Varicose Veins: the Good, the Bad, and the Ugly

Varicose Veins are incredibly common and affect around 20% of the US population. In many people they are not just a cosmetic nuisance, but can lead to pain, ulcers and swelling and severely affect quality of life.

Why Do Varicose Veins Happen?

High Pressure In the Veins – This is known as venous hypertension, a well-established cause of varicose veins. This can be worsened by failure of the valves in the veins that usually keep blood flowing in the same direction. When there is valvular incompetence, the blood can flow backward, known as venous reflux. Pressures in veins can also be increased by obstruction or narrowing in the veins such as that caused by clot. Usually pumping of the muscles of the leg allows blood to be pumped back towards the upper body. If the calf muscle pump fails then this can lead to pooling of blood and increased pressures leading to varicose veins.

Vein Wall Abnormalities – The walls of the veins themselves can be abnormal or damaged leading to varicose veins. This vein wall damage leads to weakening of the vein and allows them to stretch. There is also evidence of inflammation in the vein walls. Exposure of the veins to high pressures and the development of varicose veins leads to even greater abnormalities in these cells, like a vicious cycle.

Varicose Veins – What Increases the Risk?

• Females – Varicose Veins are much more common in women, and this is felt to be hormonal in nature and due to the female hormone estrogen.
• Lifestyle – Jobs that involve a lot of standing or a lot of sitting can lead to pooling of blood in the veins in the leg, increasing the pressure there and leading to development of varicose veins.
• Smoking – Not only does smoking increase the risk of varicose veins, but it increases the risk of developing associated complications such as ulcers.
• Pregnancy – This causes an increase in the hormone estrogen, and also increased pressure in the veins, both of which are important causes of varicose veins.
• Being Tall – Being tall can lead to increased pressure in the veins in the lower body and development of varicose veins.
• Family history – Family history of vein problems and also incompetent valves in the veins can lead to increased risk of varicose veins.
• Blood Clots – Having had blood clots in the legs increases the chance of development of varicose veins.

Signs and Symptoms of Varicose Veins

There are different categories of varicose veins. Spider veins are small venules in the skin that are <1 mm in diameter. Reticular veins are veins just under the skin that are between 1-3 mm in diameter. Varicose veins in their most well known form are deeper veins that are >3mm in diameter and are large visible structures that can be felt.

The most obvious complaint people have is a cosmetic one, and this is a significant concern for many. There can be aching in the legs and some patients describe a throbbing or burning sensation. There may also be itching of the skin and dry skin with varicose veins.

In advanced chronic vein disease, where there is failure of the valves in the veins, there can be cramps, leg swelling and skin changes. Even worse is the formation of blood clots and ulcers.

How Do Specialists Grade Vein Disease?

Vein disease is graded on a classification scheme known as the CEAP classification. C is the clinical part. This is C0 through C6, where C6. C0 is no clinical signs. C6 is skin changes with ulceration. E stands for etiology that means why did they happen in the first place. A is for anatomy, i.e. deep or superficial veins. P stands for pathophysiology, for example is there reflux from dysfunctional veins in the valves.

Treatment of Varicose Veins

The treatment required for varicose veins depends on how bad the disease is in terms of extent and symptoms. Treatments range from simple lifestyle changes to surgery. Most patients will need a combination of treatments.

Lifestyle Measures

Every patient with varicose veins or at risk for them should adopt lifestyle measures to minimize the risk of their development and to prevent the progression of disease. Overweight people are more likely to develop varicose veins and weight loss is a key part of the treatment program. Exercise, and ensuring regular physical activity involving flexion of the foot and contraction of the calf muscles is important as it improves the calf muscle pump. Its advisable to avoid prolonged standing or sitting, Elevation of the feet several times a day for half an hour at a time can improve symptoms in those with varicose veins. Smoking is a risk factor for varicose veins and should be avoided.

Compression Stockings

Compression stockings are the first step along with lifestyle measures in the treatment of varicose veins. They cannot only help progression of disease, but can also reduce swelling and pain in varicose vein patients. Compression stockings can decrease pressure in the veins that occurs with standing.

Compression stockings should be worn in the day while people are up and about. There are different grades of compression stockings, with stronger stockings for more severe disease. The stocking should cover the entire affected area. Some compression stockings, particularly the strong ones, are hard to put on, and there are in fact devices that are available to help put them on.

Treatment of Smaller Varicose Veins

These include spider veins and reticular veins. These veins are typically treated for cosmetic purposes or in those with symptoms. The treatments for these include treatments known as ablative treatments, which basically means to get rid of them. The techniques used basically injure the walls of the veins and result in the veins closing up. Sclerotherapy is one such technique that involves injecting substances in to the vein to induce a reaction. This may work in over 2/3 patients however it involves needles. In those patients that don’t want needles involved, laser therapy may be an option and is done over the skin.

Treatment of Larger Varicose Veins

It used to be that stripping operations were done for larger varicose veins that involved surgery and large scars. This has now been replaced by the use of endovenous techniques, which is where instruments are placed through the skin into the veins leaving much smaller incisions and is, of course, much less traumatic.

Endovenous treatments basically use radiofrequency energy or laser to injure the veins that results in vein closure. The procedure is done with the patient awake and to prevent pain a local anesthesia is given which basically means the area is numbed. These endovenous treatments have a high success rate. These treatments are felt to be more cost-effective and preferred by patients. As with any treatment, there is a small risk of complication that includes bruising and swelling. More rare but serious complications include clot formation and damage to the nerves.

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