Varicose veins

Last updated
Varicose veins
Leg Before 1.jpg
Left leg of a male affected by varicose veins
Pronunciation
Specialty Vascular surgery, dermatology [1]
Symptoms None, fullness, pain in the area [2]
Complications Bleeding, superficial thrombophlebitis [2] [1]
Risk factors Obesity, not enough exercise, leg trauma, family history, pregnancy [3]
Diagnostic method Based on examination [2]
Differential diagnosis Arterial insufficiency, peripheral neuritis [4]
Treatment Compression stockings, exercise, sclerotherapy, surgery [2] [3]
Prognosis Commonly reoccur [2]
FrequencyVery common [3]

Varicose veins, also known as varicoses, are a medical condition in which superficial veins become enlarged and twisted. Although usually just a cosmetic ailment, in some cases they cause fatigue, pain, itching, and nighttime leg cramps. [1] [2] [5] These veins typically develop in the legs, just under the skin. [3] Their complications can include bleeding, skin ulcers, and superficial thrombophlebitis. [1] [2] Varices in the scrotum are known as a varicocele, while those around the anus are known as hemorrhoids. [1] The physical, social, and psychological effects of varicose veins can lower their bearers' quality of life. [6]

Contents

Varicose veins have no specific cause. [2] Risk factors include obesity, lack of exercise, leg trauma, and family history of the condition. [3] They also develop more commonly during pregnancy. [3] Occasionally they result from chronic venous insufficiency. [2] Underlying causes include weak or damaged valves in the veins. [1] They are typically diagnosed by examination, including observation by ultrasound. [2]

By contrast, spider veins affect the capillaries and are smaller. [1] [7]

Treatment may involve lifestyle changes or medical procedures with the goal of improving symptoms and appearance. [1] Lifestyle changes may include wearing compression stockings, exercising, elevating the legs, and weight loss. [1] Possible medical procedures include sclerotherapy, laser surgery, and vein stripping. [2] [1] However, recurrence is common following treatment. [2]

Varicose veins are very common, affecting about 30% of people at some time in their lives. [8] [3] [9] They become more common with age. [3] Women develop varicose veins about twice as often as men. [7] Varicose veins have been described throughout history and have been treated with surgery since at least the second century BC, when Plutarch tells of such treatment performed on the Roman leader Gaius Marius.[ citation needed ]

Signs and symptoms

People with varicose veins might have a positive D-dimer blood test result due to chronic low-level thrombosis within dilated veins (varices). [14]

Complications

Most varicose veins are reasonably benign, but severe varicosities can lead to major complications, due to the poor circulation through the affected limb.

Causes

How a varicose vein forms in a leg. Figure A shows a normal vein with a working valve and normal blood flow. Figure B shows a varicose vein with a deformed valve, abnormal blood flow, and thin, stretched walls. The middle image shows where varicose veins might appear in a leg. Varicose veins-en.svg
How a varicose vein forms in a leg. Figure A shows a normal vein with a working valve and normal blood flow. Figure B shows a varicose vein with a deformed valve, abnormal blood flow, and thin, stretched walls. The middle image shows where varicose veins might appear in a leg.
Comparison of healthy and varicose veins Blausen 0891 VaricoseVein.png
Comparison of healthy and varicose veins

Varicose veins are more common in women than in men and are linked with heredity. [16] 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. [17] Less commonly, but not exceptionally, varicose veins can be due to other causes, such as post-phlebitic obstruction or incontinence, venous and arteriovenous malformations. [18]

Venous reflux is a significant cause. Research has also shown the importance of pelvic vein reflux (PVR) in the development of varicose veins. Varicose veins in the legs could be due to ovarian vein reflux. [19] [20] Both ovarian and internal iliac vein reflux causes leg varicose veins. This condition affects 14% of women with varicose veins or 20% of women who have had vaginal delivery and have leg varicose veins. [21] In addition, evidence suggests that failing to look for and treat pelvic vein reflux can be a cause of recurrent varicose veins. [22]

There is increasing evidence for the role of incompetent perforator veins (or "perforators") in the formation of varicose veins. [23] and recurrent varicose veins. [24]

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. Klippel–Trenaunay syndrome and Parkes Weber syndrome are relevant for differential diagnosis.[ citation needed ]

Another cause is chronic alcohol consumption due to the vasodilatation side effect in relation to gravity and blood viscosity. [25]

Diagnosis

Clinical test

Clinical tests that may be used include:[ citation needed ]

