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
elsewhereVarices in general refers to distended veins. It derives from the Latin word for twisted, "varix".Types of varices include:* Varicose veins of lower extremities* Gastrointestinal varices** Esophageal varices** Gastric varices** Intestinal varices...
. Veins have leaflet valves to prevent blood from flowing backwards (retrograde). 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 don't 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 cosmetic problems, varicose veins are often painful, especially when standing or walking. They often itch, and scratching them can cause ulcers. Serious complications are rare. Non-surgical treatments include
sclerotherapySclerotherapy is a procedure used to treat blood vessels or blood vessel malformations and also those of the lymphatic system. A medicine is injected into the vessels, which makes them shrink. It is used for children and young adults with vascular or lymphatic malformations. In adults,...
, elastic stockings, elevating the legs, and exercise. The traditional surgical treatment has been
vein strippingVein stripping is a surgical procedure done under general or local anaesthetic to remove varicose veins. The surgery involves making one or more incisions upon the desired area followed by insertion of a special wire into the vein. The wire is tied to and advanced through the vein to a desired...
to remove the affected veins. Newer, less invasive treatments, such as ultrasound-guided foam
sclerotherapySclerotherapy is a procedure used to treat blood vessels or blood vessel malformations and also those of the lymphatic system. A medicine is injected into the vessels, which makes them shrink. It is used for children and young adults with vascular or lymphatic malformations. In adults,...
,
radiofrequency ablationRadio frequency ablation is a medical procedure where part of the electrical conduction system of the heart, tumor or other dysfunctional tissue is ablated using high frequency alternating current to treat a medical disorder...
and endovenous laser treatment, are slowly replacing traditional surgical treatments. Because most of the blood in the legs is returned by the deep veins, the
superficial veinSuperficial vein is a term used to describe a vein that is close to the surface of the body. It is used to differentiate veins that are close to the surface from veins that are far from the surface, known as deep veins....
s, which return only about 10 per cent of the total blood of the legs, can usually be removed or ablated without serious harm. Varicose veins are distinguished from reticular veins (blue veins) and telangiectasias (spider veins), 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. These physicians are called
phlebologistA Phlebologist is a medical specialist in the diagnosis and treatment of disorders of venous origin. The specialty of Phlebology has developed to enable physicians sharing an interest in venous disease but with a variety of backgrounds such as dermatology, vascular surgery, haematology, or general...
s.
Symptoms
- Aching, heavy legs
Heavy legs is a medical condition, described as an 'unpleasant sensation of pain and heaviness', recognised primarily in France, and to a lesser extent elsewhere....
(often worse at night and after exercise).
- Appearance of spider veins (telangiectasia
Telangiectasias are small derogative blood vessels near the surface of the skin or mucous membranes, measuring between 0.5 and 1 millimeter in diameter. They can develop anywhere on the body but are commonly seen on the face around the nose, cheeks, and chin...
) in the affected leg.
- Ankle swelling.
- A brownish-blue shiny skin discoloration near the affected veins.
- Redness, dryness, and itchiness of areas of skin - termed stasis dermatitis
Stasis dermatitis refers to the skin changes that occur in the leg as a result of "stasis" or blood pooling from insufficient venous return; the alternative name of varicose eczema comes from a common cause of this being varicose veins....
or venous eczemaEczema is a disease in a form of dermatitis, or inflammation of the epidermis. The term eczema is broadly applied to a range of persistent skin conditions. These include dryness and recurring skin rashes that are characterized by one or more of these symptoms: redness, skin edema , itching and...
, because of waste products building up in the leg.
- Minor injuries to the area may bleed more than normal and/or take a long time to heal.
- In some people the skin above the ankle may shrink (lipodermatosclerosis
Lipodermatosclerosis is a skin and connective tissue disease. It is a form of lower extremity panniculitis, an inflammation of the layer of fat under the epidermis.- Symptoms :Pain may be the first noticed symptom...
) because the fat underneath the skin becomes hard.
- Restless legs syndrome
Restless legs syndrome , also known as Wittmaack-Ekbom's syndrome, is a condition that is characterized by an irresistible urge to move one's body to stop uncomfortable or odd sensations. It most commonly affects the legs, but can also affect the arms or torso and even phantom limbs. Moving the...
appears to be a common overlapping clinical syndrome in patients with varicose veins and other chronic venous insufficiencyChronic venous insufficiency or CVI is a medical condition where the veins cannot pump enough oxygen-poor blood back to the heart. This is due to damaged or "incompetent" valves as may occur after deep vein thrombosis or phlebitis.-CVI in the legs:Usually it happens in the leg's veins...
