the procedure and can do light activities over the next day or so, gradually increasing these activities until they are back to doing their normal amount of activity. 2,3

 

 

 

 

Investigations

Before treatment with VenaSeal, patients will need an ultrasound scan to determine the cause of their varicose veins. An ultrasound technician, called a sonographer, performs the ultrasound scan, viewing and recording the pictures of a patient’s veins. The ultrasound scan takes about 30-60 minutes, depending on complexity and whether the scan is of one or two legs.

 

 

 

After varicose veins treatment

After varicose veins treatment, patients wear thigh-high compression stockings. It is important that the patient wears these continuously for 10 days, including while sleeping and while in the shower. Plastic shower protectors are popular but It is okay for the stockings to get wet, taking about an hour to dry. Wearing compression stockings after varicose veins treatment helps to minimise any bruising or swelling that may occur afterwards and additionally provides support to the treated areas.

 

All of the minimally invasive treatment methods, like most medical treatments, carry a small risk of complications. There is a small risk of deep vein thrombosis (DVT) requiring blood thinners, and additionally, a small risk of wound infection requiring antibiotics.

Sometimes iron may be released from blood in the treated veins and as a result this may settle in the skin causing discolouration. This can be unsightly but will usually diminish over 3-12 months as absorption of the iron occurs. Treatment with fading creams can improve discolouration and additionally, skin laser may help improvement.

For the heating treatments, skin and nerve damage are possible complications. For VenaSeal, there is a small risk of allergic reaction to the medical sealant. A 2021 study found a 4% risk of this. Treatment for an allergic reaction is with anti-inflammatories for a short time. 4

 

 

 

 

Lipoedema (lipohyperplastic dolorosa) is an abnormal accumulation of painful fat in the legs and occasionally in the arms. It usually affects both sides symmetrically and spares the feet and hands. The torso is also relatively spared. It is a longstanding condition that mostly affects women, starting at puberty or other times of hormonal change, such as in pregnancy and menopause.

Misdiagnosis of lipoedema for leg swelling and obesity, oedema or lymphoedema is common. As a result of this, sufferers may embark on an incorrect treatment pathway, such as weight loss surgery. While all of these conditions may be present at the same time to differing degrees, it is recognised as a distinct condition, with its own set of specific treatments.

Sufferers face significant societal barriers because the condition is often misinterpreted as obesity. They often experience weight stigma 1, which may lead to stress, generally poorer health outcomes and reduced levels of productivity.

 

What is the cause?

The cause remains unclear but it runs in the female members of families and may affect up to 1 in 12 women. One of the main features is discomfort and pain, which often does not match the degree of abnormal fat tissue.

At a cellular level, lipoedema sufferers have a lot more fat cells. For obesity sufferers, the fat cells are larger but often the number of fat cells is normal.

 

 

 

Lipoedema diagnosis or fat in the legs?

Body appearance, pain symptoms and the pattern of development over time, all determine the diagnosis of lipoedema. Commonly reported symptoms include pain, pressure sensitivity and a tendency to bruise.

There are three stages of lipoedema, based on physical appearance:

 

• the legs are slim but painful
• legs appear thicker and are painful, with an uneven, wave-like skin surface
• the legs are painful, with bulky, drooping fatty tissue. Sufferers often report increasing difficulties in performing daily tasks, owing to pain and physical limitations.

 

 

 

Investigations

An ultrasound scan is a useful aid to diagnosis. It can distinguish between other causes of leg swelling, such as oedema or lymphoedema. The scan will show a diffuse and consistent deposition of fat under the skin affecting both legs.

 

 

 

 

Treatment

Treatment of lipoedema generally falls into three categories: massage, compression stockings and liposuction.

A qualified massage therapist should perform this where possible. Compression stockings support the legs and reduce any swelling. They can unfortunately make the pain symptoms worse.

Liposuction reduces the increased number of fat cells found in lipoedema but it may not reduce the associated pain symptoms. In some patients undergoing liposuction, any significant varicose veins may need treatment to avoid bleeding during the liposuction procedure.

 

 

 

 

What are spider veins?

Spiders veins and telangiectasias are small veins and arteries that are visible on the skin. Telangiectasias are very small spider veins. They are common and affect more than half of women by the age of 50 years. They are unsightly but may also cause symptoms like throbbing, aching, itching, and burning. Bleeding can also occur, often from the ankles and feet. Men also get spider veins but unsightliness is often less of a concern.

For many women, spider veins may affect self-esteem, leading to increased self-consciousness with clothes and avoiding activities involving leg exposure. This affects self-confidence and may cause someone to feel older or less attractive.

The main methods of medical treatment are sclerotherapy and skin laser. Both are low risk and can achieve very good results (see below for more detail). Non-medical options include concealing creams.

 

 

 

 

What is my spider vein risk?

The risk factors are family history, varicose veins in the family, age, being female, prolonged sitting or standing, obesity, lack of activity and local trauma, including previous surgery. Sometimes the cause of spider veins is due to other medical conditions.

Having spider veins and varicose veins in the family is the main risk factor. There is also a strong connection with pregnancy, the contraceptive pill and hormone replacement therapy. Skin damage from sun exposure can also lead to telangiasias on the face. These are often called facial veins.

 

 

Facial veins are often bright red and can have a line or star-like appearance. Spider veins on the legs often have underlying varicose veins feeding them from multiple points. Star-like facial veins arise from a central feeding vessel.

 

 

In many people, the cause of spider veins is related to underlying varicose veins. Varicose veins cause increased pressure within the small skin veins, leading to gradual enlargement over time.

