Varicose veins

Varicose veins are veins that have become enlarged and twisted. The term commonly refers to the veins on the leg, although varicose veins occur elsewhere. Veins have leaflet valves to prevent blood from flowing backwards (retrograde). Leg muscles pump the veins to return blood to the heart. When veins become enlarged, the leaflets of the valves no longer meet properly, and the valves don't work. A common cause of valve failure is Deep Vein Thrombosis (DVT), which can cause permanent damage to the valves. The blood collects in the veins and they enlarge even more. Varicose veins are common in the superficial veins of the legs, which are subject to high pressure when standing. Besides cosmetic problems, varicose veins are often painful, especially when standing or walking. They often itch, and scratching them can cause ulcers. Serious complications are rare. 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 surgical treatments are less invasive (see radiofrequency ablation) and are slowly replacing traditional surgical treatments. Since most of the blood in the legs is returned by the deep veins, and the superficial veins only return about 10%, they can be removed or ablated without serious harm.^[1][2] Varicose veins are distinguished from reticular veins (blue veins) and telangiectasias (spider veins) which also involve valvular insufficiency,^[3] by the size and location of the veins.

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Symptoms

• Aching, heavy legs (often worse at night and after exercise)
• Ankle swelling
• A brownish-blue shiny skin discoloration around the veins
• Skin over the vein may become dry, itchy and thin, leading to eczema (venous eczema)
• The skin may darken (stasis dermatitis), because of the waste products building up in the legs
• Minor injuries to the area may bleed more than normal and/or take a long time to heal
• Rarely, there is a large amount of bleeding from a ruptured vein
• In some people the skin above the ankle may shrink (lipodermatosclerosis) because the fat underneath the skin becomes hard.
• Restless Leg Syndrome^[4]. Restless Leg Syndrome appears to be a common overlapping clinical syndrome in patients with varicose veins and other chronic venous insufficiency.

Complications

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

• Pain, heaviness, inability to walk or stand for long hours thus hindering work
• Skin conditions / Dermatitis which could predispose skin loss
• 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%.^[5]

Causes

Varicose veins are more common in women than in men, and are linked with heredity^[6]. Other related factors are pregnancy, obesity, menopause, aging, prolonged standing, leg injury and abdominal straining. Varicose veins are bulging veins that are larger than spider veins, typically 3 mm or more in diameter.

Non-surgical treatment

Elevating the legs provides relief. "Advice about regular exercise sounds sensible but is not supported by any evidence." ^[7] The wearing of graduated compression stockings with a pressure of 30–40 mmHg has been shown to correct the swelling, nutritional exchange, and improve the microcirculation in legs affected by varicose veins.^[8] 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 symptoms of varicose veins can be controlled to an extent with either of the following:

• 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.

• Diosmin 95 is a dietary supplement distributed in the U.S. by Nutratech, Inc. The U.S. Food and Drug Administration does not approve dietary supplements, but concluded that there was an "inadequate basis for reasonable expectation of safety." ^[9]

Sclerotherapy has been used in the treatment of varicose veins for over 150 years^[10]. It is often used for telangiectasias (spider veins) and varicose veins that persist or recur after vein stripping ^{[11] [12]}. Sclerotherapy can also be performed using microfoam sclerosants under ultrasound guidance to treat larger varicose veins, including the greater and short saphenous veins.^[13][14] 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.^[15] A Cochrane Collaboration review^[16] 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.^[17] 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. ^[18] 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 ^[19]. There has been 1 reported case of stroke after ultrasound guided sclerotherapy when an unusually large dose of sclerosant foam was injected.

Surgical treatment

Some doctors favor traditional open surgery, while others prefer newer methods. Newer methods for treating varicose veins, such as Endovenous Laser Treatment, radiofrequency ablation, and foam sclerotherapy are not as well studied, especially in the longer term.^[20] Open surgery has been performed for over a century. Complications include deep vein thrombosis (5.3%)^[21], pulmonary embolism (0.06%), and wound complications including infection (2.2%).

Two prospective randomized trials found speedier recovery and fewer complications after radiofrequency obliteration (AKA radiofrequency ablation). ^[22][23]. Myers^[24] wrote that open surgery for small saphenous vein reflux is obsolete. (The great saphenous vein is the vein that runs along the inside of the leg from ankle to groin; the small saphenous vein is the vein that runs along the back of the calf.) 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, radiofrequency ablation has control in 80% of cases of small saphenous vein reflux at 4 years, said Myers.

Endovenous laser and radiofrequency ablation require specialized training for doctors and expensive equipment. Doctors must use ultrasound during the procedure to see what they are doing. Follow-up treatment to smaller branch varicose veins is often needed in the weeks after the initial procedure. Some practitioners also perform traditional surgery at the time of endovenous treatment.

Complications for radiofrequency ablation include bruising, burns, paraesthesia, clinical phlebitis, and slightly higher rates of deep vein thrombosis (0.57%) and pulmonary embolism (0.17%). Complications for endovenous laser treatment also include brusing (24%-100%), burns (4.8%), paraesthesia (1%-36.5%), and induration along the length of the saphenous vein (55-100%).

Another concern in varicose vein surgery is the recurrence rate. For traditional surgery, reported recurrence rates, which have been tracked for 10 years, range from 5-60%. Because the new treatments haven't been studied that long, their recurrence rates aren't known that well. One 3-year study compared radiofrequency, with a recurrence rate of 33%, to open surgery, which had a recurrence rate of 23%. The longest study of endovenous laser ablation is 39 months.

Other treatments are:

• ambulatory phlebectomy
• laser vein removal
• vein ligation