Varicose veins are veins that have become enlarged and tortuous.
The term commonly refers to the veins on the leg, although varicose veins can occur elsewhere.
Veins have leaflet valves to prevent blood from flowing backwards.
Leg muscles pump the veins to return blood to the heart, against the effects of gravity.
When veins become varicose, the leaflets of the valves no longer meet properly, and the
valves do not work.
This allows blood to flow backwards and they enlarge even more.
Varicose veins are most common in the superficial veins of the legs, which are subject to high
pressure when standing.
Besides being a cosmetic problem, varicose veins can be painful, especially when standing.
Severe long-standing varicose veins can lead to leg swelling, venous eczema, skin thickening
and ulceration.
Life-threatening complications are uncommon, but varicose veins may be confused with deep
vein thrombosis, which may be life-threatening.
Non-surgical treatments include sclerotherapy, elastic stockings, elevating the legs, and
exercise.
The traditional surgical treatment has been vein stripping to remove the affected veins.
Newer, less invasive treatments which seal the main leaking vein are available.
Alternative techniques, such as ultrasound-guided foam sclerotherapy, radiofrequency ablation
and endovenous laser treatment, are available as well.
Because most of the blood in the legs is returned by the deep veins, the superficial veins,
which return only about 10% of the total blood of the legs, can usually be removed or ablated
without serious harm.
Secondary varicose veins are those developing as collateral pathways, typically after stenosis
or occlusion of the deep veins, a common sequel of extensive deep venous thrombosis.
Treatment options are usually support stockings, occasionally sclerotherapy, and rarely limited
surgery.
Varicose veins are distinguished from reticular veins and telangiectasias, which also involve
valvular insufficiency, by the size and location of the veins.
Many patients who suffer with varicose veins seek out the assistance of physicians who
specialize in vein care or peripheral vascular disease.
These physicians include vascular surgeons, phlebologists or interventional radiologists.
Signs and symptoms Aching, heavy legs.
Appearance of spider veins in the affected leg.
Ankle swelling, especially in evening.
A brownish-yellow shiny skin discoloration near the affected veins.
Redness, dryness, and itchiness of areas of skin, termed stasis dermatitis or venous eczema,
because of waste products building up in the leg.
Cramps may develop especially when making a sudden move as standing up.
Minor injuries to the area may bleed more than normal or take a long time to heal.
In some people the skin above the ankle may shrink because the fat underneath the skin
becomes hard.
Restless legs syndrome appears to be a common overlapping clinical syndrome in patients
with varicose veins and other chronic venous insufficiency.
Whitened, irregular scar-like patches can appear at the ankles.
This is known as atrophie blanche.
Clinical Tests Clinical tests that may be used include:
Trendelenburg test Fegan's test
Perthe's test Multiple tornique test
Investigations Traditionally, varicose veins were only investigated
using imaging techniques if there was a clinical suspicion of deep venous insufficiency, if
they were recurrent, or if they involved the sapheno-popliteal junction.
This practice is not now widely accepted.
All patients with varicose veins should now be investigated using Duplex doppler ultrasound
scanning.
The results from a randomised controlled trial on the follow up of patients with and without
routine Duplex scan has shown a significant difference in recurrence rate and reoperation
rate at 2 and 7 years of follow up.
. Complications
Most varicose veins are reasonably benign, but severe varicosities can lead to major
complications, due to the poor circulation through the affected limb.
Pain, tenderness, heaviness, inability to walk or stand for long hours, thus hindering
work Skin conditions / Dermatitis which could predispose
skin loss Skin ulcers especially near the ankle, usually
referred to as venous ulcers.
Development of carcinoma or sarcoma in longstanding venous ulcers.
There have been over 100 reported cases of malignant transformation and the rate is reported
as 0.4% to 1%.
Severe bleeding from minor trauma, of particular concern in the elderly.
Blood clotting within affected veins.
Termed superficial thrombophlebitis.
These are frequently isolated to the superficial veins, but can extend into deep veins becoming
a more serious problem.
