Varicose Veins

Varicose veins are swollen and twisted veins that are visible just under the surface of the skin. They appear most commonly in the legs, but also can develop in other parts of the body.

For many people, varicose veins and spider veins — a common, mild and medically insignificant variation of varicose veins — are simply a cosmetic concern. For other people, varicose veins can cause aching pain and discomfort. Sometimes the condition leads to more serious problems. Varicose veins may also signal a higher risk of other disorders of the circulatory system.

Description

Veins are blood vessels that carry blood from the tissues of the body to the heart. In the heart, blood is pumped to the lungs to pick up oxygen. The oxygen-rich blood is then pumped out to the body through the arteries. From the arteries, blood flows through tiny blood vessels called capillaries, where it gives up its oxygen to the body's tissues. The blood then returns back to the heart through the veins to pick up more oxygen.

In the arteries, blood is under high pressure provided by the pumping action of the heart. The veins however do not have a pump and so the pressure is much lower inside them. In arteries, the very high pressure means that the force of gravity does not much affect blood flow, although sometimes standing up suddenly can cause loss of blood flow to the head, which causes people to feel dizzy and lightheaded. In the veins, because the pressure is far lower, gravity has a much more pronounced effect. To fight the force of gravity, veins have one-way valves that help to keep the blood flowing toward the heart. Blood cannot flow backwards through normal veins. These valves stop all of the blood in the body from pooling in the feet and legs. Unfortunately, these valves sometimes become damaged or incompetent. When the valves don't work well, blood backs up and pools in the veins. This causes them to swell with the increased volume of blood and to become twisty ("tortuous"). In the veins at the surface (just underneath the skin) this process of valve incompetence and swelling leads to the condition of varicose veins.

Varicose veins usually don't cause serious medical problems. On occasion, they require treatment for pain, skin problems, blood clots, or other complications. People may choose to have cosmetic treatment to improve the appearance of varicose veins.

Signs and Symptoms

Common signs and symptoms of varicose veins include:

• Enlarged veins that are visible on the skin
• Mild swelling of the ankles and feet
• Painful, achy, or heavy legs, particularly after standing or sitting with crossed legs
• Throbbing or cramping in the legs
• Itchy legs, especially in the lower leg and ankle (sometimes incorrectly diagnosed as dry skin)
• Discoloration of the skin surrounding the varicose veins

Causes

Veins, especially those in the legs, have to pump the blood uphill to the heart, against gravity. Inside the veins are one-way valves that help with pumping action and prevent blood from flowing backward. These valves allow blood to flow in only one direction, toward the heart. Varicose veins develop when the valves become weakened, damaged, or don't work well.

Weakness in the valves may be due to weakness in the walls of the veins. This weakness tends to be associated with certain factors, including increasing age, a family history of varicose veins, or high pressure inside veins due to overweight or pregnancy. Trauma and injury to veins can also cause them to become varicose. Sometimes varicose veins are there because the larger veins that run deep in the leg have become blocked, meaning that all of the blood flowing through the leg has to return through the superficial veins. These veins are varicose in that they are tortuous and swollen but they may not have incompetent valves. These types of veins can cause problems because when they are injured they tend to bleed profusely.

When the walls of the veins are weak, they lose their normal elasticity, like an overstretched rubber band. This makes them longer and wider and causes the flaps of the valves to separate. Blood is then able to flow backward through the valves, filling the vein and stretching it even more. The vein becomes enlarged, swollen, and often twisted trying to squeeze into its normal space.^[1]

Varicose veins in the leg. Source: Wikimedia Commons

Diagnosis

Varicose veins are often diagnosed based simply on the appearance of the veins. For varicose veins in the legs, the doctor will examine the patient's legs in the standing or seated position with the legs dangling. The doctor may place pressure over certain areas around the thigh and knees to see which valves have become incompetent, especially if surgery is being considered. The doctor may also ask the patient to describe pain or any other discomfort. Some diagnostic tests may be done to rule out other disorders or conditions.^[2]

Diagnostic tests and procedures

The doctor may order a Doppler ultrasound to evaluate the flow of blood in the veins and to look for blood clots. During a Doppler ultrasound, a handheld device is placed on the patient's body and passed back and forth over the affected area. A computer converts sound waves into a picture of the blood flow in the arteries and veins.

Rarely, the doctor may order an angiogram to look at blood flow through the blood vessels. The procedure involves injecting a dye into the veins that can be seen using X-ray. An angiogram can help to rule out other diagnoses besides varicose veins.

Treatment

The goals of treating varicose veins may include easing symptoms, avoiding complications, and improving cosmetic appearance. Although treatment can target existing varicose veins, it cannot keep new varicose veins from forming.

Varicose veins that cause few signs and symptoms usually do not require treatment. Instead, the doctor may recommend simple self-care measures. Varicose veins causing more severe signs and symptoms may need medical or surgical treatment. Treatment may be recommended when the varicose veins are causing skin ulcers, serious skin conditions, blood clots, significant pain, or disruption of daily life activities. Some people with varicose veins may choose to have medical or surgical treatments to improve the cosmetic appearance of varicose veins.

