Varicose veins

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Varicose veins
Classification and external resources
Leg Before 1.jpg
A person affected by varicose veins.
ICD-10 I83, I84, I85, I86
ICD-9 454-456, 671
OMIM 192200
DiseasesDB 13734
MedlinePlus 001109
eMedicine med/2788
MeSH D014648

Varicose veins are veins that have become enlarged and tortuous (twisted). The term commonly refers to the veins on the leg,[1] although varicose veins can occur elsewhere. Veins have leaflet valves to prevent blood from flowing backwards (retrograde flow or reflux). Leg muscles pump the veins to return blood to the heart (the skeletal-muscle pump), against the effects of gravity. When veins become varicose, the leaflets of the valves no longer meet properly, and the valves do not work (valvular incompetence). This allows blood to flow backwards and they enlarge even more. Varicose veins are most common in the superficial veins of the legs, which are subject to high pressure when standing. Besides being a cosmetic problem, varicose veins can be painful, especially when standing. Severe long-standing varicose veins can lead to leg swelling, venous eczema, skin thickening (lipodermatosclerosis) and ulceration. Life-threatening complications are uncommon, but varicose veins may be confused with deep vein thrombosis, which may be life-threatening.[2][medical citation needed]

Non-surgical treatments include sclerotherapy, elastic stockings, elevating the legs, and exercise. The traditional surgical treatment has been vein stripping to remove the affected veins. Newer, less invasive treatments which seal the main leaking vein are available. Alternative techniques, such as ultrasound-guided foam sclerotherapy, radiofrequency ablation and endovenous laser treatment, are available as well. Because most of the blood in the legs is returned by the deep veins, the superficial veins, which return only about 10% of the total blood of the legs, can usually be removed or ablated without serious harm.[3][4]

Secondary varicose veins are those developing as collateral pathways, typically after stenosis or occlusion of the deep veins, a common sequel of extensive deep venous thrombosis (DVT). Treatment options are usually support stockings, occasionally sclerotherapy, and rarely limited surgery.

Varicose veins are distinguished from reticular veins (blue veins) and telangiectasias (spider veins), which also involve valvular insufficiency,[5] by the size and location of the veins. Many patients who suffer with varicose veins seek out the assistance of physicians who specialize in vein care or peripheral vascular disease. These physicians include vascular surgeons, phlebologists or interventional radiologists.

Signs and symptoms[edit]

  • Aching, heavy legs (often worse at night and after exercise).
  • Appearance of spider veins (telangiectasia) in the affected leg.
  • Ankle swelling, especially in evening.
  • A brownish-yellow shiny skin discoloration near the affected veins.
  • Redness, dryness, and itchiness of areas of skin, termed stasis dermatitis or venous eczema, because of waste products building up in the leg.
  • Cramps may develop especially when making a sudden move as standing up.
  • Minor injuries to the area may bleed more than normal or take a long time to heal.
  • In some people the skin above the ankle may shrink (lipodermatosclerosis) because the fat underneath the skin becomes hard.
  • Restless legs syndrome appears to be a common overlapping clinical syndrome in patients with varicose veins and other chronic venous insufficiency.
  • Whitened, irregular scar-like patches can appear at the ankles. This is known as atrophie blanche.

Clinical Tests[edit]

Clinical tests that may be used include:

Investigations[edit]

Traditionally, varicose veins were only investigated using imaging techniques if there was a clinical suspicion of deep venous insufficiency, if they were recurrent, or if they involved the sapheno-popliteal junction. This practice is not now widely accepted. All patients with varicose veins should now be investigated using Duplex doppler ultrasound scanning. The results from a randomised controlled trial (RCT) on the follow up of patients with and without routine Duplex scan has shown a significant difference in recurrence rate and reoperation rate at 2 and 7 years of follow up. .[6]

Complications[edit]

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

  • Pain, tenderness, heaviness, inability to walk or stand for long hours, thus hindering work
  • Skin conditions / Dermatitis which could predispose skin loss
  • Skin ulcers especially near the ankle, usually referred to as venous ulcers.
  • Development of carcinoma or sarcoma in longstanding venous ulcers. There have been over 100 reported cases of malignant transformation and the rate is reported as 0.4% to 1%.[7]
  • Severe bleeding from minor trauma, of particular concern in the elderly.
  • Blood clotting within affected veins. Termed superficial thrombophlebitis. These are frequently isolated to the superficial veins, but can extend into deep veins becoming a more serious problem.
  • Acute fat necrosis can occur, especially at the ankle of overweight patients with varicose veins. Females are more frequently affected than males.