Acute fat necrosis can occur, especially at the ankle of overweight patients with varicose
veins.
Females are more frequently affected than males.
Stages C0 no visible or palpable signs of venous
disease C1 telangectasia or reticular veins
C2 varicose veins C3 edema
C4a skin changes due to venous disorders: pigmentation, eczema
C4b skin changes due to venous disorders: lipodermatosclerosis, atrophie blanche
C5 as C4 but with healed ulcers C6 skin changes with active ulcers
Causes
Varicose veins are more common in women than in men, and are linked with heredity.
Other related factors are pregnancy, obesity, menopause, aging, prolonged standing, leg
injury, and abdominal straining.
Varicose veins are unlikely to be caused by crossing the legs or ankles.
Less commonly, but not exceptionally, varicose veins can be due to other causes, as post
phlebitic obstruction or incontinence, venous and arteriovenous malformations
Varicose veins could also be caused by hyperhomocysteinemia in the body, which can degrade and inhibit
the formation of the three main structural components of the artery: collagen, elastin
and the proteoglycans.
Homocysteine permanently degrades cysteine disulfide bridges and lysine amino acid residues
in proteins, gradually affecting function and structure.
Simply put, homocysteine is a 'corrosive' of long-living proteins, i.e. collagen or
elastin, or lifelong proteins, i.e. fibrillin.
These long-term effects are difficult to establish in clinical trials focusing on groups with
existing artery decline.
See also for differential diagnosis- 1.
Klippel-Trenaunay syndrome, 2.
Parkes-Weber syndrome Treatment
Conservative The symptoms of varicose veins can be controlled
to an extent with the following: Elevating the legs often provides temporary
symptomatic relief.
Advice about regular exercise sounds sensible but is not supported by any evidence.
The wearing of graduated compression stockings with variable pressure gradients has been
shown to correct the swelling, nutritional exchange, and improve the microcirculation
in legs affected by varicose veins.
They also often provide relief from the discomfort associated with this disease.
Caution should be exercised in their use in patients with concurrent arterial disease.
The wearing of intermittent pneumatic compression devices have been shown to reduce swelling
and increase circulation Diosmin/Hesperidine and other flavonoids.
Anti-inflammatory medication such as ibuprofen or aspirin can be used as part of treatment
for superficial thrombophlebitis along with graduated compression hosiery – but there
is a risk of intestinal bleeding.
In extensive superficial thrombophlebitis, consideration should be given to anti-coagulation,
thrombectomy or sclerotherapy of the involved vein.
Topical gel application, helps in managing symptoms related to varicose veins such as
inflammation, pain, swelling, itching and dryness.
Topical application-Non invasive and has patient compliance.
Active Active medical intervention in varicose veins
can be divided into surgical and non-surgical treatments.
Some doctors favor traditional open surgery, while others prefer the newer methods.
Newer methods for treating varicose veins such as Endovenous Thermal Ablation, and foam
sclerotherapy are not as well studied, especially in the longer term.
Surgical Several techniques have been performed for
over a century, from the more invasive saphenous stripping, to less invasive procedures like
ambulatory phlebectomy and CHIVA.
Stripping Stripping consists of removal of all or part
the saphenous vein main trunk.
The complications include deep vein thrombosis, pulmonary embolism, and wound complications
including infection.
There is evidence for the Great Saphenous Vein growing back again after stripping.
For traditional surgery, reported recurrence rates, which have been tracked for 10 years,
range from 5–60%.
In addition, since stripping removes the saphenous main trunks, they are no longer available
for use as venous bypass grafts in the future Other
Other surgical treatments are: Ambulatory phlebectomy
Vein ligation Cryosurgery- A cryoprobe is passed down the
long saphenous vein following saphenofemoral ligation.
Then the probe is cooled with NO2 or CO2 to a temperature of −85o.
The vein freezes to the probe and can be retrogradely stripped after 5 second of freezing.
It is a variant of Stripping.
