Varicose veins

, , ICD9|671
ICDO =
OMIM = 192200
MedlinePlus = 001109
eMedicineSubj = med
eMedicineTopic = 2788
MeshID = D014648

Varicose veins are veins that have become enlarged and twisted. Carl Arnold Ruge is credited with having first defined varicose veins as "any dilated, elongated and tortuous vein irrespective of size". 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. One 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, less invasive treatments, such as radiofrequency ablation and endovenous laser treatment, are slowly replacing traditional surgical treatments. Because most of the blood in the legs is returned by the deep veins, the superficial veins, which return only about 10 per cent of the total blood of the legs, can usually be removed or ablated without serious harm. [Merck Manual Home Edition, 2nd ed. [http://www.merck.com/mmhe/sec03/ch036/ch036d.html] ] [NHS Direct [http://www.nhsdirect.nhs.uk/articles/article.aspx?articleId=387&sectionId=28131] ] Varicose veins are distinguished from reticular veins (blue veins) and telangiectasias (spider veins), which also involve valvular insufficiency, [Weiss R A, Weiss M A, Doppler Ultrasound Findings in Reticular Veins of the Thigh Subdermic Lateral Venous System and Implications for Sclerotherapy, Journal of Derm Surg Onc, Vol 19 No 10 (Oct 1993) p947-951.] by the size and location of the veins.

ymptoms

* Aching, heavy legs (often worse at night and after exercise).
* Appearance of spider veins (telangiectasia) in the affected leg.
* Ankle swelling.
* A brownish-blue shiny skin discoloration near the affected veins.
* Redness, dryness, and itchiness of areas of skin - termed stasis dermatitis or venous eczema, because of waste products building up in the leg.
* Minor injuries to the area may bleed more than normal and/or take a long time to heal.
* In some people the skin above the ankle may shrink (lipodermatosclerosis) because the fat underneath the skin becomes hard.
* Restless legs syndrome appears to be a common overlapping clinical syndrome in patients with varicose veins and other chronic venous insufficiency.
* Whitened irregular "scar-like" patches can appear, especially at the ankles, "atrophie blanche".

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
* Skin ulcers especially near the ankle, usually referred to as venous ulcers.
* 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%. [Goldman M. Sclerotherapy, Treatment of Varicose and Telangiectatic Leg Veins. Hardcover Text, 2nd Ed, 1995]
* Severe bleeding from minor trauma, of particular concern in the elderly.
* Blood clotting within affected veins. Termed superficial thrombophlebitis. These are frequently isolated to the superficial veins, but can extend into deep veins becoming a more serious problem.
* Acute fat necrosis can occur, especially at the ankle of overweight patients with varicose veins. Females are more frequently affected than males.

Etiology/Epidemiology

Varicose veins are more common in women than in men, and are linked with heredity [cite journal | author = Ng M, Andrew T, Spector T, Jeffery S | title = Linkage to the FOXC2 region of chromosome 16 for varicose veins in otherwise healthy, unselected sibling pairs. | journal = J Med Genet | volume = 42 | issue = 3 | pages = 235–9 | year = 2005 | pmid = 15744037 | doi = 10.1136/jmg.2004.024075 ] . 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.

Conservative treatment

The symptoms of varicose veins can be controlled to an extent with the following:
*Elevating the legs often provides temporary symptomatic relief.
*"Advice about regular exercise sounds sensible but is not supported by any evidence." [BMJ 2006;333:287-292 (5 August), Varicose veins and their management, Bruce Campbell [http://www.bmj.com/cgi/content/full/333/7562/287 (subscription)] ]
*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. [Curri SB et al. Changes of cutaneous microcirculation from elasto-compression in chronic venous insufficiency. In Davy A and Stemmer R, editors: Phlebology '89, Montrouge, France, 1989, John Libbey Eurotext.] 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.
*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, and concluded that there was an "inadequate basis for reasonable expectation of safety." [New Dietary Ingredients in Dietary Supplements, U. S. Food and Drug AdministrationCenter for Food Safety and Applied NutritionOffice of Nutritional Products, Labeling, and Dietary SupplementsFebruary 2001 (Updated September 10, 2001) [http://www.cfsan.fda.gov/~dms/ds-ingrd.html] , Memorandum [http://www.fda.gov/ohrms/dockets/dockets/95s0316/rpt0083_01.pdf] ]

Interventional treatment

Active medical intervention in varicose veins can be divided into surgical and non-surgical treatments. Some doctors favor traditional open surgery, while others prefer the newer methods. Newer methods for treating varicose veins, such as endovenous laser treatment (EVLT), radiofrequency ablation, and foam sclerotherapy are not as well studied, especially in the longer term. ["Open Surgery Is Still The Best Technique To Ablate The Great Saphenous Vein," Vascular, Vol. 14 (Nov. 2006), Suppl. 1, p. S. 25] [Systematic review of foam sclerotherapy for varicose veins.Jia X, Mowatt G, Burr JM, Cassar K, Cook J, Fraser C.Br J Surg. 2007 Aug;94(8):925-36]

urgical treatment

Open surgery has been performed for over a century. Complications include deep vein thrombosis (5.3%) [van Rij AM et al. Incidence of Deep Venous Thrombosis after Varicose Vein Surgery, Br J Surg 2004 Dec;91(12):1582-5] , pulmonary embolism (0.06%), and wound complications including infection (2.2%). For traditional surgery, reported recurrence rates, which have been tracked for 10 years, range from 5-60%.

