Arteries are blood vessels which transport blood from the heart to our organs which veins transport blood from the organs back to the heart. Blood is prevented from flowing backwards by tiny valves along the veins which open and close to let blood through in one direction, namely back towards the heart. The veins of the lower limbs can be either superficial (just under the skin) and deep (under the muscle).

Varicose veins are swollen and enlarged superficial veins which develop when these small valves are damaged or don’t work properly.

Risk Factors

Factors which can increase your chances of developing varicose veins include:

  • female
  • older age
  • overweight
  • pregnancy
  • abdominal mass such as fibroids
  • having a job that involves long periods of standing

Symptoms and stages of varicose veins

Symptoms of varicose veins include pain which is usually described as heaviness or aching pain leg swelling, itchiness and dark pigmentation of the skin. Severe cases of varicose veins can lead to skin ulcer formation which are slow to heal. Complications include bleeding, deep vein thrombosis (DVT), thrombophlebitis (painful inflammation of the veins) and varicose eczema.

When do you need to see a doctor?

Do not wait until the varicose veins become so bad that it becomes difficult to treat. The earlier it gets treated, the higher the chances of a good outcome. It should be treated when there are symptoms such as itching, bleeding or swelling.

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What is an AVF / Dialysis Access?

A Dialysis Access is a place which is constructed to allow doctors and nurses to have easy access to your blood circulation during haemodialysis. It is constructed situated just under the skin usually on your arm or sometimes on your thigh.

There are 2 types of AVF / Dialysis Access

  1. Arterio-Venous Fistula

The surgery will increase the blood flow in the fistula resulting in an increase in the diameter of the vein and the thickness of the vein wall which is important for the maturation of the site. The time for maturation ranges from 6-9 weeks before it can be used. If the fistula fails to mature, an additional procedure (such as Fistuloplasty or Balloon Assisted Maturation) or open repair may be required.

  1. Graft

A graft is placed under the skin and it bridges the artery and the vein. Grafts do not require time for maturation and can be used after 2-3 weeks once the swelling has subsided. A graft may be required for patients with veins that are too small for fistula creation. The disadvantage of a graft is that it has a shorter lifespan than a fistula and has a higher rate of infection.

What happens before the surgery?

The surgery is usually performed as a day ward admission under local anaesthesia. The non-dominant arm is the preferred site. Your doctor will examine the blood vessels carefully and may also perform an ultrasound to choose the optimal site. Patients with diabetes, hypertension, heart failure or blood vessel disease may have poorer quality blood vessels to choose from.

What to expect after the surgery?

After surgery, it is advisable to keep the hand slightly elevated to reduce the swelling and take some analgesia to reduce any pain. The hand may feel slightly cold because blood may flow into the fistula resulting in less blood flow to the hand (known as ‘steal syndrome’). The wound care post-surgery includes the following:

  • Ensure the wound is dry for at least 3 days
  • Avoid lifting heavy objects exceeding 8kgs
  • Avoid compression or sleeping on the arm
  • Do some exercises like squeezing a soft ball to help healing and maturation

If there is excessive pain, swelling or bleeding, see your doctor as soon as possible

What are the possible complications?

The complications include narrowing of the vein, blood clots in the vein, swelling or aneurysm of fistula, wound infection and bleeding.

How to take care of the AVF / Dialysis Access?

Taking good care of your dialysis access is extremely important as it is the life line of all patients with kidney failure. See your doctor as soon as possible when you suspect there is a problem.

1) Check your fistula regularly. There is a buzz (‘thrill’) when the fistula is functioning properly

2) There is minimal bleeding after dialysis. If the bleeding is excessive or it takes longer than usual to stop, please inform your doctor, nurse or the dialysis staff

3) Try not to sleep on the arm with the fistula

4) The site of the fistula or graft must be kept clean at all times

5) Look out for signs of infection such as redness, swelling or pain

6) Do not wear tight clothing or jewelry which could block the fistula flow

7) Do not carry heavy objects using the hand with the fistula

8) Do not have blood or blood pressure taken from the arm with the fistula

9) Do not have any injections or drug infusions into the arm with the fistula

10) Do not apply any cream or lotion on the puncture site

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Peripheral arterial disease (PAD) occurs when there is a cholesterol plaque on the blood vessel walls causing them to narrow resulting in reduced circulation to the upper and more commonly lower limbs.

Who is at risk? 
It commonly affects people with type 2 diabetes especially when they have poor diabetic control. According to the American Diabetes Association, about 1 in 3 people with diabetes over the age of 50 have PAD. Other people at risk include smokers, older age, people with high cholesterol, overweight and having sedentary lifestyle with minimum or no exercise.

Symptoms and Signs
The symptoms depend on the extent of narrowing of the blood vessels.

Image Source: Kids Discover

  • Initially, there will numbness or pins & needles in your legs and feet
  • Pain in your calf muscle after walking a short distance or even at rest
  • Sores on your feet or toes which heal slowly
  • Hair loss on the legs with shiny skin appearance
  • Cold feet with weak pulse

Image Source: Medicine Net

  • Toes or feet turning blue-black (gangrene)

Claudication pain is a reproducible pain at the calf muscle brought on by walking to a certain distance and relieved with rest but returns once the patient walks to the same distance. The pain occurs when there is not enough blood circulation to the leg during exercise.

