Varicosed Veins:

There are a large number of veins located immediately under the skin in the human body. They are responsible to bring the blood returning from the tissues to the heart. These veins may enlarge, loose function and may appear unsightly for several reasons.

Varicose veins are abnormal and irreversible dilatation of the blood vessels collecting deoxygenated blood from the body. They appear as blue and convoluted bulges in the lower extremities.

Varicose veins can be seen in 15-20% of men and 30-35% of women during different periods of life in Caucasian population.

 

Varicose veins cause pain and pressure sensation in the calf and thigh as well as swelling and bluish discoloration in the ankles. Symptoms usually get worse with long periods of standing and sitting. Untreated, varicose veins may progress and sometimes result in ulceration in the ankle.

There are many theories in the etiology of the varicose veins however the only common denominator is malfunctioning or damage to the valves located in the veins. Valves in the veins ensure propagation of blood in one direction-to the heart- and help veins overcome the forces of gravity and hence prevent reflux of blood into the legs and feet. As the valves loose function, deoxygenated blood will accumulate in the legs and result in pain and discomfort as well as typical appearance of varicose veins. This problem may be due to genetic (familial) causes or it may be due to acquired conditions.

There are many medical conditions that will result in or exacerbate varicose veins. These are:

1. Pregnancy: The circulating blood volume almost doubles during pregnancy. Return of blood from the lower extremities is also impeded due to pressure of the fetus on the pelvis. Hormones that are secreted during pregnancy will weaken the blood vessels and may result in varicose veins. Varicose veins acquired at the time of pregnancy may disappear in the first 12 months after delivery or more commonly they persist and progress over the next pregnancies.
2. Standing for prolonged period of time
3. Excess weight
4. Tobacco use
5. Age: Although varicose veins can be seen at any age, incidence increases with advanced age

Symptoms:
Varicose veins may be disturbing cosmetically as they are readily seen and can be felt under the skin as bulging blood vessels. They can also cause heaviness, pain and sometimes itching or burning sensation in the legs and feet. Complaints usually increase with prolonged standing. Patients may occasionally feel severe pain or cramping while standing from a sitting or recumbent position. Varicose veins are more prone to get superficial thrombophlebitis. This will result in pain, redness and swelling as well as local heat in the area of varicose veins. Varicose veins are also associated with a small increase in the incidence of deep vein thrombosis. Deep vein thrombosis is characterized by sudden swelling and severe pain in the ankle and calf. Varicose veins however may not cause any problems whatsoever.

DIAGNOSIS:
The doctor visit for varicose veins will start with questions regarding your general medical background and your home and work environment. Your doctor may ask for a test called a Duplex venous ultrasound after physical examination. This test will examine the abnormal blood vessels and determine the direction of blood flow in your veins. Ultrasound is a painless test and results are very important in the decision making for treatment of your condition.

TREATMENT:
Untreated varicose veins usually progress and worsen over time. Your doctor will outline the treatment plan after reviewing the Duplex ultrasound test. Early stage varicose veins can be treated with elastic compression stockings and leg elevation.

There are several treatment options for advanced stage varicose veins:

1. Sclerotherapy:A chemical solution is injected into the lumen of the varicose veins. The chemical will cause scarring of the veins and result in closure of the vessel lumen. This technique is most effective for small spider veins (capillary varicose veins).

2. Varicose vein surgery (vein stripping): Abnormal veins are removed surgically usually in the operating room using two small incisions (one in the groin and the other inside the leg at the knee level). The operation is usually done under general anesthesia and will last about 45 minutes. Patients are discharged home the same day or next day. You should be able to resume regular activities in 1-2 weeks. This technique is proven to be the most effective treatment modality for advanced stage varicose veins. Recurrence rates are less than 5%.

3. Endovascular Ablation: This technique entails closure of the varicose blood vessels with the help of radiofrequency or laser energy from within the vein lumen. A relatively thin walled vessel with a rather straight course is required for best results. It can be performed with local or general anesthesia. Since many varicose veins are rather long standing and have thick walls and large diameter, the amount of energy required to close the vessel can be high. This may result in damage to the surrounding tissues as well as neighboring nerves. This is a relatively new technique and long term results are still lacking. Recurrence rate may be higher than open surgical techniques.

Schematic demonstration of endovascular laser ablation technique

4. Excision of individual variceal protuberances: This procedure id usually performed together with open variceal surgery. Individual small stab wound are used to extirpate variceal clusters.

5. Leg Ulcers due to Long Standing Varicose Veins and Venous Insufficiency: Chronic ankle ulcers are usually due to long standing venous insufficiency of the deep and perforating vein systems. Venous blood is rerouted to the superficial system due to previous blood clots in the deep veins or due to valvular incompetence of the deep venous system. This leads to increased venous pressure in the most dependent part of the lower extremity-the ankle. Many of the chronic leg ulcers have periods of rexaccerbations and remissions however some may never heal. Although variable response rates have been obtained with special ointments and compression bandages, recurrences are very common. Interruption of the connections between the deep and the superficial venous systems using endoscopic techniques is the treatment of choice in this patient group and promotes ulcer healing in over 80% with a low recurrence rate.