Investigations

Traditionally, varicose veins were investigated using imaging techniques only if there was a suspicion of deep venous insufficiency, if they were recurrent, or if they involved the saphenopopliteal junction. This practice is now less widely accepted. People with varicose veins should now be investigated using lower limbs venous ultrasonography. The results from a randomised controlled trial on patients with and without routine ultrasound have shown a significant difference in recurrence rate and reoperation rate at 2 and 7 years of follow-up. [26]

Stages

The CEAP (Clinical, Etiological, Anatomical, and Pathophysiological) Classification, developed in 1994 by an international ad hoc committee of the American Venous Forum, outlines these stages [27] [28]

Each clinical class is further characterized by a subscript depending upon whether the patient is symptomatic (S) or asymptomatic (A), e.g. C2S. [29]

Treatment

Treatment can be either active or conservative.

Active

Treatment options include surgery, laser and radiofrequency ablation, and ultrasound-guided foam sclerotherapy. [8] [30] [31] Newer treatments include cyanoacrylate glue, mechanochemical ablation, and endovenous steam ablation. No real difference could be found between the treatments, except that radiofrequency ablation could have a better long-term benefit. [32]

Conservative

The National Institute for Health and Clinical Excellence (NICE) produced clinical guidelines in July 2013 recommending that all people with symptomatic varicose veins (C2S) and worse should be referred to a vascular service for treatment. [33] Conservative treatments such as support stockings should not be used unless treatment was not possible.

The symptoms of varicose veins can be controlled to an extent with the following:

Procedures

Stripping

Stripping consists of removal of all or part the saphenous vein (great/long or lesser/short) main trunk. The complications include deep vein thrombosis (5.3%), [37] pulmonary embolism (0.06%), and wound complications including infection (2.2%). There is evidence for the great saphenous vein regrowing after stripping. [38] For traditional surgery, reported recurrence rates, which have been tracked for 10 years, range from 5% to 60%. In addition, since stripping removes the saphenous main trunks, they are no longer available for use as venous bypass grafts in the future (coronary or leg artery vital disease). [39]

Other

Other surgical treatments are:

  • CHIVA method (ambulatory conservative haemodynamic correction of venous insufficiency) is a relatively low-invasive surgical technique that incorporates venous hemodynamics and preserves the superficial venous system. [40] The overall effectiveness compared to stripping, radiofrequency ablation treatment, or endovenous laser therapy is not clear and there is no strong evidence to suggest that CHIVA is superior to stripping, radiofrequency ablation, or endovenous laser therapy for recurrence of varicose veins. [40] There is some low-certainty evidence that CHIVA may result in more bruising compared to radiofrequency ablation treatment. [40]
  • Vein ligation is done at the saphenofemoral junction after ligating the tributaries at the saphenofemoral junction without stripping the long saphenous vein, provided the perforator veins are competent and DVT is absent in the deep veins. With this method, the long saphenous vein is preserved.
  • Cryosurgery – A cryoprobe is passed down the long saphenous vein following saphenofemoral ligation. The probe is then cooled with NO2 or CO2 to −85°F. The vein freezes to the probe and can be retrogradely stripped after 5 seconds of freezing. It is a variant of stripping. The only purpose of this technique is to avoid a distal incision to remove the stripper. [41]

Sclerotherapy

A commonly performed non-surgical treatment for varicose and "spider leg veins" is sclerotherapy, in which medicine called a sclerosant is injected into the veins to make them shrink. The medicines that are commonly used as sclerosants are polidocanol (POL branded Asclera in the United States, Aethoxysklerol in Australia), sodium tetradecyl sulphate (STS), Sclerodex (Canada), hypertonic saline, glycerin and chromated glycerin. STS (branded Fibrovein in Australia) 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[ medical citation needed ], and there is no clear evidence that foams are superior. [42] Sclerotherapy has been used in the treatment of varicose veins for over 150 years. [15] Sclerotherapy is often used for telangiectasias (spider veins) and varicose veins that persist or recur after vein stripping. [43] [44] Sclerotherapy can also be performed using foamed sclerosants under ultrasound guidance to treat larger varicose veins, including the great saphenous and small saphenous veins. [45] [46]

