Patient Information and consent
Deep Vein Surgery
What is the Post thrombotic syndrome?
To understand what happens after a deep vein thrombosis it is necessary to understand
how blood flows in the veins of the legs.
The Normal leg and valves
In a normal leg, blood flows from the foot, back to the heart, through tubes called
veins. When you stand up, the blood is prevented from falling back to the ankle by a
series of one way valves in the deep veins and superficial veins.
The Calf muscle pump
In the calf muscle in each leg, there are many veins. As the muscle contracts, when
you walk, run, or move the foot, the muscle squeezes the veins and pumps the blood
in the vein back towards the heart. This is called the calf muscle pump. It is a bit like
a heart for the veins.
What happens when a clot forms in the deep vein?
This is called a deep vein thrombosis or DVT. Reduced flow in the vein, damage to
the wall of the vein or a thickening of the blood can cause blood to clot in the vein.
When this happens, no blood can flow through the vein. This means the leg can
become hot and swollen as the venous blood can only get back to the heart through
small channels.
An analogy would be a dam being built across a river bed. The fields that drain into
the river would become flooded or water-logged ( the swelling of the leg). The fields
can only drain through other streams away from the river.
In time, and this varies, the small channels gradually enlarge to carry more of the
blood. This is why some people who have had a DVT can develop prominent veins.
Some people think these might be varicose veins. If the valves in these veins are
working normally, then removing them can make the leg worse. This is why anyone
who is going to have varicose vein surgery after a DVT should have a Duplex scan.
As the small channels enlarge, the leg swelling can reduce.
At the same time, several things can happen to the veins that were affected by the
DVT. The human body is good at clearing thrombus by a process called thrombolysis.
If all the thrombus is cleared then the deep veins may be undamaged. In many people
who have had a DVT, the thrombus leaves scars within the vein. This scarring can
damage the valves and narrow the diameter of the veins.
What problems does scarring of the veins cause?
Aching legs and swollen legs.
If the valves in the deep veins are damaged then blood runs in the wrong direction,
towards the ankle. This puts extra pressure on the ankle's blood vessels which means
the leg can swell. Many people with this problem of incompetent deep veins ( valves
that do not work) have pain in their leg when they stand up. The pain can get worse as
the day continues. They only get relief when they lie down again.
Some people have a feeling of a rush of blood into the calf when the deep veins are
incompetent.
Failure of the calf pump.
The scarring of the veins can narrow their diameter. This means the calf muscle can
only pump small amounts of blood out of the leg. This makes it difficult to pump the
blood from the leg.
When the incompetent valves and failed calf pump are combined, the leg can become
increasingly swollen and painful. This condition is the Post-Thrombotic or PostPhlebitic Syndrome.
What can happen if I develop the Post-Thrombotic Syndrome?
Apart from the aching and swelling of the leg, there can be changes in the colour of
the skin of the leg. Ultimately, the skin of the leg can become so damaged that an
ulcer develops.
The leg can change in appearance to look a little like an upside down champagne
bottle.
Can anything be done to help?
The most important thing to do is to prevent the deep vein thrombosis in the first
place.
When a DVT has occurred, it may be possible to remove the thrombus by dissolving
it or removing it surgically. Most doctors will, however, suggest that the DVT is
treated by anticoagulation ( thinning of the blood) with an injection called heparin or a
tablet called warfarin.
If you have the post-thombotic syndrome, you will have been advised to wear some
form of compression stocking. These can help the swelling and pain.
Some patients cannot or do not want to wear stockings. For these patients it may be
possible to correct the deep vein problems with an operation.
What are the Benefits of Deep Vein Surgery?
If the operation is successful, you should be able to stand without a feeling of
heaviness in the leg. If you have an ulcer, there is a greater chance that it will heal and
stay healed. Any swelling of the ankle should reduce and you may be able to walk
more easily.
You have been given this information sheet as you are thought to be suitable for deep
vein surgery.
Are there alternatives to surgery?
You may have already tried wearing special compression stockings. If not, this is the
only alternative to surgery.
What will happen if I decide not to have the operation for my deep veins?
You will have to continue as you are. If you are not using compression stockings, you
will be advised to wear them.
