VARICOSE VEINS

Varicose veins (varices) are a significant cause of leg swelling and pain. The underlying problem is buildup of pressure inside the vessels that lead to enlargment of the vessel diameter. In the past, varices of the legs were thought to be a cosmetic issue. However, over the past few years, there has been a better understanding of chronic venous insufficiency (CVI), and the symptoms that they can cause.

WHAT ARE VARICOSE VEINS?

Varicose veins are vessels that have lost their structural integrity. Normally, veins are elastic, meaning that they stretch and snap back to their normal size. When they lose the ability to snap back to their normal size, they become dilated permanently. Most varices occur in the legs, although they can be present at other sites. So what is the normal vein anatomy?

VENOUS ANATOMY

There are numerous variations in the normal venous anatomy. However, in general, the venous structures of the leg can be divided into the deep and superficial venous system. Almost all veins carry blood from the body back to the heart. The deep venous system of the legs carries about 90-95% of the blood back up the legs toward the heart. The remaining 5-10% is carried by the superficial system. The deep system is buried in the compartments of the leg muscles and is not visible. The superficial system is closer to the skin, and can be seen. There are several parts to the deep venous system (Fig 1). The superficial system is comprised of the greater and lesser saphenous veins (GSV and LSV).
There are one way valves in the veins that try to prevent backflow of blood down the leg. Since the venous system is a low pressure network, blood tends to pool in the leg veins if one is sitting or standing for a long period of time. These valves prevent the backflow of blood. However, if the valves are not working well and leaking blood backwards, then the pressure in the network increases, and leads to enlarged veins.

Fig 1. Picture of normal vein anatomy, divided into the superficial and deep venous systems

RISK FACTORS FOR CVI There are numerous risk factors for CVI and varices. These include the following:
1. Family history of varicose veins
2. Occupation: Working on your feet all day increases the vein pressure
3. Overweight
4. Women
5. Pregnancy
6. Age
7. Previous history of deep vein blood clots
8. Hormonal changes


DIAGNOSIS

The diagnosis of CVI is made through a complete history with careful attention to the duration of symptoms, location of pain, swelling, and skin color changes. The symptoms of CVI include a deep seated aching, typically in the calf muscles. The pain might be worse at the end of the day when one has been standing. There might be swelling at the ankles that gets better overnight with elevation of the legs. The typical physical findings are of enlarged veins with or without venous stasis. Venous stasis changes are a discoloration of the skin, initially starting a a blotchy, red color that with time turns to a brown hue. The skin tends to be thicker than normal and shiny. Recurrent swelling leads to dryness of the skin and cracking. The light brown discoloration can changes to a dark brown leather appearance. Small skin erosions can coalesce into large venous stasis ulcers which can be very difficult to heal. Doppler ultrasound confirms the diagnosis of CVI and possibly inform us of previous vein problems such as blood clots. The Doppler ultrasound can pinpoint the site of underlying valve problems, and also helps plan the treatment of varicose veins.

Note the enlarged vein on the inside part of the thigh

Venous stasis changes with early brown discoloration

TREATMENT OPTIONS
The treatment options of CVI depends on the site of valve leakage as documented by Doppler ultrasound evaluation. In general, the first therapeutic option is conservative, or medical management. The 4 main components of conservative management are as follows:

1. Compression hose
2. Exercise
3. Weight control
4. Elevation of the legs

Compression hose is a very important part of management of CVI, even if surgical intervention is contemplated. Compression hose acts as an external skeleton, compressing the leg and providing support for the weakened veins. By providing external support, the tissues tend not to swell as much, and the discomfort of CVI is better controlled. Compression hose does not get rid of the varices; it helps to control the symptoms. Compression hose comes in various sizes and colors, and can be custom made if needed. The strength of the hose is measures in millimeters of Mercury (mmHg). The standard hose strengths are <15 mmHg, 15-20 mmHg, 20-30 mmHg, and 30-40 mmHg. Obviously the higher the mmHg, the tighter the hose.

Weight is an important risk factor for vein problems. Carrying extra weight increases the work that veins have to do in order to carry blood back toward the heart. Therefore, by controlling one's weight, there is less strain placed on the venous system. Exerising helps to push blood back towards the heart. The calf muscles have mini-pumps that drive blood up the venous system with calf muscle motion. In addition, exercising helps to control weight, and therefore decrease venous work. Elevation of the legs recruits the effect of gravity in returning blood back to the heart, reducing the pressure in the venous system.

If the problem is in the superficial system (greater or lesser saphenous veins), then there are other surgical options available. In previous years, the only surgical option was to strip veins under general or spinal anesthesia in the operting room. This procedure involved making a skin incision in the groin and ankle, and essentially avulsing the vein from the leg. Over the past few years, novel approaches have essentially made vein stripping obsolete. These new techniques are performed in the office under local anesthesia, with minimal downtime and excellent symptomatic and cosmetic results. This general type of approach has been named EndoVenous Laser Treatment of varicose veins. Essentially, under ultrasound guidance, the greater or lesser saephenous vein is cannulated with a laser fiber or a radiofrequency devise (RF), which is guided to the main valve site. Local anesthesia is infiltrated around the vein, and the fiber is turned on and slowly pulled back. The energy from the laser or RF coagulates the inside of the vessel. The vein is then slowly broken down by the body. Patients have a pulled muscle feeling in the thigh for one week, but are able to return to work within several days, depending on their occupation.

We use an endoluminal laser for treatment of venous insufficiency. These technique is called endovenous laser treatment (EVLT)

ALTERNATIVE OPTIONS FOR MANAGEMENT OF VARICOSE VEINS

There are other herbal and alternative supplements for the prevention and management of spider and varicose veins. These alternatives have been used more in Europe, but are gaining a more prominent role in the U.S.A. There are numerous supplements that are touted to improve vein health.