About 23% of adults in the US have varicose veins. This condition is more common in women than in men. An estimated 22 million women in the USA between the ages of 40 and 80 have reported to show visible varicose veins. A study of men and women ages 18-64 found that 74% of women and 56% of men reported to have lower extremity varicose veins. Data from patients with CEAP 6 stage CVI or with venous ulcers confirm the progressive nature of these serious forms of Chronic Venous Disorders with regards to symptoms and quality of life over a 4-year period.
Varicose veins are dilated, elongated, and tortuous veins which are usually found in the legs and thighs. The term varicose is derived from the Latin word ‘varix’, which means twisted. Any vein may become varicose, but the veins most commonly affected are those in the legs and feet. This is because standing and walking increases the pressure in the veins of the lower body. For many people, varicose veins and spider veins, a common, mild variation of varicose vein, are simply a cosmetic concern. For other people, varicose veins can cause aching pain and discomfort. Sometimes varicose veins lead to more serious problems. Varicose veins may also signal a higher risk of other circulatory problems. Treatment may involve self-care measures or procedures by your doctor to close or remove veins.
Definition of Varicose Veins
Superficial spider veins, in most cases, are a different, milder form of venous insufficiency. They are smaller, red, purple, and blue vessels that also twist and turn but are closer to the skin surface and are not swollen. Reticular veins are the green and blue veins beneath the skin that can bulge over time. Varicose veins can, in some cases, be asymptomatic. Some patients may also have a medical condition called chronic venous insufficiency, which is long-term varicose veins and valve failure. This condition can result in skin changes and/or ulcers in the lower legs.
Varicose veins are enlarged, swollen, and twisting veins, often appearing blue or dark purple. They happen when faulty valves in the veins allow blood to flow in the wrong direction or to pool. More than 23% of all adults are thought to be affected by varicose veins. Women are twice as likely as men to have them. They become more common with age and are also hereditary. Pregnancy, leg injury, obesity, prolonged standing, and hormone replacement all increase the risk of varicose veins. They cause a heavy or aching feeling in the legs, night cramps, and leg swelling. Standing or sitting for long periods of time can make your varicose veins feel worse. Long-term varicose veins can cause swelling and changes in the skin. Seek medical attention if your symptoms are causing pain or affecting your daily activities.
Prevalence of Varicose Veins
Varicose veins may also signal a higher threat of other circulatory problems. Self-care, such as exercise, elevating the legs or wearing compression stockings, can aid in decreasing the pain of varicose veins and may prevent them from getting worse. But for other folks, varicose veins can be a sign of a more serious problem that requires treatment.
Varicose veins are twisted, enlarged veins near the surface of the skin and can be easily recognized. Any vein becomes varicose, but the veins most commonly affected are those in your legs and feet. This is because standing and walking upright increases the pressure in the veins of your lower body. For many people, varicose veins are simply a cosmetic concern. For other people, varicose veins can cause considerable pain and discomfort. Sometimes varicose veins lead to more serious problems.
Risks and Complications
Of great importance is the understanding that varicose veins are an indication of a significant underlying problem with vein health. As the varicose veins are a manifestation of widespread blood reflux in the leg veins, the other superficial and deeper veins are also affected. This chronic venous insufficiency can lead to chronic leg swelling and skin changes or venous eczema. A more severe outcome is the development of a venous leg ulcer. This most common type of ulcer that occurs on the lower leg in middle-aged and elderly patients affects up to 3% of the population and has a large impact on quality of life. Measures in treating leg ulcers account for 2-3% of total healthcare expenditure in Western countries.
It is important to understand that varicose veins are not merely a cosmetic problem. Varicose veins are a sign of underlying venous insufficiency that, if left untreated, can lead to more serious health problems. Factors contributing to the development of varicose veins include genetics, age, gender, and pregnancy. Studies have shown that up to 50% of people with varicose veins have a family history of the condition. As the aging process weakens the veins, the likelihood of developing varicose veins increases. Women are more likely to develop the condition than men due to hormonal factors affecting vein strength and relaxation of the vein walls during pregnancy. These factors all lead to the enlargement of the veins and the accompanying symptoms of heaviness, aching, swelling, fatigue, and restless legs in the affected limbs.
Factors Contributing to Varicose Veins
Weight gain can be an aggravating factor in the development of varicose veins. It puts increased pressure on the veins in the legs. Prolonged standing can cause the veins to strain to pump blood to the heart. This occurs because the muscles are not contracting to push the blood up the veins. The primary cause of this is gravity. Normally, the leg veins have one-way valves to prevent the backflow of blood. Leg muscles pump the veins to help return blood to the heart. When the muscles are inactive, the calf muscle pump is not working, and blood may collect in the veins. High pressure of any type within the veins is one of the main causes of varicose veins.
Gender is an important factor. Women are two to three times more likely to develop varicose veins than men. Up to half of American women have varicose veins. Changes in hormones during pregnancy, pre-menstruation or menopause can be a factor, women taking birth control pills or hormone replacement therapy are also at increased risk. The reason for the increased risk in women is not fully known. An increased volume of blood in the body is intended to support the growing fetus, but it can also produce an enlarged vein. The position of the fetus also can add increased pressure to the leg veins. At the same time, any condition that places increased pressure on the legs (including weight gain) can be a cause.
Factors that contribute to the development of varicose veins include heredity, gender, pregnancy, weight gain, and prolonged standing. The influence of heredity has not been well determined. However, it is generally agreed that those with a family history of varicose veins are more likely to develop them, indicating that heredity is a significant factor.
Potential Health Risks
So, potential health risks are chronic venous insufficiency, skin changes, and venous ulcers. These are unpleasant for the people affected and are costly to the healthcare system. This is why it may be worthwhile for patients with their first episode of varicose veins to seek advice about treatment.