There is some evidence that sclerotherapy is a safe and possibly effective treatment option for improving the cosmetic appearance, reducing residual varicose veins, improving the quality of life, and reducing symptoms that may be present due to the varicose veins. [42] There is also weak evidence that this treatment option may have a slightly higher risk of deep vein thrombosis. It is not known if sclerotherapy decreases the chance of varicose veins returning (recurrent varicose veins). [42] It is also not known which type of substance (liquid or foam) used for the sclerotherapy procedure is more effective and comes with the lowest risk of complications. [42]

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. [47] [48] There has been one reported case of stroke after ultrasound-guided sclerotherapy when an unusually large dose of sclerosant foam was injected. [49]

Endovenous thermal ablation

There are three kinds of endovenous thermal ablation treatment possible: laser, radiofrequency, and steam. [50]

The Australian Medical Services Advisory Committee (MSAC) in 2008 determined that endovenous laser treatment/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." [51] 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%) [52] and temporary paresthesia (2.1%). The longest study of endovenous laser ablation is 39 months. [53]

Two prospective randomized trials found speedier recovery and fewer complications after radiofrequency ablation (ERA) compared to open surgery. [54] [55] Myers [56] 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%. By 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%.[ citation needed ]

Steam treatment consists in injection of pulses of steam into the sick vein. This treatment which works with a natural agent (water) has results similar to laser or radiofrequency. [57] The steam presents a lot of post-operative advantages for the patient (good aesthetic results, less pain, etc.) [58] Steam is a very promising treatment for both doctors (easy introduction of catheters, efficient on recurrences, ambulatory procedure, easy and economic procedure) and patients (less post-operative pain, a natural agent, fast recovery to daily activities). [59]

ELA and ERA require specialized training for doctors and special equipment. ELA is performed as an outpatient procedure and does not require an operating theatre, nor does the patient need a general anaesthetic. Doctors use high-frequency ultrasound during the procedure to visualize the anatomical relationships between the saphenous structures.[ citation needed ]

Some practitioners also perform phlebectomy or ultrasound-guided sclerotherapy at the time of endovenous treatment. This is also known as an ambulatory phlebectomy. The distal veins are removed following the complete ablation of the proximal vein. This treatment is most commonly used for varicose veins off of the great saphenous vein, small saphenous vein, and pudendal veins. [60] Follow-up treatment to smaller branch varicose veins is often needed in the weeks or months after the initial procedure.

Medical Adhesive

Also called medical super glue, medical adhesive is an advanced non-surgical treatment for varicose veins during which a solution is injected into the diseased vein through a small catheter and under the assistance of ultrasound-guided imagery. The "super glue" solution is made of cyanoacrylate, aiming at sealing the vein and rerouting the blood flow to other healthy veins. [61]

Post-treatment, the body will naturally absorb the treated vein which will disappear. Involving only a small incision and no hospital stay, medical super glue has generated great interest within the last years, with a success rate of about 96.8%. [62]

A follow-up consultation is required after this treatment, just like any other one, in order to re-assess the diseased vein and further treat it if needed.[ citation needed ]

Echotherapy Treatment

In the field of varicose veins, the latest medical innovation is high-intensity focused ultrasound therapy (HIFU). This method is completely non-invasive and is not necessarily performed in an operating room, unlike existing techniques. This is because the procedure involves treating from outside the body, able to penetrate the skin without damage, to treat the veins in a targeted area. [63] This leaves no scars and allows the patient to return to their daily life immediately.

Epidemiology

Varicose veins are most common after age 50. [64] It is more prevalent in females. [65] There is a hereditary role. It has been seen in smokers, those who have chronic constipation, and in people with occupations which necessitate long periods of standing such as wait staff, nurses, conductors (musical and bus), stage actors, umpires (cricket, javelin, etc.), the King's guards, lectern orators, security guards, traffic police officers, vendors, surgeons, etc. [29]

Related Research Articles

<span class="mw-page-title-main">Great saphenous vein</span> Large, subcutaneous, superficial vein of the leg

The great saphenous vein (GSV) or long saphenous vein is a large, subcutaneous, superficial vein of the leg. It is the longest vein in the body, running along the length of the lower limb, returning blood from the foot, leg and thigh to the deep femoral vein at the femoral triangle.

