Varicose Veins

Definition

Varicose veins are dilated, tortuous, elongated superficial veins that are usually seen in the legs.

Description

Varicose veins, also called varicosities, are seen most often in the legs, although they can be found in other parts of the body. Most often, they appear as lumpy, winding vessels just below the surface of the skin. There are three types of veins: superficial veins that are just beneath the surface of the skin, deep veins that are large blood vessels found deep inside muscles, and perforator veins that connect the superficial and deep veins. The superficial veins are the blood vessels most often affected by varicose veins and are the veins first seen when the varicose condition has developed.

The inside walls of veins have valves that open and close in response to blood flow. When the left ventricle of the heart pushes blood out into the aorta, it produces the high pressure pulse of a heartbeat and pushes blood throughout the body. Between heartbeats, there is a period of low blood pressure. During the low pressure period, blood in the veins is affected by gravity and tends to flow backward. The valves in the veins prevent this from happening. Varicose veins start when one or more valves fail to close. The blood pressure in that section of vein increases, causing additional valves to fail. This allows blood to pool and stretch the veins, further weakening the walls of the veins. The walls of the affected veins lose their elasticity in response to increased blood pressure. As the vessels weaken, more and more valves are unable to close properly. The veins become larger and wider over time and begin to appear as lumpy, winding chains underneath the skin. Varicose veins can also develop in the deep veins. Varicose veins in the superficial veins are called primary varicosities, while varicose veins in the deep veins are called secondary varicosities.

Liver disease can cause the appearance of varicose veins in the esophagus or on the surface of the abdomen. These appear in response to increased pressure of blood that is unable to move through a diseased liver. Varicose veins in the esophagus are called esophageal varicosities. Varicose veins on the surface of the abdomen often resemble a spider or the head (caput) of the mythological character Medusa.

Causes and symptoms

The predisposing causes of varicose veins are multiple. Lifestyle and hormonal factors play a role. Some families seem to have a higher incidence of varicose veins, indicating that there may be a genetic component to this disease. Varicose veins are progressive. As one section of a vein weakens, it causes increased pressure on adjacent sections. These sections often develop varicosities. Varicose veins can appear following pregnancy, thrombophlebitis, congenital blood vessel weakness, or obesity, but are not limited to these conditions. Edema of the surrounding tissue, ankles, and calves, is not usually a complication of primary (superficial) varicose veins and, when seen, usually indicates that the deep veins may have varicosities or clots.

Varicose veins are a common problem. Approximately 15% of the adult population in the United States has varicose veins. Women have a much higher incidence of this disease than men. The symptoms can include aching, pain, itchiness, or burning sensations, especially when standing. In some cases, with chronically bad veins, there may be a brownish discoloration of the skin or ulcers (open sores) near the ankles. A condition that is frequently associated with varicose veins is spider-burst veins. Spider-burst veins are very small veins that are enlarged. They may be caused by back-pressure from varicose veins, but can be caused by other factors. They are frequently associated with pregnancy, and there may be hormonal factors associated with their development. They are primarily of cosmetic concern and do not present any medical concerns.

Diagnosis

Varicose veins can usually be seen. In cases where varicose veins are suspected, but cannot be seen, a physician may frequently detect them by palpation (pressing with the fingers). X rays or ultrasound tests can detect varicose veins in the deep and perforator veins and rule out blood clots in the deep veins.

Treatment

There is no cure for varicose veins. Treatment falls into two classes: relief of symptoms and removal of the affected veins. Symptom relief includes such measures as wearing support stockings, which compress the veins and hold them in place. This keeps the veins from stretching and limits pain. Other measures are sitting down, using a footstool when sitting, avoiding standing for long periods of time, and raising the legs whenever possible. These measures work by reducing the blood pressure in leg veins. Prolonged standing allows the blood to collect under high pressure in the varicose veins. Exercise such as walking, biking, and swimming, is beneficial. When the legs are active, the leg muscles help pump the blood in the veins. This limits the amount of blood that collects in the varicose veins and reduces some of the symptoms. These measures reduce symptoms, but do not stop the disease.

