Varicose Veins

What are varicose veins?

Varicose veins occur in several different forms all of which are based on some malfunction of the venous system of the lower extremities. In order to understand varicose veins one must first understand the normal anatomy and normal path of blood flow in these veins.

The function of veins is to return blood from the peripheral tissues to the heart.  In the lower extremities this flow is upward, against gravity. In order to accomplish this task, veins of the lower extremities have valves which only permit blood to flow in one direction. The muscles of the legs serve as a pump which squeeze the veins when we walk and thus force blood from the feet towards the heart. 

In fact, there are two sets of veins, superficial and deep. While blood in both systems flows from distal to proximal, the blood in the superficial system flows into the deep system via perforating veins located in a line along the inside of the tibia. These perforators also contain valves which prevent blood from flowing in the opposite direction from the deep system to the superficial.

Veins become varicosed when the pressure caused by pooling blood in the vein causes distension of the vein wall, injury and scarring of the vein wall and damage to the valves resulting in valvular incompetence. This results in veins which are elongated, tortuous, thin walled and fragile. Additionally, because they no longer function properly, tissue fluid builds up in the tissues drained by these veins. The skin becomes hard and swollen and feels almost like tree bark. Hemosiderin, a breakdown product of red blood cells is deposited in these tissues giving them their characteristic brownish discoloration. This pattern of tissue swelling and discoloration is called brawny edema. When tissue pressure builds up to a critical degree, circulation at the tissue level is interrupted and tissues may begin to break down resulting in venous ulceration. Of course, not all patients progress in this manner and in practice, patients are encountered with degrees of symptoms spanning the spectrum. 

Spider angiomata are varicosities of capillaries and small veins in the most superficial layers of the skin. Though they can occasionally be painful or even ulcerate, more commonly they are merely bothersome because of their cosmetic appearance. They are frequently encountered together with true varicose veins, however, they may occur alone. 

Who gets varicose veins?

The development of varicose veins is multi-factorial and includes age, pregnancy, hereditary factors, female hormones and in some cases, jobs which involve long periods of standing, particularly without walking. Smoking and diabetes, via the damage they produce to vascular structures in general, may also contribute to the development of varicose veins and venous stasis disease. The function of age may be considered that of longer exposure to all of the above factors however, the development of varicose veins and venous insufficiency clearly begins in young adulthood.

There appears to be a family predisposition to the development of venous disease however it is not directly inheritable. That is to say, if your father had varicose veins it does not mean that you will get them, but your chances are higher than in the general population.

The influence of female hormones on the development of varicose veins is well documented, particularly that of progesterone. It is not uncommon for women to complain of leg swelling or for varicose veins that are present to become worse during the latter part of a woman’s cycle. 

Pregnancy is a state in which the circulating blood volume of the pregnant female is greatly expanded. This, in combination with the mechanical effect of a large pregnant uterus, produces an increase in pressure in the veins of the legs of a pregnant woman. In addition, the hormonal changes that occur in pregnancy also contribute to the development of varicose veins and venous stasis. In many cases the varicosities that develop during pregnancy disappear or at least improve following delivery.

What are the symptoms of varicose veins?

Symptoms vary and depend on the severity of venous insufficiency.  Some people are concerned only with the unsightly appearance of their veins. However, even small varicose veins or spider angiomata can be painful. Even small superficial varicosities can bleed, and when they do, the bleeding is often severe because of the increased pressure in these abnormal veins.

Occasionally, thrombosis may occur in varicose veins secondary to the sluggish blood flow. This can be very painful and lead to superficial thrombophlebitis.

Many people complain of heaviness in the legs particularly at the end of the day.  This is often relieved, at least somewhat, with leg elevation. Other patients with severe venous insufficiency may go on to develop the above described brawny skin changes and ultimately, severe ulceration which may be difficult if not impossible to heal.

Primary treatment for most other forms of venous stasis and varicose veins involves combinations of compression stockings, maintaining ones legs elevated whenever possible, and occasionally medications that alter blood viscosity or thin the blood. I frequently recommend that patients put a cinder block under the foot of their beds so that at least when in bed their feet are elevated above the level of the heart. Venous compression stockings are made in a variety of styles, lengths, and pressures to try to tailor them to a specific patients needs. 

Superficial thrombophlebitis usually responds to a combination of leg elevation, warm compresses, anti-inflammatory medications and antibiotics. Some cases may require hospitalization and others may require surgery to remove the involved vein.

Standard surgery for varicose veins involves stripping of the main superficial vein in the leg and its tributaries. This is usually done via incisions made in the groin and in the ankle, allowing passage of a special stripping device through the vein which then removes the vein. Other small incisions in the leg are then required to remove varicosed tributaries. Recovery is usually rapid, however the first few days are with the leg tightly wrapped with ace bandages to prevent bleeding and minimize swelling.   Two newer procedures, Trivex (Transilluminated Vein Excision), and VNUS (venous) Closure present great advances to the standard surgery and allow for treatment of varicose veins with much less scarring and more rapid recovery.

Patients with severe venous stasis with ulceration due to incompetent perforators frequently improve following subfascial endoscopic perforator surgery. This procedure is a modification of an open procedure which used to be associated with a high incidence of wound complications. With this new videoscopic procedure, the incisions are made away from the site of ulceration and the wound complication rate is extremely low.  Furthermore, this technique is being shown to have an excellent results in terms of helping to heal very difficult ulcers. Recovery following this procedure which is performed as an outpatient is also rapid.

As always, I welcome any comments or questions.