<span class="mw-page-title-main">Vascular surgery</span> Medical specialty of the blood/lymph vessels

Vascular surgery is a surgical subspecialty in which vascular diseases involving the arteries, veins, or lymphatic vessels, are managed by medical therapy, minimally-invasive catheter procedures and surgical reconstruction. The specialty evolved from general and cardiovascular surgery where it refined the management of just the vessels, no longer treating the heart or other organs. Modern vascular surgery includes open surgery techniques, endovascular techniques and medical management of vascular diseases - unlike the parent specialities. The vascular surgeon is trained in the diagnosis and management of diseases affecting all parts of the vascular system excluding the coronaries and intracranial vasculature. Vascular surgeons also are called to assist other physicians to carry out surgery near vessels, or to salvage vascular injuries that include hemorrhage control, dissection, occlusion or simply for safe exposure of vascular structures.

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.

<span class="mw-page-title-main">Telangiectasia</span> Small dilated blood vessels

Telangiectasias, also known as spider veins, are small dilated blood vessels that can occur near the surface of the skin or mucous membranes, measuring between 0.5 and 1 millimeter in diameter. These dilated blood vessels can develop anywhere on the body, but are commonly seen on the face around the nose, cheeks and chin. Dilated blood vessels can also develop on the legs, although when they occur on the legs, they often have underlying venous reflux or "hidden varicose veins". When found on the legs, they are found specifically on the upper thigh, below the knee joint and around the ankles.

Endovenous laser treatment (ELT) is a minimally invasive ultrasound-guided technique used for treating varicose veins using laser energy commonly performed by a phlebologist, interventional radiologist or vascular surgeon.

<span class="mw-page-title-main">Sclerotherapy</span> Shrinking of the varicose blood vessels by the injection of medicine

Sclerotherapy is a procedure used to treat blood vessel malformations and also malformations of the lymphatic system. A medication is injected into the vessels, which makes them shrink. It is used for children and young adults with vascular or lymphatic malformations. In adults, sclerotherapy is often used to treat spider veins, smaller varicose veins, hemorrhoids, and hydroceles.

Polidocanol is a local anaesthetic and antipruritic component of ointments and bath additives. It relieves itching caused by eczema and dry skin. It has also been used to treat varicose veins, hemangiomas, and vascular malformations. It is formed by the ethoxylation of dodecanol.

The small saphenous vein is a relatively large superficial vein of the posterior leg.

<span class="mw-page-title-main">Venous ulcer</span> Skin sore sustained by a vasculatory disease

Venous ulcer is defined by the American Venous Forum as "a full-thickness defect of skin, most frequently in the ankle region, that fails to heal spontaneously and is sustained by chronic venous disease, based on venous duplex ultrasound testing." Venous ulcers are wounds that are thought to occur due to improper functioning of venous valves, usually of the legs. They are an important cause of chronic wounds, affecting 1% of the population. Venous ulcers develop mostly along the medial distal leg, and can be painful with negative effects on quality of life.

<span class="mw-page-title-main">Radiofrequency ablation</span> Interventional procedure

Radiofrequency ablation (RFA), also called fulguration, is a medical procedure in which part of the electrical conduction system of the heart, tumor, sensory nerves or a dysfunctional tissue is ablated using the heat generated from medium frequency alternating current. RFA is generally conducted in the outpatient setting, using either a local anesthetic or twilight anesthesia. When it is delivered via catheter, it is called radiofrequency catheter ablation.

<span class="mw-page-title-main">Vascular disease</span> Medical condition

Vascular disease is a class of diseases of the vessels of the circulatory system in the body, including blood vessels – the arteries and veins, and the lymphatic vessels. Vascular disease is a subgroup of cardiovascular disease. Disorders in this vast network of blood and lymph vessels can cause a range of health problems that can sometimes become severe, and fatal. Coronary heart disease for example, is the leading cause of death for men and women in the United States.

The term venous translucence has been used in phlebology since 1996 by surgeon Pedro Fernandes Neto during ambulatory clinical exams in Brazil. His results were published in the annals of the national and international congresses of angiology. Venous translucence is the process of reflective image visualization of veins by light, which reaches up to the superficial venous system. It is a non-invasive method. Since it is a simple, low-cost technique it can be repeated as needed, which is useful in disease-process monitoring. It is a new diagnostic procedure, still undergoing investigation; more analysis is necessary to hone its technical aspects. Venous translucence is based on optical physics. It is caused by the refraction, absorption and reflection of light. The color which is not absorbed is reflected, and is the one that is seen. Therefore, venous translumination is based on the incidence of luminosity on the vein, where part of the light is absorbed and another reflected.