How to prevent PAD
You can reduce your risk of developing PAD by changing to a healthier lifestyle and this includes:

  • stopping smoking immediately
  • controlling your blood sugar level (if you have diabetes)

Image Source: The Samaja

Image Source: Heart and Vascular Care

It is extremely important to treat the causes of PAD (as well as PAD itself) because if left untreated, there is a very high chance of the person getting a stroke or heart attack in the next 5 years.

How is PAD diagnosed?
1. Measuring the ankle-brachial index which is the ratio of blood pressure in the feet compared to the arm blood pressure.
2. Doppler ultrasound to measure the flow rate in the blood vessels in the feet and toes.
3. CT Angiography.

Treatment of PAD
Treatment of PAD has to achieve 2 goals:
(a) treat underlying risk factors to prevent further cholesterol plaque blockage
(b) treat the leg symptoms to reduce pain and prevent progression to gangrene

1. Angioplasty and stent insertion
This is a minimally invasive procedure to widen the blood vessel narrowing and also to place a stent to prevent the blood vessel from blocking again.

2. Open endarterectomy
Endarterectomy is required to remove the cholesterol plaque if the PAD is severe or the plaque is hard and large. The artery is then closed using stitches or with a patch made of your own vein or synthetic graft.

3. Bypass surgery 
In cases where the blockage is long and very hard (calcified), bypass surgery may be required whereby a graft (made up of either your own vein or synthetic graft) is used to create a new passage to flow around the blockage to the feet.

Follow-up foot care
Lifelong close regular follow-up surveillance is essential for all patients with PAD as the disease may recur. In addition to the lifestyle changes, you must also invest time to take of your feet with the help of a podiatrist. This is because any sore or injury heals slowly which increases the risk of infection.

Image Source: Live Strong

  • Wash your feet daily, dry them thoroughly and moisturise regularly to prevent cracks which can lead to infection
  • Wear well-fitting shoes and dry socks to prevent fungus growth

Image Source: WebMD

  • Treat any fungal infections of the feet (such as athlete’s foot) quickly
  • Take care when cutting your nails
  • Never walk barefoot out in the garden or beach

Download Teleme’s mobile app and connect with a Vascular Surgeon if you experience symptoms of PAD, a Podiatrist for foot care and a Fitness Coach to help you reduce weight by going on a supervised exercise program



Treatment is necessary when there are symptoms of itching, bleeding or swelling. Type of treatment required depends of the severity of the varicose veins.

Health tips you can do by yourself when you have varicose veins

Mild or early stage varicose veins can be improved by:

  • doing regular exercise by brisk walking or light jogging daily
  • reducing your weight if you are over weight
  • elevating the affected leg when resting
  • avoiding crossing your legs when sitting
  • taking short breaks every 60 minutes of sitting to move your legs
  • using compression stockings during the day. These stockings are tight on the ankle (ankle pressure 20-30 mmHg) and squeeze the venous blood towards the heart when you walk. They improve calf muscle function, compress the varicose veins and reduce venous reflux. Stockings are useful for varicose veins which occur during pregnancy and for after varicose vein ablation, laser or surgery.

Click below to watch a video on how to measure for compression stockings

Click below to watch a video on how to put on compression stockings

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Treatment of varicose veins is necessary when there are symptoms of itching, bleeding or swelling.  Type of treatment required depends of the severity of the varicose veins.

A. Sclerotherapy.  This involves having sclerosant agents like Sodium Tetradecyl Sulphate injected (usually with ultrasound guidance) into the vein causing the veins to get obliterated.

Click below to watch a video on how Radio Frequency Ablation treats varicose veins

Source: Leg Veins 

B. Endogenous laser or radio frequency ablation uses laser heat or radio frequency waves respectively to seal off the affected veins.  Once the vein has been sealed shut, blood will then drain into the normal healthy veins in the legs.

Before laser treatment

After laser treatment

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Surgery for varicose veins may be required when conservative treatment does not work or when complications from varicose veins appear. These symptoms include:

  • Skin ulceration
  • Thrombophlebitis
  • Lipodermatosclerosis
  • Haemorrhage

Saphenous vein ligation and stripping is the classical way of treating varicose veins. In this method, the cause of the disease which is the vein with the defective valve is ligated (tied off). The tortuous veins are then either stripped out or avulsed (removed).

Click below to watch a video on how  varicose vein ligation and stripping is carried out

Source: Bupa Health UK Watch how varicose vein surgery is done

Photo of a varicose vein which has been successfully removed.

Post-surgery treatment care

Most patients can be discharged the same evening of the procedure or the next morning. There is no restriction to ambulation but vigorous activities should be avoided for at least 1 week. There could be some swelling, bleeding or bruising which usually resolves after a few weeks. Some doctors may advise you to use compression stockings for a short while after treatment.

Before surgery
After surgery
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