Veins are, of course, vascular tubes that return blood to the heart. Consequently, the return of blood from the legs to the heart must defy gravity. Inside the veins are paired sets of tiny, one-way valves to help propel blood back to the heart. Now take a moment to think about the distance, the increased pressure, and the gravitational challenge to venous return posed by obesity. Still, see the picture? Let’s proceed. Between 70% and 90% of such varicosities are due to incompetent valves in the deep veins – a condition that commonly progresses to cause varicose veins in the superficial venous system. This “primary” cause in the development of varicose veins is a common point skipped over in many ultrasound reports and is frequently ignored by physicians during the examination of patients with either cosmetic spider veins or varicose veins.
Definition of Varicose Veins
Veins contain one-way valves to prevent blood from flowing backwards. If the walls of the vein become stretched and less flexible (elastic), the valves may become weak. This will allow blood to flow backwards and pool in the vein, causing the vein to become varicose. Varicose veins are veins that have become enlarged and twisted. The term commonly refers to the veins on the leg, although varicose veins can occur elsewhere. In the superficial system, which is close to the skin, there are perforator veins that have extra valves to prevent blood flowing backwards from the deep to the superficial veins. If high pressure in the deep vein system is passed to the superficial veins, it will cause the perforator veins to stretch and the valves to become weak. This will lead to varicose veins and skin damage.
In a healthy person, blood is filtered by the kidneys, and returns to the heart through a series of arteries and veins. The heart then pumps the blood from the arteries back to the rest of the body. Veins in the legs return blood to the heart through a system called the deep vein system. This deep system is more important than the superficial system in returning blood back to the heart.
Varicose vein and varicose veins, an Italian word means “twisted”.
Causes of Varicose Veins
Varicose veins are caused by failing valves within the veins that allow blood to flow in the wrong direction. This results in the congestion of blood in the legs. High blood pressure within the superficial leg veins, caused by long standing or sitting, is the most common cause of varicose veins. The reason why this occurs is not entirely understood. The presence of a deep vein thrombosis occasionally results in the development of secondary varicose veins. This happens because the deep vein thrombosis causes damage to the valves in the deep veins. Superficial veins then develop as a secondary channel for the return blood flow since the deep veins are blocked. This then causes the superficial veins to become varicose. Various other factors may cause varicose vein development or the worsening of an already existing case. These include an increase in age, female gender, family history, obesity, pregnancy and leg injury. Varicose veins often progress slowly over many years. During this time there are sometimes further changes in the vein and the surrounding tissues, caused by the continued increased pressure inside the veins. This may result in the development of skin changes or even venous leg ulcers.
Symptoms of Varicose Veins
Heavy, tired legs, swollen feet and ankles, and a change in skin color are all common symptoms of varicose veins. Typically, the symptoms are worse during very warm weather or if you have been standing up for long periods. Symptoms can also be worse during the menstrual cycle. These symptoms may be worse at the end of the day. Simple measures to ease the discomfort include rest, elevation of the legs, and the use of elastic support stockings. Although varicose veins are not always symptomatic, they are always progressive. Sometimes more troublesome symptoms are caused by the condition or are due to a complication. An itchy rash (varicose eczema) can be particularly disturbing, often over the lower part of the leg. If severe, dry, red, irritable areas often with skin staining affecting both ankles and consisting of small ulcers (petal ulcers) may develop. These latter symptoms indicate more severe venous problems which, if left untreated, can lead to long-term skin damage. In the long term, swollen ankles and brown skin discoloration near the lower part of the leg may be a sign of lipodermatosclerosis, a condition which if left untreated can cause changes in the skin to become irreversible.
Treatment Options
In the category of self-care, exercise is the most important measure. It is important to break the cycle of inactivity which aggravates the condition. Walking is an excellent form of exercise, since it tones the calf-muscle pump and encourages blood to flow up from the legs. It is wise to avoid activities that are stop/start in nature, such as tennis and badminton. Leg elevation is also recommended. Patients should spend 30 minutes with their legs elevated above the level of their heart to improve symptoms. This can be especially useful at the end of the day to relieve leg symptoms. High quality elastic compression stockings may also be used to help prevent skin changes from venous disease. They act as a “second skin” to provide gradient pressure on the veins and enhance the calf muscle pump. If properly fitted, compression stockings can be worn all day. This treatment allows patients to avoid the potential risks and complications of surgery if this is not considered in their best interest.