Non-surgical treatment

clerotherapy

A commonly performed non-surgical treatment for varicose and "spider" leg veins is sclerotherapy. It has been used in the treatment of varicose veins for over 150 years [Goldman M, Sclerotherapy Treatment of varicose and telangiectatic leg vein, Hardcover Text, 2nd Ed, 1995] . Sclerotherapy is often used for telangiectasias (spider veins) and varicose veins that persist or recur after vein stripping ["Veins & Lymphatics," L. K. Pak et al, "in" Lange's Current Surgical Diagnosis & Treatment, 11th ed., McGraw-Hill, ] [Tisi PV, Beverley C, Rees A. Injection sclerotherapy for varicose veins. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD001732.] . Sclerotherapy can also be performed using microfoam sclerosants under ultrasound guidance to treat larger varicose veins, including the greater and short saphenous veins. [Paul Thibault, Sclerotherapy and Ultrasound-Guided Sclerotherapy, The Vein Book / editor, John J. Bergan, 2007.] [Padbury A, Benveniste G L, Foam echosclerotherapy of the small saphenous vein, Australian and New Zealand Journal of Phlebology Vol 8, Number 1 (Dec 2004)] 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. [Kanter A, Thibault P. Saphenofemoral junction incompetence treated by ultrasound-guided sclerotherapy, Dermatol Surg. 1996. 22: 648-652.] A Cochrane Collaboration review [http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD001732/abstract.html] 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. [Rigby KA, Palfreyman SJ, Beverley C, Michaels JA. Surgery versus sclerotherapy for the treatment of varicose veins. Cochrane Database of Systematic Reviews 2004, Issue 4. Art. No.: CD004980. [http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD004980/abstract.html] ] 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. [Michaels JA, Campbell WB, Brazier JE, MacIntyre JB, Palfreyman SJ, Ratcliffe J, et al. Randomized clinical trial, observational study and assessment of cost-effectiveness of the treatment of varicose veins (REACTIV trial). Health Technol Assess 2006;10(13). [http://www.hta.ac.uk/fullmono/mon1013.pdf] This Health Technology Assessment monograph includes reviews of the epidemiology, assessment, and treatment of varicose veins, as well as a study on clinical and cost effectiveness of surgery and sclerotherapy] 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 [William R. Finkelmeier, Sclerotherapy, Ch. 12, ACS Surgery: Principles & Practice, 2004, WebMD (hardcover book)] . There has been one reported case of stroke after ultrasound guided sclerotherapy when an unusually large dose of sclerosant foam was injected.

Endovenous laser and radiofrequency ablation

The Australian Medical Services Advisory Committee (MSAC) in 2008 has determined that endovenous laser treatment for varicose veins "appears to be more effective in the short term, and at least as effective overall, as the comparative procedure of junction ligation and vein stripping for the treatment of varicose veins." [Medical Services Advisory Committee, Endovenous laser therapy (ELT) for varicose veins. MSAC application 1113, Dept of Health and Ageing, Commonwealth of Australia, 2008. http://www.msac.gov.au/internet/msac/publishing.nsf/Content/2E0BACBB8704139ACA25745E001C2F21/$File/1113report.pdf] It also found in its assessment of available literature, that "occurence rates of more severe complications such as DVT, nerve injury and paraesthesia, post-operative infections and haematomas, appears to be greater after ligation and stripping than after EVLT". Complications for endovenous laser treatment include minor skin burns (0.4%) Elmore FA and Lackey D, Effectiveness of laser treatment in eliminating superficial venous reflux, Phlebology 2008 :23 :21-31] and temporary paraesthesia (2.1%). The longest study of endovenous laser ablation is 39 months.

Two prospective randomized trials found speedier recovery and fewer complications after radiofrequency obliteration (AKA radiofrequency ablation) compared to open surgery. [Rautio, T, et al., Endovenous oblitration versus conventional stripping operation in the treatment of primary varicose veins, J Vasc Surg 2002:35:958-65] [Lurie F, et al., Prospective randomized study of endovenous radiofrequency oblitration (closure) versus ligation and vein stripping (EVOLVeS: two-year follow-up. Eur J Vasc Endovasc Surg 2005;29:67-73] . Myers [Kenneth Myers, An opinion —surgery for small saphenous reflux is obsolete!" Australian and New Zealand Journal of Phlebology, Vol 8, Number 1 (Dec 2004)] wrote that open surgery for small saphenous vein reflux is obsolete. 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 been shown to control 80% of cases of small saphenous vein reflux at 4 years, said Myers. Complications for radiofrequency ablation include burns, paraesthesia, clinical phlebitis, and slightly higher rates of deep vein thrombosis (0.57%) and pulmonary embolism (0.17%).One 3-year study compared radiofrequency, with a recurrence rate of 33%, to open surgery, which had a recurrence rate of 23%.

Endovenous laser and radiofrequency ablation require specialized training for doctors and expensive equipment. Endovenous laser treatment is performed as an outpatient procedure and does not require the use of an operating theatre, nor does the patient need a general anaesthetic. Doctors must use ultrasound during the procedure to see what they are doing. Some practitioners also perform phlebectomy or ultrasound guided sclerotherapy at the time of endovenous treatment. Follow-up treatment to smaller branch varicose veins is often needed in the weeks after the initial procedure.

Other treatments are:
*ambulatory phlebectomy
*vein ligation

External links

* [http://www.venousresearchfoundation.com/ Non-profit organization for varicose veins and varicosities research]
* [http://www.phlebology.org/ American College of Phlebology]
* [http://www.nhsdirect.nhs.uk/en.aspx?articleId=387 NHS Direct - Varicose Veins]
* [http://www.phlebology.com.au/forms/selmenu.aspx?selmenu=5 Australasian College of Phlebology] Information from the Australasian College of Phlebology Website
* [http://www.medi-data.co.uk/phlebology/ European Journal of Vascular and Endovascular Phlebology]

References