The only point of this technique is to avoid a distal incision to remove the stripper.
Non-surgical treatment Sclerotherapy management
A commonly performed non-surgical treatment for varicose and "spider" leg veins is sclerotherapy
in which medicine is injected into the veins to make them shrink.
The medicines that are commonly used as sclerosants are polidocanol, sodium tetradecyl sulphate,
Sclerodex, Hypertonic Saline, Glycerin and Chromated Glycerin.
STS and Polidocanol liquids can be mixed at varying concentrations of sclerosant and varying
sclerosant/gas proportions, with air or CO2 or O2 to create foams.
Foams may allow more veins to be treated per session with comparable efficacy.
Their use in contrast to liquid sclerosant is still somewhat controversial.
Sclerotherapy has been used in the treatment of varicose veins for over 150 years.
Sclerotherapy is often used for telangiectasias and varicose veins that persist or recur after
vein stripping.
Sclerotherapy can also be performed using foamed sclerosants under ultrasound guidance
to treat larger varicose veins, including the great saphenous and small saphenous veins.
A study by Kanter and Thibault in 1996 reported a 76% success rate at 24 months in treating
saphenofemoral junction and great saphenous vein incompetence with STS 3% solution.
A Cochrane Collaboration review concluded sclerotherapy was better than surgery in the
short term for its treatment success, complication rate and cost, but surgery was better after
5 years, although the research is weak.
A Health Technology Assessment found that sclerotherapy provided less benefit than surgery,
but is likely to provide a small benefit in varicose veins without reflux.
This Health Technology Assessment monograph includes reviews of the epidemiology, assessment,
and treatment of varicose veins, as well as a study on clinical and cost effectiveness
of surgery and sclerotherapy.
Complications of sclerotherapy are rare but can include blood clots and ulceration.
Anaphylactic reactions are "extraordinarily rare but can be life-threatening," and doctors
should have resuscitation equipment ready.
There has been one reported case of stroke after ultrasound guided sclerotherapy when
an unusually large dose of sclerosant foam was injected.
Endovenous thermal ablation The Australian Medical Services Advisory Committee
in 2008 has determined that endovenous laser treatment/ablation for varicose veins "appears
to be more effective in the short term, and at least as effective overall, as the comparative
procedure of junction ligation and vein stripping for the treatment of varicose veins."
It also found in its assessment of available literature, that "occurrence rates of more
severe complications such as DVT, nerve injury and paraesthesia, post-operative infections
and haematomas, appears to be greater after ligation and stripping than after EVLT".
Complications for ELA include minor skin burns and temporary paraesthesia.
The longest study of endovenous laser ablation is 39 months.
Two prospective randomized trials found speedier recovery and fewer complications after radiofrequency
ablation compared to open surgery.
Myers wrote that open surgery for small saphenous vein reflux is obsolete.
Myers said these veins should be treated with endovenous techniques, citing high recurrence
rates after surgical management, and risk of nerve damage up to 15%.
In comparison, ERA has been shown to control 80% of cases of small saphenous vein reflux
at 4 years, said Myers.
Complications for ERA include burns, paraesthesia, clinical phlebitis, and slightly higher rates
of deep vein thrombosis and pulmonary embolism.
One 3-year study compared ERA, with a recurrence rate of 33%, to open surgery, which had a
recurrence rate of 23%.
ELA and ERA require specialized training for doctors and expensive equipment.
ELA is performed as an outpatient procedure and does not require the use of an operating
theatre, nor does the patient need a general anaesthetic.
Doctors must use high frequency ultrasound during the procedure to visualize the anatomical
relationships between the saphenous structures.
Some practitioners also perform phlebectomy or ultrasound guided sclerotherapy at the
time of endovenous treatment.
Follow-up treatment to smaller branch varicose veins is often needed in the weeks or months
after the initial procedure.
See also Saphena varix
Varicocele References
External links American College of Phlebology site for the
PUBLIC Society for Vascular Surgery
American College of Phlebology Canadian Society of Phlebology