Stages[edit]

  • C0 no visible or palpable signs of venous disease
  • C1 telangectasia or reticular veins
  • C2 varicose veins
  • C3 edema
  • C4a skin changes due to venous disorders: pigmentation, eczema
  • C4b skin changes due to venous disorders: lipodermatosclerosis, atrophie blanche
  • C5 as C4 but with healed ulcers
  • C6 skin changes with active ulcers (venous insufficiency ulceration)

Causes[edit]

The illustration shows 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

Varicose veins are more common in women than in men, and are linked with heredity.[8] 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.[9] Less commonly, but not exceptionally, varicose veins can be due to other causes, as post phlebitic obstruction or incontinence, venous and arteriovenous malformations[10]

Varicose veins could also be caused by elevated levels of homocysteine 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. See also for differential diagnosis- 1. Klippel-Trenaunay syndrome, 2. Parkes-Weber syndrome

Treatment[edit]

Conservative[edit]

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

  • Elevating the legs often provides temporary symptomatic relief.
  • Advice about regular exercise sounds sensible but is not supported by any evidence.[11]
  • The wearing of graduated compression stockings with variable pressure gradients (Class II or III) has been shown to correct the swelling, nutritional exchange, and improve the microcirculation in legs affected by varicose veins.[12] They also often provide relief from the discomfort associated with this disease. Caution should be exercised in their use in patients with concurrent arterial disease.
  • The wearing of intermittent pneumatic compression devices have been shown to reduce swelling and increase circulation[medical citation needed]
  • Diosmin/Hesperidine and other flavonoids.
  • Anti-inflammatory medication such as ibuprofen or aspirin can be used as part of treatment for superficial thrombophlebitis along with graduated compression hosiery – but there is a risk of intestinal bleeding. In extensive superficial thrombophlebitis, consideration should be given to anti-coagulation, thrombectomy or sclerotherapy of the involved vein.[medical citation needed]
  • Topical gel application, helps in managing symptoms related to varicose veins such as inflammation, pain, swelling, itching and dryness. Topical application-Non invasive and has patient compliance.[medical citation needed]

Active[edit]

Active medical intervention in varicose veins can be divided into surgical and non-surgical treatments. Some doctors favor traditional open surgery, while others prefer the newer methods. Newer methods for treating varicose veins such as Endovenous Thermal Ablation (endovenous laser treatment or radiofrequency ablation), and foam sclerotherapy are not as well studied, especially in the longer term.[13][14]

Surgical[edit]

Several techniques have been performed for over a century, from the more invasive saphenous stripping, to less invasive procedures like ambulatory phlebectomy and CHIVA.

Stripping[edit]

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%),[15] pulmonary embolism (0.06%), and wound complications including infection (2.2%). There is evidence for the Great Saphenous Vein growing back again after stripping.[16] For traditional surgery, reported recurrence rates, which have been tracked for 10 years, range from 5–60%. 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)[17]

Other[edit]

Other surgical treatments are:

  • Ambulatory phlebectomy
  • Vein ligation
  • Cryosurgery- A cryoprobe is passed down the long saphenous vein following saphenofemoral ligation. Then the probe is cooled with NO2 or CO2 to a temperature of −85o. The vein freezes to the probe and can be retrogradely stripped after 5 second of freezing. It is a variant of Stripping. The only point of this technique is to avoid a distal incision to remove the stripper.[18]

Non-surgical treatment[edit]

Sclerotherapy management[edit]

A commonly performed non-surgical treatment for varicose and "spider" leg veins is sclerotherapy in which medicine (sclerosant) is injected into the veins to make them shrink. The medicines that are commonly used as sclerosants are polidocanol (POL), sodium tetradecyl sulphate (STS), Sclerodex (Canada), Hypertonic Saline, Glycerin and Chromated Glycerin. STS (branded Fibrovein in Australia) and Polidocanol (branded Asclera in the United States, Aethoxysklerol 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. Sclerotherapy has been used in the treatment of varicose veins for over 150 years.[7] Sclerotherapy is often used for telangiectasias (spider veins) and varicose veins that persist or recur after vein stripping.[19][20] Sclerotherapy can also be performed using foamed sclerosants under ultrasound guidance to treat larger varicose veins, including the great saphenous and small saphenous veins.[21][22] A study by Kanter and Thibault in 1996 reported a 76% success rate at 24 months in treating saphenofemoral junction and great saphenous vein incompetence with STS 3% solution.[23] A Cochrane Collaboration review[20] concluded sclerotherapy was better than surgery in the short term (1 year) for its treatment success, complication rate and cost, but surgery was better after 5 years, although the research is weak.[24] A Health Technology Assessment found that sclerotherapy provided less benefit than surgery, but is likely to provide a small benefit in varicose veins without reflux.[25] This Health Technology Assessment monograph includes reviews of the epidemiology, assessment, and treatment of varicose veins, as well as a study on clinical and cost effectiveness of surgery and sclerotherapy. 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.[26][27] There has been one reported case of stroke after ultrasound guided sclerotherapy when an unusually large dose of sclerosant foam was injected.