Conservative measures

Self-care measures are a common option for treating varicose veins. If self-care measures are called for, the doctor may ask the patient to:

• Avoid excess amounts of standing when possible. Take frequent breaks during prolonged periods of standing.
• Elevate the legs when sitting, resting, or sleeping. Elevating the legs above the level of the heart is very important.
• Wear compression stockings. These are typically worn all day long. Doctors may prescribe special-strength stockings or over-the-counter support stockings, which may be available at pharmacies and medical supply stores.
• Exercise. Exercise gets the legs moving and improves muscle tone, which helps the circulation of blood through the veins.
• Lose weight. Taking off extra pounds may help with blood circulation and pressure on the veins.
• Avoid wearing tight clothes. Tight clothes, especially those that are tight around the waist, groin (upper thighs), and legs, can make varicose veins worse.

Therapies

Medical and surgical treatments are used to either remove varicose veins or close them. Removing or closing varicose veins usually does not create circulation problems because the blood reroutes itself through other veins. These therapies range from approaches that do not involve incisions or injections to those that are surgical procedures. It may be necessary to combine therapies, depending on the patient's condition and lifestyle. Long term results after these procedures should be enquired about before the patient considers surgery. This is because varicose veins often recur in the same, or different areas, usually several months or years after the original procedure. This is because other veins carry the blood instead, and eventually the valves in these veins may also become damaged.^[3]

Sclerotherapy. This procedure uses a liquid chemical to close off the vein. The solution is injected into the vein to cause irritation and scarring inside the vein, which causes the vein to close off and fade away. It is usually used to treat smaller varicose veins and spider veins. Sclerotherapy is typically done in the doctor's office, while the patient is standing. Several sclerotherapy treatments may be required to close off a vein completely. In this case, treatments are typically given every four to six weeks. Following each treatment, the legs are wrapped in elastic bandaging to help healing and decrease swelling.

Microsclerotherapy. This procedure is used to treat spider veins and other very small varicose veins. It involves injection of small amounts of a liquid chemical using a very fine needle. The chemical causes scarring in the inner lining of the veins, causing them to close off.

Laser Surgery. This procedure uses no incisions or injections. Light energy from a laser is used to make the vein fade away. Laser surgery is typically used to treat smaller varicose veins. With new technology, lasers are more effective than they used to be.^[4]

Endovenous ablation therapy. This procedure uses an energy source (either laser or radiowave) to create heat to close off the vein. A tiny incision is made in the skin, and a small catheter (tube) is inserted into the vein. A device at the tip of the catheter heats up the inside of the vein, which causes it to close off. The patient is awake during the procedure, but the doctor numbs the area of the vein. The patient is usually able to go home on the same day. The patient may experience less pain and recover more quickly with this procedure than with some of the others.

Endoscopic vein surgery. This procedure uses a tiny camera at the end of a thin tube to move through the varicose veins. A surgical instrument at the end of the camera is used to close the veins. Endoscopic vein surgery is currently only used in severe cases in which there are skin ulcers due to the varicose veins. Only small incisions are required for this procedure.

Ambulatory phlebectomy. In this procedure, small varicose veins are removed through small incisions in the skin. Ambulatory phlebectomy is typically used to treat varicose veins close to the surface of the skin. The patient remains awake during the procedure, but the doctor numbs the area of the vein. The patient is usually able to go home the same day.

Vein stripping and ligation. In this procedure, veins are tied shut (ligation) and removed (stripping) through small incisions. The procedure is typically used in severe cases, in which the varicose veins cause pain or skin ulcers. The patient is given medicine to sleep so no pain is felt during the procedure.

Prevention

Varicose veins cannot be prevented from forming, but there are ways to reduce the severity of existing varicose veins and the risk of getting new varicose veins. To decrease the risk for and severity of varicose veins, the following is recommended:

• Exercise. Moving the legs by walking or other forms of exercise can help move blood through the body.
• Control body weight. For people who are overweight or obese, losing weight will reduce pressure on the veins.
• Avoid high heels and tight clothes. Flat or low-heeled shoes give the calf muscles a better workout, which helps to improve muscle strength and blood circulation. Avoiding tight clothing will reduce unnecessary pressure on the veins.
• Avoid excessive standing or sitting with the legs bent or crossed. This will help blood flow and avoid additional pressure on the veins. During long periods of standing, taking frequent sitting breaks is recommended.
• Elevate the legs. Elevating the legs when sitting, resting, or sleeping can help the flow of blood, especially if the legs are raised above the level of the heart.

Living With Varicose Veins

People with varicose veins often require only simple self-care measures, such as performing certain leg exercises, wearing compression stockings, and avoiding long periods of sitting or standing. For those who are concerned about the appearance of varicose veins, several cosmetic treatments are available. Although uncommon, in some cases, complications such as pain, infection, skin ulcers, and blood clots can develop. A variety of medical and surgical procedures are used to treat varicose veins in these more complicated cases.