.
- Whitened, irregular scar-like patches can appear at the ankles. This is known as atrophie blanche
Livedo reticularis is a common cutaneous finding consisting of a mottled reticulated vascular pattern that appears like a lace-like purplish discoloration of the lower extremities. The discoloration is caused by swelling of the small veins in the skin, which makes them more visible...
.
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
Eczema is a disease in a form of dermatitis, or inflammation of the epidermis. The term eczema is broadly applied to a range of persistent skin conditions. These include dryness and recurring skin rashes that are characterized by one or more of these symptoms: redness, skin edema , itching and...
- C4b skin changes due to venous disorders: lipodermatosclerosis
Lipodermatosclerosis is a skin and connective tissue disease. It is a form of lower extremity panniculitis, an inflammation of the layer of fat under the epidermis.- Symptoms :Pain may be the first noticed symptom...
, atrophie blanche
- C5 as C4 but with healed ulcers
- C6 skin changes with active ulcers
Complications
Most varicose veins are relatively benign, but severe varicosities can lead to major complications, due to the poor circulation through the affected limb.
- Pain, heaviness, inability to walk or stand for long hours thus hindering work
- Skin conditions / Dermatitis
Dermatitis is a blanket term meaning any "inflammation of the skin" . There are several different types of dermatitis. The different kinds usually have in common an allergic reaction to specific allergens. The term may be used to refer to eczema, which is also known as dermatitis eczema or...
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.
Causes
Varicose veins are more common in women than in men, and are linked with
heredityHeredity is the passing of traits to offspring . This is the process by which an offspring cell or organism acquires or becomes predisposed to the characteristics of its parent cell or organism. Through heredity, variations exhibited by individuals can accumulate and cause a species to evolve...
. Other related factors are
pregnancyPregnancy is the carrying of one or more offspring, known as a fetus or embryo, inside the uterus of a female. In a pregnancy, there can be multiple gestations, as in the case of twins or triplets. Human pregnancy is the most studied of all mammalian pregnancies. Obstetrics is the surgical field...
,
obesityObesity is a medical condition in which excess body fat has accumulated to the extent that it may have an adverse effect on health, leading to reduced life expectancy and/or increased health problems...
,
menopauseMenopause is the time in a woman’s life when menstruation ends. It is part of a biological process that begins, for most women, in their mid-fifties. During this time, the ovaries gradually produce lower levels of natural sex hormones—estrogen and progesterone...
,
agingSenescence refers to the biological changes which take place in organisms as they age. It encompasses all of the biological processes of a living organism's approaching an advanced age...
, prolonged standing, leg injury and abdominal straining. Varicose veins are bulging veins that are larger than spider veins, typically 3 mm or more in diameter.
Less commonly, but not exceptionally, varicose veins can be due to other causes, as post phlebitic obstruction and/or incontinence, venous and arteriovenous malformations.
Conservative treatment
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
Compression stockings are used to support the venous and lymphatic systems of the leg. They offer graduated compression where maximum compression is achieved at the ankle and decreases as you move up the leg...
with a pressure of 30–40 mmHg 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.
- Diosmin
Diosmin is a semisynthetic phlebotropic drug, a member of the flavonoid family. It is an oral phlebotropic drug used in the treatment of venous disease, i.e., chronic venous insufficiency and hemorrhoidal disease , in acute or chronic hemorrhoids, in place of rubber-band ligation, in combination...
.
- anti-inflammatory medication such as ibuprofen
Ibuprofen is a non-steroidal anti-inflammatory drug originally marketed as Brufen, and since then under various other trademarks , most notably Nurofen, Advil and Motrin...
or aspirinAspirin , also known as acetylsalicylic acid , is a salicylate drug, often used as an analgesic to relieve minor aches and pains, as an antipyretic to reduce fever, and as an anti-inflammatory medication....
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.
Interventional treatment
Active medical intervention in varicose veins can be divided into surgical and non-surgical treatments. Some doctors favor traditional
open surgeryVein stripping is a surgical procedure done under general or local anaesthetic to remove varicose veins. The surgery involves making one or more incisions upon the desired area followed by insertion of a special wire into the vein. The wire is tied to and advanced through the vein to a desired...
, while others prefer the newer methods.
Newer methods for treating varicose veins such as Endovenous Thermal Ablation (endovenous laser treatment or
radiofrequency ablationRadio frequency ablation is a medical procedure where part of the electrical conduction system of the heart, tumor or other dysfunctional tissue is ablated using high frequency alternating current to treat a medical disorder...