 

 

Spider veins and telangiectasias also commonly occur in the absence of varicose veins. In these cases, the cause relates to other factors, such as sun damage, trauma, including previous surgery, or female hormones.

 

 

What tests will I need for spider veins?

Investigation usually involves an ultrasound scan of the leg veins to determine whether there are underlying varicose veins, as these may need treatment first.

 

 

 

What are the treatments for spider veins?

Treatment involves sclerotherapy, usually followed by skin laser.  In sclerotherapy, a fine needle is introduced into the vein and a small amount of an irritant agent is injected into the spider veins, causing them to block off. Sclerotherapy is often performed with magnifying glasses and the use of ultrasound guidance (UGS).

Polidocanol and Sodium Tetradecyl Sulphate (STS) are common irritant agents. They act by damaging the wall of the vein, causing it to seal and eventually diminish over time. Both of these irritant agents are approved for use in New Zealand by Medsafe.

Following the procedure, patients need to wear compress stockings for 5-10 days, depending on the veins number and size and any other veins needing attention. The interval for skin laser is usually 6-8 weeks. For some people, skin laser may be the only treatment needed.

 

 

 

What about the results?

The aim of most treatments is to improve appearance, and it is important to understand the treatment will not eliminate all visible veins. Individual results also tend to vary. Sometimes people need several sessions of both sclerotherapy and skin laser to achieve an optimum result.

As with any procedure, there is always a risk of a complication or poor outcome afterwards. Allergic reactions can occur with sclerotherapy using Polidocanol and STS. Fortunately, these are very uncommon. When there is suspicion a person may be at higher risk of an allergic reaction, a test dose of the irritant agent can determine any risk.

Brownish discolouration of the skin relates to the accumulation of iron released from the blood in the treated veins. It is more likely to occur with bigger veins, lack of adequate compression after the procedure, sun exposure after the treatment and in patients with a history of discolouration. All skin types, colours and tones are susceptible. Fortunately, most cases will resolve after 3-12 months. About 1% to 2% of patients will have persistent discolouration, where it persists for more than a year. Skin creams such like Dermaka can useful to hasten fading.1

 

 

Compression Stockings and Post-thrombotic Syndrome (PTS)

Leg swelling, venous eczema, skin discolouration with thickening, and leg ulcers, occur in about 20-50% of patients who develop deep vein thrombosis (DVT). This cluster of changes, which often occurs gradually over several years, is called post-thrombotic syndrome (PTS). The cause of PTS is failure of blood to return efficiently to the heart after a DVT has blocked or damaged the deep veins of the legs. These vein valves keep blood flowing towards the heart, even while standing. Compression stockings play an essential role in maintaining blood flow towards the heart, and subsequently reducing the risk of PTS.

 

PTS symptoms caused by swelling, such as aching and heaviness, reduce a patient’s quality of life. Everyday activities, like walking and standing, become difficult and painful. As bending is difficult, simple actions like getting dressed and other everyday tasks take longer. Patients may withdraw from their normal social and family activities and may show signs of lowered mood as their condition deteriorates and their self-confidence deteriorates. If their condition worsens, some patients might need extra help to cope with their everyday activities, like showering, dressing and preparing food. This places a greater burden on health services and the economy as patients also seek care in the public health system.

 

 

There is controversy as to whether compression stockings can prevent the venous eczema, pigmentation and ulceration that may occur several years after a DVT 1. Recent studies have shown that wearing compression stockings regularly after a DVT can help to prevent these skin problems developing, and improve an individual’s quality of life 2.

 

Investigations

An ultrasound scan, performed by a technician called a sonographer, is the next step in confirming the diagnosis of DVT. This can also confirm blockage or failure of the deep vein valves, and subsequently determine firstly the risk of developing PTS, and secondly the usefulness of long term compression stockings. An ultrasound scan of the leg arteries is also often useful for compression stockings planning purposes.

 

 

 

 

 

 

Treatments

Treatment of DVT in the early stage usually involves blood thinners, such as Warfarin and Rivaroxaban. In some large DVTs affecting the leg and pelvic veins together, a clot-dissolving treatment called thrombolysis can be effective. The purpose of blood thinners is prevention of more blood clots, and detachment with travel to the lungs. This is a serious and sometimes life-threatening condition called pulmonary embolism.

 

 

Compression Stockings

 

 

Properly fitted compression stockings reduce leg swelling caused by DVT, and other causes such as varicose veins and lymphoedema. Compression stockings aid circulation and increase by controlling the build-up of swelling during the day.

People who work in standing occupations, particularly those who are prone to leg swelling will gain significant benefit from wearing well-fitted stockings. Even people who do not have any problems with leg swelling will get benefit from the regular use of compression stockings, as they support legs throughout the day.

 

Where can I get compression stockings?

 

Vascular specialists recommend that a vascular nurse or other allied health professional measures and fits the compression stockings. The correct fit is important for the best results in terms of comfort and effectiveness. Once wearing them in everyday life, a patient may find a pair of rubber gloves useful to apply the stockings. Custom made rubber gloves, with grips on the palms and fingers are also available. This is especially helpful for patients with poor strength in their fingers. Other aids include fixture glue, which helps to keep the stockings up. Medical fixture glue is specially formulated for use on sensitive skin, especially the skin on the thigh area, as this is where the stockings are most likely to sag.

Stockings fitting appointments are available in any of our clinics. Compression stockings (to the knee) are available in our online shop.