Varicose Veins

Introduction:

The veins are blood vessels which return blood to the heart after it has been supplied to the organs by the pulsatile arteries originating in the heart.

The return of the blood to the heart, particularly from the legs and the lower parts of the body, is more difficult to achieve than the distribution of the blood to the arteries. This is because the veins are not pulsatile and the venous drainage of the blood is rather passive, and occurs against the gravitational forces. The contraction of the muscles of the lower extremities compresses the peripheral veins and assists in the venous return. Furthermore, one-way valves inside the veins prevent the blood from flowing backwards.

The deep veins of the legs are the ones which finally drain the blood into the internal large veins and from there into the heart. The superficial veins of the legs drain through “communicating” (so called “perforating” veins) into the deep veins of the legs. It is therefore clear that the legs have a tri-dimensional inter-relating venous drainage, (the deep veins, the perforating veins and the superficial veins) and that disturbances of flow in one compartment may affect the others. This is particularly true for disturbances of deep and/or perforating veins affecting the superficial veins.

Varicose veins are enlarged veins resulting from disturbances of blood flow and/or from incompetent or malfunctioning venous valves. They may occur in various locations but are most common in the lower extremities, especially on the back of the calf and the inside of the leg. The veins’ varicosities develop gradually following a stepwise increase in the volume and pressure of the blood within the veins and subsequent failure of the system of valves to control the flow and pressure.

Varicose veins are a very common condition and are found in an estimated 80 million Americans. They are much more common in women and as many as 60% of all women may eventually develop varicose veins as opposed to 10-20% of men.

Superficial veins varicosities or primary varicose veins:

Superficial or primary varicosities develop within the superficial veins themselves just beneath the skin. There are two types of superficial varicose veins:

1. “Spider veins,” meshwork or webs of delicate, thin veins that occur primarily on the face and legs.
2. Larger “varicose veins” of the lower extremities that present as “snaky” bluish-red cords or tubular structures. They occur much more frequently in women than men. This is a particularly cruel twist of fate since society puts so much more emphasis on the appearance of women’s legs than those of men. Primary varicose veins alone are generally benign and aside from minor complications are usually no more than a cosmetic nuisance.

Deep or perforating veins varicosities (secondary varicosities):

In secondary varicosities the venous enlargement occurs as a result of blood flow interferences such as obstructions in the perforating or larger deep veins. This leads to a backup of the blood flow into the superficial veins, leading to their enlargement. A poorly draining deep venous system will result in a reduced venous blood return to the heart from the legs, chronic swelling of the lower extremities, and an impaired blood circulation to the skin of the legs.

The most feared complication of impaired flow of blood from the lower extremities is Pulmonary Embolism, i.e., blood clots migrating to the lungs from veins of the legs. When the normally smooth flow of blood is hindered, there is a significant potential for blood clots (thrombi) to form within the veins, a condition known as thrombophlebitis. The clots may eventually dislodge and float with the returning blood stream, up to the heart and from there to the lungs through the pulmonary arteries. In the lungs, the clots (thrombo-emboli) can get trapped in the pulmonary blood vessels, interrupting the flow of blood to a section of the lung. This leads to a decrease in the oxygenation of the blood. Depending on the size of the blood clots and the vessels affected, the symptoms can vary from mild shortness of breath to severe respiratory distress and sudden death.

Causes and risk factors for varicose veins:

Quite a number of factors play an important role in the formation of varicose veins, alone or in combination. They include:

• Gender - Women are more affected for undetermined reasons, perhaps because of their estrogens hormones. Hormonal changes at menopause are also considered to be a risk factor for varicose veins.
• Older age - In older people the walls of the veins may weaken and lose their elasticity and this results in dilatation and formation of varicosities. However it should be emphasized that young people also may often develop varicose veins if they have one or more significant risk factors.
• Obesity - This condition increases the pressure on the blood vessels returning the blood to the heart.
• Heredity - Many of the people suffering from varicose veins, have a parent or a grand parent who had also suffered from the same condition.
• Prolonged standing - The body’s mass and gravity oppose the return of the blood to the heart and favor reflux of the blood flow with secondary damage to the valves of the veins of the lower extremities.
• Pregnancy - A very common cause of varicose veins is pregnancy. The enlarged uterus compresses the large veins in the pelvis causing the flow of blood to stagnate and raising the venous blood pressure. The increased venous blood pressure is then transmitted back into the deep veins of the lower extremities and eventually into the superficial veins. The condition usually improves after delivery, but because the venous valves have often become somewhat damaged, it may well persist in a milder form.
• Congestive heart failure can also promote the development of varicose veins. This is due to the backup of pressure into the venous system of the body because of the weakened pumping force of the failing heart.
• Pelvic tumors compressing the pelvic veins and interfering with the venous supply from the legs.
• Venous inflammation and clotting (thrombophlebitis) may occasionally precede rather than follow the development of varicose veins.

