A 38-year-old woman noticed warm, bluish veins behind her knees six months after giving birth to her third child. She was embarrassed to wear skirts and dresses after gaining 20 pounds. She wants her unsightly veins disappear the moment she closes her eyes. Sounds familiar?
Varicose veins are swollen and enlarged veins – usually blue or dark purple – that occur when blood flow is reversed (blood goes downwards instead of upwards). These veins usually occur in the legs, but they also can form in other parts of the body. Imagine, 22 million women and 11 million men between 40 to 80 years of age have varicose veins. Of these, 2 million men and women will develop symptoms and signs of chronic venous insufficiency, a condition that occurs when the venous wall and/or valves in the leg veins are not working effectively, making it difficult for blood to return to the heart from the legs. Even varicose veins alone, without more advanced signs of chronic venous insufficiency, can result in important reductions in quality of life.
Studies show that varicose veins can be related to hormonal disorders, lifestyle (e.g. smoking), or acquired after deep vein thrombosis (DVT) wherein blood clot (thrombus) forms within a deep vein, predominantly in the legs. Increasing venous pressures (venous hypertension), valvular incompetence, structural changes in the vein wall, inflammation, and alterations in shear stress are the major pathophysiological mechanisms resulting in varicose veins.
Symptoms of varicose veins vary according to their size and extent. It can start as an aching or throbbing discomfort, burning, itching, and dry irritated skin. Larger involvement of veins and valvular incompetency may manifest as leg heaviness and fatigue, cramping, hyperpigmentation, swelling (edema), skin changes and crater formation (ulceration).
The clinical evaluation of a patient with varicose veins begins with the physical examination to determine the type, location, extent, and possibly the cause of the venous disease. Varicose veins should be examined in the standing position and inspected for redness, tenderness, or induration that may suggest superficial vein thrombosis. If the cause of varicose veins is not clear from the clinical examination or if an intervention is being considered, venous ultrasonography is used to evaluate presence of venous reflux.
There are several options for the management of varicose veins, including compression hosiery and lifestyle advice, and interventional treatments:
Graduated compression hosiery is widely used as first line treatment for varicose veins. Compression stockings work by compressing the veins to keep them collapsed and empty of blood and thereby pushing more blood into the larger network of veins in the body. This results in a reduction of venous pressure in the leg and subsequently a decrease in leg swelling.
Whether or not more advanced therapies such as ablation are considered, lifestyle modification is crucial to ensure as complete and durable a treatment response as possible. Because varicose veins are associated with obesity, weight loss is an important step in reducing progression and preventing recurrence. Regular physical activity such as walking and foot flexion exercises may improve calf muscle pump function. Elevation of the feet to at least heart level for 30 minutes at least 4 times a day and avoidance of prolonged standing and sitting decompress lower extremity veins and improve symptoms. Smoking cessation should be emphasized in patients with varicose veins.
Creams containing heparinoid, a compound similar to heparin, is also used to improve circulation after bruising or soft tissue injuries including inflammation of a vein in the skin associated with blood clot formation (superficial thrombophlebitis). Heparinoid works by dissolving small blood clots and improving the blood supply to the skin. Heparinoid such as mucopolysaccharide polysulfate cream and gel can be used to help relieve pain and inflammation associated with superficial thrombophlebitis.
Interventional treatments such as surgery, foam sclerotherapy and endothermal ablation are reserved for more complicated cases. Surgery is a traditional treatment that involves surgical removal by 'stripping' out the vein or ligation (tying off the vein). In foam sclerotherapy, a sclerosant foam (irritating agent) is injected into the vein to cause an inflammatory response which consequently closes it. There are two main endothermal methods: radiofrequency and laser ablation, these methods heat the vein from inside causing irreversibly damage to the vein and its lining and closes it off. All treatments may be performed under general or local anesthesia and do not usually require an overnight stay in hospital. Studies demonstrate that the rate of recurring varicose veins at 3 years after treatment is likely to be between 10 to 30%.