<span class="mw-page-title-main">Chronic venous insufficiency</span> Pooling of blood in the veins

Chronic venous insufficiency (CVI) is a medical condition in which blood pools in the veins, straining the walls of the vein. The most common cause of CVI is superficial venous reflux which is a treatable condition. As functional venous valves are required to provide for efficient blood return from the lower extremities, this condition typically affects the legs. If the impaired vein function causes significant symptoms, such as swelling and ulcer formation, it is referred to as chronic venous disease. It is sometimes called chronic peripheral venous insufficiency and should not be confused with post-thrombotic syndrome in which the deep veins have been damaged by previous deep vein thrombosis.

<span class="mw-page-title-main">Klippel–Trénaunay syndrome</span> Medical condition

Klippel–Trénaunay syndrome, formerly Klippel–Trénaunay–Weber syndrome and sometimes angioosteohypertrophy syndrome and hemangiectatic hypertrophy, is a rare congenital medical condition in which blood vessels and/or lymph vessels fail to form properly. The three main features are nevus flammeus, venous and lymphatic malformations, and soft-tissue hypertrophy of the affected limb. It is similar to, though distinct from, the less common Parkes Weber syndrome.

<span class="mw-page-title-main">Paolo Zamboni</span>

Paolo Zamboni is an Italian doctor and scientist. He is full Professor and Director of the School of Vascular Surgery at the University of Ferrara in Italy.

<span class="mw-page-title-main">Perforator vein</span>

Perforator veins are so called because they perforate the deep fascia of muscles, to connect the superficial veins to the deep veins where they drain.

<span class="mw-page-title-main">Ultrasonography of chronic venous insufficiency of the legs</span> Non-invasive medical procedure

Ultrasonography of suspected or previously confirmed chronic venous insufficiency of leg veins is a risk-free, non-invasive procedure. It gives information about the anatomy, physiology and pathology of mainly superficial veins. As with heart ultrasound (echocardiography) studies, venous ultrasonography requires an understanding of hemodynamics in order to give useful examination reports. In chronic venous insufficiency, sonographic examination is of most benefit; in confirming varicose disease, making an assessment of the hemodynamics, and charting the progression of the disease and its response to treatment. It has become the reference standard for examining the condition and hemodynamics of the lower limb veins. Particular veins of the deep venous system (DVS), and the superficial venous system (SVS) are looked at. The great saphenous vein (GSV), and the small saphenous vein (SSV) are superficial veins which drain into respectively, the common femoral vein and the popliteal vein. These veins are deep veins. Perforator veins drain superficial veins into the deep veins. Three anatomic compartments are described, (N1) containing the deep veins, (N2) containing the perforator veins, and (N3) containing the superficial veins, known as the saphenous compartment. This compartmentalisation makes it easier for the examiner to systematize and map. The GSV can be located in the saphenous compartment where together with the Giacomini vein and the accessory saphenous vein (ASV) an image resembling an eye, known as the 'eye sign' can be seen. The ASV which is often responsible for varicose veins, can be located at the 'alignment sign', where it is seen to align with the femoral vessels.

<span class="mw-page-title-main">Giacomini vein</span>

The Giacomini vein or cranial extension of the small saphenous vein is a communicating vein between the great saphenous vein (GSV) and the small saphenous vein (SSV). It is named after the Italian anatomist Carlo Giacomini (1840–1898). The Giacomini vein courses the posterior thigh as either a trunk projection, or tributary of the SSV. In one study it was found in over two-thirds of limbs. Another study in India found the vein to be present in 92% of those examined. It is located under the superficial fascia and its insufficiency seemed of little importance in the majority of patients with varicose disease, but the use of ultrasonography has highlighted a new significance of this vein. It can be part of a draining variant of the SSV which continues on to reach the GSV at the proximal third of the thigh instead of draining into the popliteal vein. The direction of its flow is usually anterograde but it can be retrograde when this vein acts as a bypass from an insufficient GSV to SSV to call on this last one to collaborate in draining. Many discussions exist about this vein, some of them confusing to a non-expert reader. Insufficiency in the Giacomini vein can present in isolation but is mostly seen together with a GSV insufficiency. It has been shown to be effectively treated either with endovenous laser ablation or by ultrasound guided sclerotherapy.

<span class="mw-page-title-main">Claude Franceschi</span>

Claude Franceschi is an angiologist French MD.

CHIVA method is a type of surgery used to treat varicose veins that occur as a result of long term venous insufficiency. The term is a French acronym for Conservatrice Hémodynamique de l'Insuffisance Veineuse en Ambulatoire.

References

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