Risk factors

It is estimated that 25 million Americans are affected by varicose veins.^[5]

Risk factors for developing varicose veins include:

• Genetics. Having a family member with varicose veins may increase the risk for developing them. Approximately half of the people who get varicose veins have a family history of them.
• Age. Varicose veins are most common in people aged 30 to 70. The normal wear and tear of aging may cause valves to weaken and not work as well.
• Gender. Women are two to three times more likely to develop varicose veins than men. Up to half of American women have varicose veins. Changes in hormones due to puberty, pregnancy, menopause, or taking birth control pills may increase a woman's risk of developing varicose veins.
• Pregnancy. During pregnancy, the growth of the fetus increases the pressure on the veins in the legs, causing them to swell. Varicose veins that occur during pregnancy usually improve within 3 to 12 months following delivery.
• Obesity or being overweight. Having extra weight on the body can put additional pressure on the veins.
• Prolonged standing or sitting. When standing or sitting, especially with legs bent or crossed, the veins have to work harder to pump the blood up to the heart.

Related Problems

Complications

Only a small percentage of people have complications from varicose veins. Complications may include dermatitis and thrombophlebitis.

Dermatitis

Dermatitis is an itchy rash that can occur on the lower leg or ankle of a person with varicose veins in the legs. It can sometimes cause bleeding or a skin ulcer to develop if scratched or irritated.

Thrombophlebitis

This is a blood clot (thrombus) that occurs in a vein. Though there are two types of thrombophlebitis, only superficial thrombophlebitis is associated with varicose veins:

• Superficial thrombophlebitis. This is a blood clot that occurs in a superficial vein and usually causes only minor problems that are limited to the area of the affected vein. Clots in varicose veins are usually of this type. Infections, chemical irritation, or other conditions that cause irritation and inflammation of the veins also can lead to superficial thrombophlebitis. Superficial thrombophlebitis IS a blood clot but it does NOT cause pulmonary embolus.

• Deep vein thrombosis (DVT). DVT is a blood clot then develops in veins deeper in the body. It can be life threatening if the clot breaks off and travels to the lungs, which is called pulmonary embolism. This type of thrombophlebitis does not occur in varicose veins.

Related disorders

A number of other types of vein problems are related to varicose veins.

• Spider veins. Spider veins are a smaller version of varicose veins. They occur in the capillaries, which are the smallest blood vessels in the body. Spider veins are commonly found on the legs and face, and they usually resemble a spider web or tree branch in shape. They can be red or blue. Spider veins are usually not a medical concern.

• Telangiectasias (tel-AN-juh-ek-TA-ze-uhs). These are small clusters of blood vessels that look similar to spider veins. They are red in color and are commonly found on the upper body, including the face. They can develop during pregnancy and in people who have certain genetic disorders, viral infections, and other medical conditions (such as liver disease). Newly developed telangiectasias are often a reason to see a doctor.

• Venous lakes. Venous lakes are another type of varicose veins in which blood collects in the veins of the face and neck.

• Reticular veins. Reticular veins are flat blue veins commonly seen behind the knees.

• Hemorrhoids. Hemorrhoids are varicose veins in blood vessels in and around the anus.

• Varicoceles. Varicoceles (VAR-i-ko-seals) are varicose veins in the scrotum (the skin over the testicles). Varicoceles may be linked to male infertility and should be checked by a doctor. New varicoceles in middle aged and more elderly people should always be investigated as they may indicate serious medical problems including cancer.

Expected Outcome

Recovery time

Recovery times vary based on the specific procedure that is performed. Vein stripping and ligation requires more recovery than most other procedures. Activity is not significantly limited following most other procedures. In fact, walking is often recommended during recovery. Some treatments may require the patient to wear compression stockings or bandages for a period of time ranging from a couple days to a few weeks following the procedure.

Common side effects immediately following a procedure may include bruising, swelling, skin discoloration, cramping, and itching. Swelling and skin discoloration may last for several months. Less common side effects include blood clots or nerve damage. An uncommon side effect of sclerotherapy is liquid chemical leaking out of the vein, which could cause tissue damage or ulcers.

Clinical Trials

Varicose Veins Clinical Trials

Current Research (ClinicalTrials.gov)

References

1. ↑ Raffetto, JD and Khalil, RA. Mechanisms of varicose vein formation: valve dysfunction and wall dilation. Phlebology. 2008;23(2):85-98. Abstract
2. ↑ Campbell, B. Varicose veins and their management. BMJ. 2006;333:287-292 (5 August). Full Text
3. ↑ Subramonia, S, and LeesAnn, TA. The Treatment of Varicose Veins. R Coll Surg Engl. 2007 March; 89(2): 96–100. Full Text
4. ↑ Campbell B. New treatments for varicose veins. BMJ. 2002 March 23; 324(7339): 689–690. Full Text
5. ↑ Vascular Disease Foundation. Varicose Veins

External Links

Mayo Clinic: Varicose Veins

VascularWeb.org: Varicose Veins