Endovenous thermal ablation[edit]

The Australian Medical Services Advisory Committee (MSAC) in 2008 has 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."[28] 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%)[29] and temporary paraesthesia (2.1%). The longest study of endovenous laser ablation is 39 months.

Two prospective randomized trials found speedier recovery and fewer complications after radiofrequency ablation (ERA) compared to open surgery.[30][31] Myers[32] 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%. In 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%.

ELA and ERA require specialized training for doctors and expensive equipment. ELA is performed as an outpatient procedure and does not require the use of an operating theatre, nor does the patient need a general anaesthetic. Doctors must use high frequency ultrasound during the procedure to visualize the anatomical relationships between the saphenous structures. Some practitioners also perform phlebectomy or ultrasound guided sclerotherapy at the time of endovenous treatment. Follow-up treatment to smaller branch varicose veins is often needed in the weeks or months after the initial procedure.

See also[edit]

References[edit]

  1. ^ "Varicose Veins". 2010-07-06.  Mount Sinai Hospital, New York
  2. ^ Żylaki – Przewlekła niewydolność żylna: Zakrzepica – Medycyna Praktyczna: Lekarze pacjentom. Zakrzepica. Retrieved on 2013-09-02.
  3. ^ Merck Manual Home Edition, 2nd ed. Merck.com. Retrieved on 2013-09-02.
  4. ^ "Varicose veins". in Health Encyclopaedia. nhsdirect.nhs.uk
  5. ^ Weiss RA, Weiss MA (1993). "Doppler ultrasound findings in reticular veins of the thigh subdermic lateral venous system and implications for sclerotherapy". J Dermatol Surg Oncol 19 (10): 947–51. doi:10.1111/j.1524-4725.1993.tb00983.x. PMID 8408914. 
  6. ^ Blomgren L, Johansson G, Emanuelsson L, Dahlberg-Åkerman A, Thermaenius P, Bergqvist D. Late follow-up of a randomized trial of routine duplex imaging before varicose vein surgery. Br J Surg. 2011 Aug;98(8):1112-6. doi:10.1002/bjs.7579.
  7. ^ a b Goldman M. (1995) Sclerotherapy, Treatment of Varicose and Telangiectatic Leg Veins. Hardcover Text, 2nd Ed.
  8. ^ Ng M, Andrew T, Spector T, Jeffery S (2005). "Linkage to the FOXC2 region of chromosome 16 for varicose veins in otherwise healthy, unselected sibling pairs". Journal of Medical Genetics 42 (3): 235–9. doi:10.1136/jmg.2004.024075. PMC 1736007. PMID 15744037. 
  9. ^ Kate Griesmann (March 16, 2011). "Myth or Fact: Crossing Your Legs Causes Varicose Veins". Duke University Health System. Retrieved March 1, 2014. 
  10. ^ Franceschi, Claude (1996) "Physiopathologie Hémodynamique de l'Insuffisance veineuse", p. 49 in Chirurgie des veines des Membres Inférieurs, AERCV editions 23 rue Royale 75008 Paris France.
  11. ^ Campbell B (2006). "Varicose veins and their management". BMJ 333 (7562): 287–92. doi:10.1136/bmj.333.7562.287. PMC 1526945. PMID 16888305. 
  12. ^ Curri SB et al. (1989) "Changes of cutaneous microcirculation from elasto-compression in chronic venous insufficiency". In Davy A and Stemmer R (eds.) Phlebology '89, Montrouge, France, 'John Libbey Eurotext.
  13. ^ "Open Surgery Is Still The Best Technique To Ablate The Great Saphenous Vein Vascular, Vol. 14 (November 2006), Suppl. 1, p. S. 25
  14. ^ Jia, X; Mowatt, G; Burr, JM; Cassar, K; Cook, J; Fraser, C (2007). "Systematic review of foam sclerotherapy for varicose veins". The British journal of surgery 94 (8): 925–36. doi:10.1002/bjs.5891. PMID 17636511. 
  15. ^ van Rij AM, Chai J, Hill GB, Christie RA (2004). "Incidence of deep vein thrombosis after varicose vein surgery". Br J Surg 91 (12): 1582–5. doi:10.1002/bjs.4701. PMID 15386324. 
