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Varicose veins - symptoms, causes, treatment


Varicose veins are veins that become enlarged and contorted, and sometimes cause discomfort or pain. A range of treatments – surgical and non-surgical – are available, depending on the severity of the symptoms and a person's circumstances and preferences.
 
Varicose veins are more common in women than in men and tend to run in families. They usually develop between the ages of 30 and 60 years and tend to worsen with age.

General information

Veins are the blood vessels that carry blood from the body to the heart (whereas arteries carry blood from the heart to the body). Properly functioning veins have a series of one-way valves that keep the blood flowing in one direction towards the heart.

Varicose veins occur when, as a result of various causes, the valves within the veins become inefficient (incompetent) and allow blood to backflow. The blood pools in the area below the affected valve causing the vein to enlarge and stretch. Varicose veins appear under the skin as bluish-green lines, which may bulge out or appear twisted and contorted.

Veins that lie just beneath the skin surface are referred to as “superficial veins” while the veins found deep inside the muscles are referred to as “deep veins”. Other veins, called "communicating veins", connect the superficial and deep veins, allowing blood to flow between them.

The superficial veins in the legs are the most common place for varicose veins to occur – due mainly to incompetent vein junctions in the upper thigh, behind the knee, and in the calf muscle. However, they can occur in other areas of the body such as the pelvic region and the rectal area (haemorrhoids).

Symptoms

Common symptoms include:

  • Bulging or twisting of the affected vein(s)
  • Pain or aching of the affected area, especially after sitting or standing for lengthy periods
  • Swelling in the legs
  • A feeling of heaviness and muscle fatigue in the legs
  • Itching around the affected veins
  • Leg cramps at rest.

Some women experience a worsening of symptoms during menstruation.

Complications due to varicose veins may include:

  • The skin above the affected veins may become thin making it susceptible to cuts, nicks, and ulcers
  • Inflammation of the affected veins (phlebitis)
  • A slightly increased risk of developing blood clots in the deep veins (deep vein thrombosis) connected to varicose veins.

Causes

A number of factors contribute to the development of varicose veins. These include:

  • A genetic predisposition
  • Hormonal factors
  • Excess weight
  • Pregnancy
  • Circulatory problems, such as blood clots (thrombosis)
  • Injury or inflammation of the veins
  • Chronic constipation may contribute to the development of rectal varicose veins (haemorrhoids).

Lifestyle factors also play an important role and people who have jobs that involve standing for prolonged periods of time are at greater risk of developing varicose veins, eg: nurses, flight attendants, and teachers.

Diagnosis

Varicose veins are usually easily visible so it is possible to make a diagnosis simply from their appearance. A doctor will perform a physical examination to assess the extent of the varicose veins. They may also order an ultrasound test called a Doppler which enables the blood flow and structure of the veins to be seen on a monitor. It can also show if any blood clots are present. A duplex ultrasound may also be performed. This is a more advanced scan and displays the image in colour.

Another test, known as air plethysmography (APG), may be performed to better identify the function of the affected veins. For this test, pressure cuffs are placed on the leg and are connected to a computer. The cuffs are pumped up and released at pre-determined rates and intervals, while the computer measures how the blood flows through the veins and arteries in the leg.

Treatment

Treatment may not be medically necessary unless symptoms are problematic. However, some people may want treatment for cosmetic reasons, because they are unhappy with the appearance of varicose veins.

If varicose veins are small and not too uncomfortable, elastic compression stockings may be recommended. These are worn during daily activities and help to compress the veins, keeping them from stretching and limiting any discomfort or pain.

For more problematic cases a range of procedures – surgical and non-surgical – are available to seal or remove varicose veins. A combination of treatment techniques may sometimes be used. Treatment options for varicose veins have changed significantly in the past 25 years and continue to evolve.

NON-SURGICAL TREATMENT:

Sclerotherapy:

Sclerotherapy (also known as chemical sclerosis or endovenous chemoablation) involves using a fine needle to inject a special solution into the affected vein. The solution irritates the lining of the vein causing it to harden (sclerose) and seal off. Blood is therefore prevented from entering that portion of the vein and is forced to flow through other, healthier veins. Sclerotherapy can be performed without the need for an anaesthetic.

Deeper varicose veins can be treated with ultrasound guided sclerotherapy (UGS). The doctor is able to use a duplex ultrasound to see the vein on a screen, thus enabling them to accurately guide the fine needle within the vein. This technique also makes it possible to locate and treat the often-hidden origin of the varicose vein.

Sclerotherapy can also be used to treat “spider veins” – very small veins that are enlarged and appear as fine red/purple lines just under the surface of the skin.