), and foam
sclerotherapySclerotherapy is a procedure used to treat blood vessels or blood vessel malformations and also those of the lymphatic system. A medicine is injected into the vessels, which makes them shrink. It is used for children and young adults with vascular or lymphatic malformations. In adults,...
are not as well studied, especially in the longer term.
Surgical treatment
Several techniques have been performed for over a century, from the more invasive saphenous stripping, to less invasive procedures like ambulatory phlectomy and CHIVA.
Stripping
Stripping consists of removal of all or part the saphenous vein main trunk. The complications include deep vein thrombosis (5.3%), pulmonary embolism (0.06%), and wound complications including infection (2.2%). 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 venous bypass in the future (coronary and/or leg artery vital disease)
CHIVA
CHIVA is an acronym from the scientific paper "Conservatrice et Hémodynamique de l'Insuffisance Veineuse en Ambulatoire"
[claude Franceschi, Cure CHIVA, 1988, Editions de L'Armançon, 21390 Precy-Sous-Thil France] published in France in 1988. CHIVA relies on an hemodynamic impairment assessed by data and evidences depicted through ultrasound dynamic venous investigations. According to this new concept, the clinical symptoms of venous insufficiency are not the cause but the consequence of various abnormalities of the venous system. For example,a varicose vein being overloaded, may be dilated not only because of valvular incompetence (the most frequent) but because of a venous block (thombosis) or arterio-venous fistulae and so the treatment has to be tailored according the hemodynamic features.
It generally consists in 1 to 4 small incisions under local anaesthesia in order to disconnect the varicose veins from the abnormal flow due to valvular incompetence which dilates them. The patient is dismissed the same day. This method leads to an improvement of the venous function in order to:
- Cure the symptoms of venous insufficiency as varicose veins, legs swelling, ulcers.
- Prevent varicose recurrence due to progressive enlargement of collateral veins which replace and overtake the destroyed veins: CHIVA vs Stripping: varicose recurrence divided by 2 to 5 at 10 years.
- Preserve the superficial venous capital for unpredictable but possible need for coronary or leg artery vital by-pass which increases with ageing.
Lurie in his analysis of Chiva states that "CHIVA definitely falls into a research category and should be continued as such until sufficient evidence of its validity is generated".Unfortunately at this stage, the best available publication of CHIVA outcomes that meets current methological standards is a study by Carandina et al. . The authors estimate that only 30-35% of patients with varicose veins can be treated with CHIVA. This study showed that there were recurrent varices in 18% of cases treated by CHIVA despite there being some bias in the selection of patients favoring CHIVA.
Other
Other surgical treatments are:
- Ambulatory phlebectomy
Ambulatory phlebectomy is a treatment for superficial varicose veins. The procedure involves the removal of the varicose veins through small 2-3 mm incisions in the skin overlying the veins. The procedure may be performed in hospital or outpatient settings...
- Vein ligation
In surgery or medical procedure, a ligature consists of a piece of thread tied around an anatomical structure, usually a blood vessel or an other hollow structure to shut it off...
Sclerotherapy
A commonly performed non-surgical treatment for varicose and "spider" leg veins is
sclerotherapySclerotherapy is a procedure used to treat blood vessels or blood vessel malformations and also those of the lymphatic system. A medicine is injected into the vessels, which makes them shrink. It is used for children and young adults with vascular or lymphatic malformations. In adults,...
in which medicine is injected into the veins to make them shrink. It has been used in the treatment of varicose veins for over 150 years. Sclerotherapy is often used for telangiectasias (spider veins) 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 and short 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 (1 year) 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.
AnaphylacticAnaphylaxis is an acute systemic and severe type I hypersensitivity allergic reaction in humans and other mammals. The term comes from the Greek words ανα ana and φύλαξις phylaxis . Minute amounts of allergens may cause a life-threatening anaphylactic reaction...
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 (MSAC) in 2008 has determined that endovenous laser ablation (ELA) 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 (0.4%) and temporary paraesthesia (2.1%). The longest study of endovenous laser ablation is 39 months.
Two prospective randomized trials found speedier recovery and fewer complications after radiofrequency ablation (ERA) compared to open surgery. Myers wrote that open surgery for
small saphenous veinThe small saphenous vein , is a relatively large vein of the superficial posterior leg.-Path:Its origin is where the dorsal vein from the fifth digit merges with the dorsal venous arch of the foot, which attaches to the great 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 (0.57%) and pulmonary embolism (0.17%).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 ultrasound during the procedure to see what they are doing. 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 after the initial procedure.
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