What does the operation involve?
A variety of anaesthetic techniques are possible. Your anaesthetist will discuss the
options with you and will recommend what they think is best for you.
Your surgeon will make a cut in your groin over the common femoral vein. They may
make other cuts on your leg depending on the results of your tests (Duplex scan,
plethysmography and venography).
Your surgeon will use part of a vein in your leg to build a new valve or move an
existing valve. The aim is to stop the blood in the vein from passing in the wrong
direction as it does now.
At the end of the operation, your surgeon will close the skin with stitches or clips.
After the operation you will need to lie in bed for 3 days with your leg raised. You
will be started on a medicine called warfarin to thin the blood. When the level of
warfarin is correct and you are comfortable, you will go home. This is usually 5 to 10
days after the operation. If you cannot take Warfarin, other medicines can be given
using injections.
What risks or complications can happen?
We try to make sure your operation is safe. This may include prescribing medicines to
reduce the riks of complications. Most operations are successful with few
complications.
However, every procedure has risks and potential complications. Those most relevant
to this operation are listed below. Please discuss them with your doctor if there is
anything you do not understand.
The risks and complications fall in to 3 categories:
1.
2.
3.
Complications of anaesthesia
General Complications of any operation
Specific Complications of deep vein surgery.
The specific complications of deep vein surgery include:
Deep vein thrombosis can occur if the blood clots at the site of the operation. You
will be given blood-thinning medicines called Heparin and Warfarin to reduce the risk
of this happening. You will need to take the Warfarin ( or injections) for 3 months.
This might affect any medicines you take and your alcohol consumption.
Swelling of the leg can occur for a few weeks because the glands in the groin may be
damaged ( Lymphatics). Rarely the swelling can be permanent.
Neuralgia and pain can occur if the femoral nerve is damaged in the groin. This
usually gets better on its own. Sometimes medicine or an operation is required to help
the pain of the neuralgia
Fluid collection under the wound (seroma), which leads to a continued leak of fluid.
This usually settles with time.
Loss of the leg can occur if the operation fails to work or makes the condition of the
leg worse. This is highly unlikely but theoretically possible. You need to consider
how bad your symptoms are and whether you wish to take this very small risk.
How soon will I recover?
After the operation you will be transferred to the recovery room and then to the ward.
You will be able to drink and eat after the anaesthetic wears off. You will be given
painkillers to control the pain and keep you comfortable. Most patients stay in
hospital for 5 to 10 days. However, your doctor may recommend that you stay a little
longer.
Returning to normal activities
Your surgeon will advise when you can resume normal activities.
Are the benefits and risks of deep vein surgery clear?
No, they are not. Most of the procedures used in the NHS are not new, and we have
learnt how well they work and what risks they have. Some procedures, like deep
venous surgery, are too new to have all the information we need. We are not yet sure
just how much benefit deep vein surgery can give and which patients get the most
from the operation. We know the short-term results of some of the operations but not
the long-term ones. Research has shown that some forms of deep vein surgery ( New
Valve construction) work well after one year. Other types of deep vein surgery
(transposition and valvuloplasty) continue to work after 5 years in half of the patients
who have been treated.
All procedures have side effects and risks. It may take some time to discover exactly
what the problems are with Deep vein Surgery and how common they are.
It may be right to choose a procedure for which the benefits and risks are uncertain if
doctors think it is likely to help a patient, and the patient agrees, knowing the
outcomes are uncertain – but we must take special care when we have not got all the
answers about the procedure. This is the case for deep vein surgery.
Who decides about the use of deep venous surgery?
The National Institute For Clinical Excellence (NICE) can help. NICE is part of the
NHS, and its role is to provide patients, health professionals and the public with
guidance on treatment and care for people using the NHS. As part of its work, NICE
looks into new procedures which have been notified to it and decides whether we
know enough about how well they work, and how safe they are, to use them routinely.
NICE was asked about Deep Venous Surgery by the Nottingham Surgeons, in 2005.
Further Information
You can get more information from:
Patient Advice and Liason service (PALS) on 0800 123 0204
Mr Braithwaite’s web site: www.bdb.org.uk
NICE: www.nice.org.uk