Symptoms and diagnosis:

The symptoms associated with varicose veins vary according to the location and severity of the condition. The symptoms range from dull aches and a sense of heaviness of the legs in the case of injury limited to the superficial veins to more severe symptoms, when the superficial veins varicosities reflect damage to the deeper veins.

Such symptoms include:

• Considerable aching or cramps of the legs, particularly after prolonged sitting or standing. The pain is usually relieved when the leg is elevated.
• Skin changes - usually with brown pigmentation and induration or eczema of the skin (so called “venous stasis” or venous blood stagnation). The skin changes usually result from the force of gravity and valve failure in the perforating veins.
• Swelling of the legs (edema).
• Itching (the skin becomes dry and irritated over the varicosities).
• Inflammation of the varicose veins (phlebitis).
• Skin ulcers - because of associated venous back flow and insufficient blood supply to the skin. Varicose ulcers will not heal as long as the veins associated with it remain under increased pressure.
• Bleeding - uncommonly a varicose vein may be torn by trauma with resulting bleeding. Bleeding from the swollen veins can occasionally occur with very minimal trauma. These episodes are quite annoying, as the bleeding often comes from a pin point sized hole but can be very difficult to stop because of the increased pressure within the vein.

It is important to see a doctor if any of the above manifestations of varicose veins are present. The reasons for that are not just evaluation and possible treatment, but the possibility that the varicose veins are due to more malignant causes, such as a compressing tumor, which may require prompt medical attention. Furthermore it is important to exclude other diseases that may masquerade as symptoms of varicose veins. For example lumbar nerve root irritation, osteoarthritis of the hip or knee or arterial disease of the legs, or neurological damage in alcoholics may cause pain, skin tenderness or other symptoms mimicking those of varicose veins.

Treatment:

Because of the unsightliness of varicose veins, most people would like to have the situation corrected. The measures employed are usually conservative, at least in the beginning. Walking is good as it helps promote the return of blood up the leg by the actions of the muscles. When seated the legs should be elevated in order to neutralize the force of gravity. Elastic support stockings are also used to maintain external pressure on the veins and promote blood return.

In cases in which the varicosities are more severe, such as when skin ulcers develop or where cosmetically the varices are virtually disfiguring, surgery may be necessary. This involves sclerotherapy or vein stripping or both. Sclerotherapy involves injecting an irritant solution into the vein. The solution then causes a reaction within the vein that leads to scarring and closing of the channel in the vessel. Vein stripping involves making incisions in the skin over the vessel, tying off the ends and pulling the section of vein out of the leg. The removal of the superficial veins is safe and effective because the deep veins are the major draining veins of the legs. The procedure involves minimal discomfort and recovery time. Although about 85% of the people who have this surgery have good results and no recurrences, the remaining 15% experience recurrences and may require additional minor surgery.

More recent treatment include the use of Lasers and Photoderm treatment. Photoderm treatment involves the application of an intense pulsed light source to the affected veins. Photoderm is claimed to be less invasive and not to cause bruising or scarring as seen following laser therapy.

Prevention Measures:

A few simple measure can prevent, delay or minimize the development of varicose veins, especially in people at risk:

• Avoidance of prolonged sitting or standing. If the job requires prolonged sitting a brief walk every 30 minutes or so may be helpful. During a long trip by car stop every hour or so, and walk for a minute or two. During a plane flight walk for a couple of minutes along the aisle or move your legs while sitting, every 30-40 minutes..
• One should never wear stockings, garters or socks which constrict the blood flow in the thigh or at the knee.
• Leg exercises (walking, jogging, running, cycling, aerobics, cycling or swimming) enable the muscles of the legs to push blood up the vein.
• Avoiding excessive weight gain.
• Sleeping at night with legs elevated to permit gravity to assist in the venous drainage
• Legs should not be crossed at the knee as this interferes with the flow of blood.
• Pregnant women should wear elastic stockings. A stocking that reaches the knee is usually sufficient but occasionally a higher stocking may be required.
• Persons confined to bed should wear light elastic hose and move their legs as much as possible.

Varicose veins in locations other than the legs:

Varicose veins occur also in other locations than the legs. Most common are the hemorrhoids (varicose veins in the area of the anus) and varicose veins of the vagina during pregnancy. Varicose veins may also occur in the blood vessels around the testes (varicocele).

A very dangerous type of varicose vein occurs in the esophagus (gullet) in patients suffering of cirrhosis of liver due to alcohol abuse. In such patients the scarred liver interferes with the blood drainage from the intestines, and blood bypasses through the upper stomach and esophagus resulting in esophageal varices that may rupture and cause severe or fatal bleeding.

Summary:

Varicose veins are a common problem that affect a large part of the population, especially women. Some relatively simple steps can be taken to alleviate their symptoms in many instances, however, more serious cases require medical attention. When necessary, surgical procedures can be performed which will help the more severe cases.