When medical advice is considered appropriate, the goal of treatment for varicose veins and spider veins is to relieve symptoms, prevent further complications, and improve their appearance. In addition to surgery, there are a number of lifestyle changes and alternative treatments that may benefit patients with varicose veins.
Non-Surgical Treatments
Non-surgical treatments that can be completed in a doctor’s office are becoming quite popular for patients with small to medium size varicose veins. These methods concentrate on the occlusion closure of the greater saphenous vein. The procedures are minimally invasive and require percutaneous access. Local or regional anaesthetic is often used. The VNUS closure system delivers radiofrequency energy to the vein wall and lumen with less pain and bruising as compared to endovenous laser. This mode of treatment is highly successful, less painful and a better long-term result than the previously popular method of vein stripping. Sclerotherapy is another alternative to vein stripping. It is often used to treat the minor form of varicose veins. A solution is injected into the veins which make them collapse so that blood can no longer flow through them. The collapsed vein is reabsorbed back into local tissue and eventually fades. Foam sclerotherapy has been shown to be more effective than liquid sclerotherapy, particularly for larger veins. However, foam sclerotherapy requires more monitoring with ultrasound imaging to ensure that it has been administered effectively to its target site and is not going to cause deep vein thrombosis in the greater saphenous vein. A more recent, but less known treatment is mechanico-chemical occlusion. This method involves a catheter that rotates within the vein to cause endothelial damage. During the treatment the vein is flushed with a detergent solution to cause sclerosis. Again this procedure provides an alternative means to vein stripping. All of these procedures have a shorter recovery time and are more cost-effective than conventional vein stripping. High compression stockings are required after treatment for a period, usually 2 weeks.
Surgical Treatments
The main surgical treatments for varicose veins are ligation and stripping, phlebectomy, and endoscopic surgery. Ligation and stripping is the removal of the incompetent greater saphenous vein. This operation involves tying off the vein at the upper end and then removing it. Stripping is a blind technique and frequently causes damage to the surrounding tissues and less frequently nerve damage. A recently formed technique for ligation and stripping, which can be more effective, is echo-guided sclerotherapy. This involves injecting a small amount of solution of sclerosant into the vein, then using high-resolution ultrasound applied over the skin, the position of the injected solution can be seen in the vein. If it is in the correct place, then there will be some bright echoes seen in the vein as a result of the air bubbles since the sclerosant is not visible with the ultrasound. This procedure can prevent unnecessary stripping and reduce the risk of damaging the surrounding tissues. High ligation of the greater saphenous vein is a technique that is commonly used with endoscopic surgery or stripping and should be a standard component of varicose vein surgery. Phlebectomy is the extraction of the smaller varicose veins in the legs. It is a simple and more powerful operation that will diminish the pain and bruising of the previously used techniques. A surgical hook is inserted at the site of the vein, and an incision is made to pull the vein out. This is done in local anesthesia and skin sterility on an outpatient basis and is the treatment of choice for some patients. This is successful when it is clear what the cause of the varicose vein is, as in the instance of incompetence of the short saphenous vein. Endoscopic surgery can be another surgical treatment option for varicose veins. This is usually used as a last resort if other procedures have failed. A small incision is made just below the patient’s knee, and using an endoscope, the surgeon will identify the vein and use a flexible catheter to destroy it. With these surgical treatments, there is the risk of deep vein thrombosis, and all patients will have postoperative pain. This can be managed with simple analgesics to prescription of opioids, but most of the pain will decrease within a few weeks. Any postoperative wound infections will require antibiotics and alternative treatment for unsatisfactory recovery.