Side effects of sclerotherapy treatment may include:

  • Irritation and damage to the tissue surrounding the affected vein
  • Trapping of blood within the treated vein (this is usually absorbed by the body after 2–3 months)
  • Light brown streaks or discolouration over the treated vein (these will fade over a period of months).

The majority of people who have had sclerotherapy treatment achieve good results with minimal side effects. However, sclerotherapy is not suitable for everyone. Factors such as pregnancy, pre-existing clotting disorders, and allergy to the sclerotherapy solution are contraindications for this treatment.

Endovenous laser treatment (EVLT):

EVLT is also known as endovenous laser ablation (EVLA). A small incision is made at one end of the affected vein and ultrasound is used to guide a laser catheter into the vein. The laser is activated and, after approximately 60 seconds, the vein is destroyed. As the entire vein is destroyed, rather than just the lining (as occurs with sclerotherapy) compression stockings are not required and the recovery time is rapid (usually a return to work can be achieved the next day).

SURGICAL TREATMENT:

If the vein junction where the varicose vein originates has been shown by an ultrasound scan to be incompetent, then the most common surgical treatment is to tie off the varicose vein at this junction, which is most commonly the upper thigh, behind the knee, or in the calf muscle. Surgery involves making a small incision in the leg, locating the vein junction, and tying off the varicosed vein. The vein is left in place but blood is prevented from flowing into it.

Another surgical technique for treating superficial varicose veins is “vein stripping”, which is where the affected vein is completely removed. A small incision is made in the skin at either end of the affected vein and the junction where the affected varicose vein joins a larger vein is tied off. A flexible wire is then inserted into the varicose vein and withdrawn – removing the vein in the process.

Both types of surgery can be performed under general or spinal anaesthetic and a stay in hospital may be required. This will be determined by the surgeon performing the surgery.

Surgical techniques used in the treatment of varicose veins may also include:

Mini-stab avulsion:
This involves removing the veins through a series of tiny skin incisions. It is suitable for smaller varicose veins. Specialised surgical instruments are used to remove the affected veins and the incisions are so small that they do not usually require stitches.

Endoscopic vein surgery:
This technique (also known as ambulatory phlebectomy) may be used for more severe cases of varicose veins. It involves making several small incisions in the leg. A thin tube containing a tiny camera (endoscope) is inserted through one of the incisions, into the affected vein, and small surgical instruments are inserted through the other incisions. The camera enables the surgeon to see the inside of the vein on a television monitor and perform the necessary surgery.

Transilluminated powered phlebectomy:
During this technique, a small incision is made in the skin at one end of the affected vein and a thin tube with a bright light is introduced under the skin and behind the vein, thus showing the shadow of the vein. Another small incision is made at the other end of the affected vein and a specialised instrument attached to a suction unit is positioned under the skin. Guided by the strong light, the specialised instrument destroys and removes the affected vein. This technique is performed as a day-stay procedure. Bandages need to be worn for approximately 48 hours after the procedure and there is less discomfort, recovery is quicker, and scarring is less than other surgical techniques.

Prevention

Things you can do to help prevent the development of varicose veins include:

  • Avoid crossing your legs when sitting
  • Exercise regularly
  • Maintain a healthy body weight
  • Avoid tight clothing that constricts the legs, groin or waist, eg: knee-high pantyhose
  • Avoid constipation
  • When standing for long periods, shift your weight from one leg to the other every few minutes.

References

Fernando, R.S., Muthu, C. Adoption of endovenous laser treatment as the primary treatment modality for varicose veins: the Auckland City Hospital experience. N Z Med J. 2014;127(1399):43-50.
O’Toole, M.T. (Ed.) (2013). Varicose vein. Mosby’s Dictionary of Medicine, Nursing & Health Professions (9th ed.). St Louis: Elsevier Mosby.
Clinical Reference Systems (2006). Varicose Veins (Disease/Disorder Overview). McKesson Health Solutions LLC. In Thompson Gale Health and Wellness Resource Centre.
Lohr, J.T. (2006). Varicose Veins. In Gale Encyclopaedia of Medicine. Third Edition. Longe, J. L. (editor). Farmington Hills, MI: Thompson Gale.
Mayo Clinic (2016). Varicose veins (Web Page). Rochester: Mayo Foundation for Medical Education and Research. http://www.mayoclinic.org/diseases-conditions/varicose-veins/home/ovc-20178078 [Accessed: 13/01/17].
Weiss, R. (2016). Varicose veins and spider veins (Web page). Medscape Drugs and Diseases. New York, NY: WebMD LLC. http://emedicine.medscape.com/article/1085530-overview [Accessed: 13/01/17].

Last Reviewed – January 2017

 

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