  16. ^ Munasinghe A, Smith C, Kianifard B, Price BA, Holdstock JM, Whiteley MS (2007). "Strip-tract revascularization after stripping of the great saphenous vein". Br J Surg 94 (7): 840–3. doi:10.1002/bjs.5598. PMID 17410557. 
  17. ^ Hammarsten J, Pedersen P, Cederlund CG, Campanello M (1990). "Long saphenous vein saving surgery for varicose veins. A long-term follow-up". Eur J Vasc Surg 4 (4): 361–4. doi:10.1016/S0950-821X(05)80867-9. PMID 2204548. 
  18. ^ Shouten R, Mollen RM, Kuijpers HC (2006). "A comparison between cryosurgery and conventional stripping in varicose vein surgery: perioperative features and complications". Annals of vascular surgery 20 (3): 306–11. doi:10.1007/s10016-006-9051-x. PMID 16779510. 
  19. ^ Pak, L. K. et al. "Veins & Lymphatics," in Lange's Current Surgical Diagnosis & Treatment, 11th ed., McGraw-Hill.
  20. ^ a b Tisi, Paul V; Beverley, Catherine; Rees, Angie (2006). Injection sclerotherapy for varicose veins. In Tisi, Paul V. "Cochrane Database of Systematic Reviews". Cochrane Database Syst Rev (4): CD001732. doi:10.1002/14651858.CD001732.pub2. PMID 17054141. 
  21. ^ Thibault, Paul (2007) Sclerotherapy and Ultrasound-Guided Sclerotherapy, The Vein Book, John J. Bergan (ed.).
  22. ^ Padbury A, Benveniste G L (December 2004). "Foam echosclerotherapy of the small saphenous vein". Australian and New Zealand Journal of Phlebology 8 (1). 
  23. ^ Kanter A, Thibault P (1996). "Saphenofemoral incompetence treated by ultrasound-guided sclerotherapy". Dermatol Surg 22 (7): 648–52. doi:10.1016/1076-0512(96)00173-2. PMID 8680788. 
  24. ^ Rigby KA, Palfreyman SJ, Beverley C, Michaels JA (2004). "Surgery versus sclerotherapy for the treatment of varicose veins". In Rigby, Kathryn A. Cochrane Database Syst Rev (4): CD004980. doi:10.1002/14651858.CD004980. PMID 15495134. 
  25. ^ Michaels JA; Campbell WB; Brazier JE; MacIntyre, JB; Palfreyman, SJ; Ratcliffe, J; Rigby, K (2006). "Randomised clinical trial, observational study and assessment of cost-effectiveness of the treatment of varicose veins (REACTIV trial)". Health Technol Assess 10 (13): 1–196, iii–iv. PMID 16707070. 
  26. ^ Finkelmeier, William R. (2004) "Sclerotherapy", Ch. 12 in ACS Surgery: Principles & Practice, WebMD, ISBN 097483274X.
  27. ^ Scurr JR, Fisher RK, Wallace SB (2007). "Anaphylaxis Following Foam Sclerotherapy: A Life Threatening Complication of Non Invasive Treatment For Varicose Veins". EJVES Extra 13 (6): 87–89. doi:10.1016/j.ejvsextra.2007.02.005. 
  28. ^ Medical Services Advisory Committee, ELA for varicose veins. MSAC application 1113, Dept of Health and Ageing, Commonwealth of Australia, 2008.
  29. ^ Elmore FA, Lackey D (2008). "Effectiveness of ELA in eliminating superficial venous reflux". Phlebology 23 (1): 21–31. doi:10.1258/phleb.2007.007019. PMID 18361266. 
  30. ^ Rautio TT, Perälä JM, Wiik HT, Juvonen TS, Haukipuro KA (2002). "Endovenous obliteration with radiofrequency-resistive heating for greater saphenous vein insufficiency: a feasibility study". J Vasc Interv Radiol 13 (6): 569–75. doi:10.1016/S1051-0443(07)61649-2. PMID 12050296. 
  31. ^ Lurie F; Creton D; Eklof B; Kabnick, L.S.; Kistner, R.L.; Pichot, O.; Sessa, C.; Schuller-Petrovic, S. (2005). "Prospective randomised study of endovenous radiofrequency obliteration (closure) versus ligation and vein stripping (EVOLVeS): two-year follow-up". Eur J Vasc Endovasc Surg 29 (1): 67–73. doi:10.1016/j.ejvs.2004.09.019. PMID 15570274. 
  32. ^ Myers, Kenneth (December 2004). "An opinion — surgery for small saphenous reflux is obsolete!". Australian and New Zealand Journal of Phlebology 8 (1). 

External links[edit]