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Varicose Veins

AUTHOR: Dr. Jim Dooner FRCS, FACS, MBA

What is Varicose Veins?

Varicose veins are part of a spectrum of chronic vein problems. They are common and can be found in up to 20% of the adult population. The range of severity is considerable and while they are responsible for significant discomfort and potential skin breakdown in the leg, the symptoms are not always directly related to the size of the abnormal veins.

By definition, the varicose vein is a dilated and tortuous channel at least 4 mm in diameter. In the most simple form, they may appear as prominent or bulging blue protursions under the skin of the leg. In more advanced or severe cases, there may be permanent discoloration of the skin, a change in texture of the skin and ulceration.

What causes Varicose Veins?

In almost all cases there malfunction of valves at critical junctions of the venous system allowing wrong way flow of blood down the leg in the opposite direction through which  veins were intended to conduct the flow of blood. The valve malfunction is often a spontaneous problem, not generally related to injury or occupation. Women are slightly more likely to have them thatn men by a ration of 60/40%. Varicose veins may become visible after an episode of phlebitis (DVT, Deep Vein Thrombisis) as a result of destruction of the valves by the clotting process. It is important to document these problems in the evaluation of varicose veins and the selection of a treatment plan.

What are the symptoms of Varicose Veins?

Seventy percent of people will complain of pain (heaviness, aching) in the affected leg. Itching is also common and nocturnal itching or burning is commonly described if the legs become swollen during the day. Localized pain and tenderness will be quite severe if the varicose veins clot causing a superficial phlebitis. This is often associated with some redish discoloration.
Skin changes in some cases can resemble exzema.

Some individuals will comment that their legs do not bother them despite rather well developed varicosities but often find that post treatment they realize the leg actually feels better having eliminated the problem.

Diagnosis and tests for Varicose Veins

Evaluation of venous disease including varicose veins is best carried out by a professional trained in the evaluation and management of the entire spectrum of venous insufficiency. As well as a thorough physical examination, the optimum current practice should include an ultrasound evaluation of the venous system of the leg(s) to check for obstruction and reflux (wrong way flow of blood). Rarely a more invasive test using a catheter based injection of dye (venography) is needed to complete an assessment.

Lifestyle modification for Varicose Veins

The calf muscles are the pump that push blood out of the leg and back to the heart. Movement is good and use of the calf muscles reduces the pressure build up in the veins. Avoiding prolonged sitting is desirable and avoidance of standing still is important. Any intervention should be deferred in women planning future pregnancy.

Non-surgical and medical management for Varicose Veins

The use of compression stockings is highly recommended in order to reduce symptoms and slow the progression of the problem. Knee length stockings meet with more success than over the knee simply because they deal with the most common areas affected and are easier to wear and keep in place than thigh high stockings.

While there are no medications that shrink or repair varicose veins there is evidence that horse chestnut extract (Venastat) can reduce the symptoms of pain related to the varicose veins.

Guidelines for Intervention for Varicose Veins

There is a tendency to regard varicose veins as a benign, almost cosmetic problem but the level of pain and impact on quality of life that has been assessed would suggest that treatment of varicose veins associated with reflux in the superficial and or deep veins benefits from an active treatment plan. Although treatment is recommended, there are many options that have developed over the years lending confusion to the situation. Not all treatment methods are equivalent so they should not be considered as alternatives or preferences. Treatment should be guided by the clinical and ultrasound findings.

The most important principle is to eliminate the reflux ( or wrong way flow of blood).

Surgical treatment for Varicose Veins

The traditional stripping operation eliminates the reflux of blood through the long or short saphenous vein and has proven to be the most thorough and durable method of control for many years. Less aggressive options have a much higher chance of failure and recurrence of the problem. At the same time most surgeons will remove many of the visible varicose veins (referred to as phlebectomies or Stab avulsions). This procedure is done as a daycare operation and will usually require a recovery of approximately two weeks.  If the vein is Long or short saphenous veins are simply tied off the results are not as good in the long term.

This procedure continues to be a very valid option.

Endovascular Treatment for Varicose Veins

In recent years another option has emerged using energy from a laser source or a radiofequency power generator to deliver a thermal injury to the saphenous (long or short) vein through a small puncture in the lower leg. The catheter is advanced to the junction with the deep system (groin or knee) and the entire length of the vein is surrounded with a dilute local anaesthetic solution (tumescent anaesthesia). Under ultrasound guidance the device is slowly withdrawn, sealing the entire length of the treated vein. Some patients require a touch up with sclerotherapy or phlebectomy at a later office visit. Long term control of the problem is excellent. Recovery is quicker than with surgery.

When should I see my doctor?

Patients with symptoms of heaviness, aching, pain a dn clearly visible varicose veins should have a proper consultation and assessment in order to know their options. All patients with more advanced venous pathology with skin damage, pigmentation and/or ulcer formation should be seen urgently and evaluated thoroughly for a comprehensive treatment plan and long term management strategies.

References and Resources

The Care of Patients with Varicose Veins and Associated Chronic Venous Disease:
Clinical Practice Guidelines of the Society for Vascular Surgery and the American Venous Forum: Journal of Vascular Surgery Volume 53 May 2011 Suplement S

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