Surgery is also used to remove varicose veins from the body. It is recommended for those that cause pain or are very unsightly and when hemorrhaging or recurrent thrombosis appear. Surgery involves making an incision through the skin at both ends of the section of vein being removed. A flexible wire is inserted through one end and extended to the other. The wire is then withdrawn, pulling the vein out with it. This is called "stripping" and is the most common method to remove superficial varicose veins. As long as the deeper veins are still functioning properly, a person can live without some of the superficial veins. Because of this, stripped varicose veins are not replaced.

Injection therapy is an alternate therapy used to seal varicose veins. This prevents blood from entering the sealed sections of the vein. The veins remain in the body, but no longer carry blood. This procedure can be performed on an out-patient basis and does not require anesthesia. It is frequently used if people develop more varicose veins after surgery to remove the larger varicose veins and to seal spider-burst veins for people concerned about cosmetic appearance. Injection therapy is also called sclerotherapy. At one time, a method of injection therapy was used that did not have a good success rate. Veins did not seal properly and blood clots formed. Modern injection therapy is improved and has a much higher success rate.

Prognosis

Untreated varicose veins become increasingly large and more obvious with time. Surgical stripping of varicose veins is successful for most people. Most do not develop new, large varicose veins following surgery. Surgery does not decrease a person's tendency to develop varicose veins. Varicose veins may develop in other locations after stripping.

Health care team roles

Family physicians or gynecologists often make a initial referral to a vascular surgeon for treatment. Nurses may instruct patients in practices to prevent worsening of the condition, if surgery is not warranted.

Prevention

Varicose veins in the legs can be minimized by maintaining good physical condition and engaging in exercise throughout life. This is especially important for women during pregnancy. Persons who are at risk of developing varicose veins can wear support hosiery. Refraining from standing for long periods of time is helpful. If standing is inevitable, flexing the muscles of the calf every minute or two will help to prevent blood pooling.

Resources

BOOKS

Goldman, Michael P., Robert A. Weiss, and John J. Bergan. Varicose Veins and Telangiectasias: Diagnosis and Treatment. 2nd ed. New York: Matthew Medical Books, 1999.

Hull, Russell. "Peripheral Venous Disease." In Cecil Textbook of Medicine, 21st ed. Ed. Lee Goldman and J. Claude Bennett. Philadelphia: W.B. Saunders, 2000.

Sadick, Neil S. Manual of Sclerotherapy. Philadelphia: Lippincott Williams & Wilkins, 2000.

Townsend, Courtney M. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 16th ed. Philadelphia: Saunders, 2001.

Tretbar, L. L. Venous Disorders of the Legs: Principles and Practice. New York: Springer Verlag, 1999.

PERIODICALS

de Cossart, L. "Varicose Veins and Pregnancy." British Journal of Surgery 88, no. 3 (2001): 323-324.

Foldi, M., and G. Idiazabal. "The Role of Operative Management of Varicose Veins in Patients with Lymphedema and/or Lipedema of the Legs." Lymphology 33, no. 4 (2001): 167-171.

Guex, J. J., and M. N. Isaacs. "Comparison of Surgery and Ultrasound Guided Sclerotherapy for Treatment of Saphenous Varicose Veins: Must the Criteria for Assessment be the Same?" International Journal of Angiology 19, no. 4 (2000): 299-302.

Tessari, L., A. Cavezzi, and A. Frullini. "Preliminary Experience with a New Sclerosing Foam in the Treatment of Varicose Veins." Dermatological Surgery 27, no. 1 (2001): 58-60.

ORGANIZATIONS

American Association for Vascular Surgery. 13 Elm Street, Manchester, MA 01944-1314. (978) 526-8330. 〈http://www.vascsurg.org/doc/842.html〉.

Peripheral Vascular Surgery Society. 824 Munras Avenue, Suite C, Monterey, CA 93940. (831) 373-0508. 〈http://www.pvss.org〉 suzanne@DMCcompanies.com.

OTHER

Merck Manual. 〈http://www.merck.com/pubs/mmanual/section16/chapter212/212h.htm〉.

National Library of Medicine. 〈http://www.nlm.nih.gov/medlineplus/varicoseveins.html〉.

University of Michigan School of Medicine. 〈http://www.med.umich.edu/llibr/topics/circ03.htm〉.