Prevention and Self-Care
Exercise and Weight Management
Regular exercise is one of the key factors in preventing varicose veins. It helps to improve blood circulation and may prevent varicose veins from getting worse. Other benefits of exercise are less weight gain and improved muscle strength. Whatever exercise you choose, whether it is walking, cycling, swimming, or running, try to get into the habit of exercising regularly. It is not advisable to start an exercise program that is too severe or high impact as this may make the varicose veins worse. Exercise and weight management can help to avoid varicose veins. When you are walking or exercising, try to take regular breaks and elevate your legs. Elevation of the legs and feet above the level of the heart, for example lying on the floor with legs up on the sofa, for 10-15 minutes, two to three times daily can be very beneficial. This helps to improve the blood flow back towards the heart and reduce swelling in the lower legs. Losing weight can also help to improve varicose veins, as there is less pressure and stress on the veins in the legs. This can be achieved by regular exercise and healthy eating. It has been shown that people who are moderately overweight and walk just 15 minutes a day can extend their life expectancy by three years. Unfortunately, inactivity is an increasing problem in modern society, with people expending less energy on physical tasks at home or work. This can be a risk factor for developing varicose veins. Similarly, obesity is known to increase the movement of blood and pressure on the veins, which may then lead to varicose veins developing.
Avoiding Prolonged Standing or Sitting
When sitting or lying down, it is helpful to avoid tight clothing, especially tight belts, waistbands, and leg wear. Loose clothing is much less likely to restrict blood flow. This is also the case with low-heeled shoes, as they tone leg muscles and help to promote better venous circulation. At rest, contracted calf muscles from high heels or tight hosiery can increase discomfort in the legs.
When sitting, elevate the feet and legs slightly if possible. It is beneficial to rest with the legs elevated higher than the heart several times during the day, whether at home or at work. This is the best way to keep the blood flowing, as it reduces the pressure in the leg veins and helps to improve overall leg circulation. If it is difficult to rest with the legs elevated, taking breaks to lie down and elevate the legs against a wall or the back of a chair for 10-15 minutes can be effective. This can also help to relieve aching or discomfort in the legs, with or without noticeable varicose veins.
It is important to avoid prolonged sitting and standing, which may impede blood flow to the legs. When this is unavoidable, such as at work, taking a break and walking around every 30 minutes can help to keep the blood flowing. While sitting, it is good to avoid crossing the legs, as this can further impair circulation.
Elevating Legs and Wearing Compression Stockings
The best way to prevent new varicose veins from forming and to alleviate the discomfort caused by existing ones is to elevate your legs. For every hour of the day, 10 minutes should be spent with your legs elevated above the level of your heart. This will enhance return of venous blood to the heart and will decrease the pressure in the veins in your lower legs. When elevating your legs, the best position is to lie on the floor and rest your legs on a chair or ottoman. Simply raising your feet up onto a footstool while sitting in a chair is inadequate. Legwear compression stockings have also been shown to prevent the progression of varicose veins. These stockings put graduated pressure on the lower legs and act to improve the return of venous blood to the heart. This, in turn, will prevent blood from pooling in the leg veins and will decrease the pressure in the veins. Additionally, compression stockings will reduce the chronic swelling that occurs in the lower legs and will decrease the risk of developing a venous leg ulcer. The most favorable encouragement to wear compression stockings is their cosmetic result. Due to their effect on decreasing varicose veins, they will also improve skin changes and eczema that result from chronic vein disease. More importantly, wearing compression stockings will alleviate the pain and discomfort from varicose veins and will prevent progression to a more severe form of chronic venous insufficiency.
Healthy Diet and Hydration
A healthy diet not only maintains body weight, but also has a great impact on the general health of the individual. A diet rich in high-fiber foods (i.e. fruits, vegetables, whole grain breads and cereals) can prevent constipation, which can foster varicose vein formation. By avoiding constipation, the individual can also avoid straining which is another cause for varicose veins. It is also important to consume less sodium. Excessive salt intake can cause the body to retain water which in turn may lead to increased pressure on the veins. Opting for low salt or salt-free substitutes on a meal-to-meal basis can greatly reduce sodium intake. Adequate water consumption is also necessary in preventing varicose veins. Drinking plenty of water is essential in maintaining proper body function. Proper consumption can actually prevent water retention and lessen the chances of developing varicose veins. Sufficient consumption of water along with a proper diet can result in the maintenance of a healthy body weight which in turn will reduce the pressure on the veins. Considering that many people in western cultures are overweight and are more likely to develop varicose vein, a well-maintained diet can greatly benefit millions of individuals. Weight loss from a strictly followed diet may make a significant impact on the vein health of an individual. Understanding that faulty veins do not outwardly show signs of ill health, it is important to remember that varicose veins are a real medical issue that can only be treated or prevented with understanding of the condition and changes to certain aspects of an individual’s life.