Varicose veins are sometimes painful and may cause chronic venous insufficiency when the valves stop functioning properly. Chronic venous insufficiency makes it hard for the blood to move up to the heart. Chronic venous insufficiency can cause swelling in the ankles and skin changes in the lower leg. Because of the decreased blood flow to the skin and fat, an itchy rash and skin damage may occur. In a severe case, these skin changes may cause an open sore to develop. In some people, varicose veins can cause blood clots or severe bleeding from ruptured veins.
Complications Associated with Untreated Varicose Veins
Many times, varicose veins are merely thought of as a cosmetic problem. It is true that swollen, twisted and painful veins are common symptoms, and the number of people looking for treatment is approximately 1 in 22. However, these numbers are largely outnumbered by people who are unaware of the risks involved when choosing not to seek treatment. The greatest complication occurs when skin on the lower leg is affected by a longstanding varicose vein. A color change will occur because of the breakdown of red blood cells, which can lead to an open sore known as a venous ulcer. Venous ulcers pose the risk of infection and cellulitis; a bacterial skin infection involving the inner layers of skin. More severe complications include bleeding from vein injury and blood clots. Deep vein thrombosis is a clot located in the deep veins of the calf or thigh. Although it is not a common result from varicose veins, the superficial thrombophlebitis that can occur in a swollen varicose vein is identified as an inflammation in a vein caused by a blood clot. When considering these complications, it is important for a person to gauge the impact varicose veins are having on their overall quality of life and weigh that against the risks of treatment.
Early Detection and Diagnosis
The most important factor in diagnosing the presence of varicose veins is a visual examination by a qualified physician. This allows a direct evaluation of the superficial veins, which is where varicose veins develop. The physician will observe the patient’s legs while standing and while elevated. This will be sufficient in most typical cases of varicose veins. In severe cases where there is a history of skin ulcers in the ankle area, a physician may further assess the patient’s condition with more advanced techniques, such as ultrasound. This is an excellent tool for evaluating the leg veins. While other diagnostic methods, such as venography, are available, they are rarely necessary for diagnosing varicose veins, and are used only in isolated cases.
Early detection of varicose veins is a useful tool in successfully treating the condition. The earlier the diagnosis is made, the better are the chances for a successful treatment to eliminate the varicose veins. In recognizing the potential for varicose veins, one would note that veins that have become varicose will often be dark in color, usually purple or blue. Some might also experience a heavy feeling in the legs, accompanied by fatigue. If these symptoms are not relieved by rest, elevation of the legs, or if one would continue to experience nighttime cramping of the legs, it would be advisable to seek a consultation with a doctor, as these symptoms may not only indicate varicose veins, but also other more serious conditions.
Recognizing the Symptoms
Pain, swelling of the ankle, leg cramps, and restless leg are symptoms that the majority of the population dismiss as ‘normal’ aches and pains. These symptoms are common among the population but could be an indication of something more serious. An early sign of varicose veins is heaviness and aching of the legs, usually after standing for long periods. Neither heaviness nor aching of the legs, nor ankle swelling should occur, and both symptoms are a sign that venous reflux (backward flow) is occurring. If left untreated, it will cause further damage to the skin and soft tissues of the legs. In chronic venous disease, ankle swelling usually becomes chronic, and it is associated with varicose eczema and ultimately, ulceration. Busy individuals often dismiss their symptoms as tiredness. This is a mistake, as the underlying cause will not improve, and if left untreated, the leg discomfort and ankle swelling will interfere with normal daily activities. Other symptoms are nocturnal leg cramps and restless leg. These symptoms may cause less damage to the skin and soft tissues, but they are distressing for the sufferer. The leg cramps are caused by muscle ischemia (an inadequate blood supply), and studies have shown that cramps are associated with varicose veins. Nocturnal leg cramps are also a common cause of sleeping disturbance. Restless leg is the feeling of an urge to move the legs and of the creepy-crawly sensation under the skin. This symptom is not specific to chronic venous disease, but it is often reported by patients with varicose veins, and it is frequently relieved when the refluxing veins are treated.
Diagnostic Methods
Several methods are available to diagnose varicose veins. Visual examination of the legs with the patient standing is the most valuable diagnostic tool. Duplex ultrasound is a remarkable technique now considered the gold standard in evaluating the anatomy and blood flow in the venous system. It is a noninvasive, painless procedure that takes about thirty minutes. Duplex ultrasound is done not only for diagnostic purposes but also to help plan the treatment and to confirm that the varicose vein treatment has been successful. The information obtained by ultrasound allows the doctor to make a more accurate assessment and gives the patient and doctor the opportunity to discuss the most appropriate treatment. This is considered important because varicose veins are a chronic condition and the aim of treatment may not only be to eradicate existing varicose veins, but also to prevent the occurrence of more varicose veins in the future. Other diagnostic methods such as venography and CT scans are rarely needed. Venography is an x-ray examination of the veins, which requires a dye to be injected into the vein so that the vein can be seen on an x-ray. This method is considered more accurate than ultrasound in assessment of the deep venous system. However, it is an invasive and uncomfortable procedure and is not commonly performed. CT scans are unnecessary and are only occasionally done for certain unusual presentations of varicose veins to help plan complicated surgery.
Importance of Timely Diagnosis
As a chronic and progressive condition, varicose veins must be treated early for the best results. This includes treatment done for cosmetic reasons. The longer a patient waits to seek treatment, the more likely they are to develop CEAP Clinical Class 4, 5 or 6 that can result in varicose vein associated complications (VACs). This is important, as patients with VAC 4, 5 or 6 are often not good candidates for insurance coverage for treatment. VACs include lipodermatosclerosis and atrophie blanche, healed and active ankle ulceration, spontaneous superficial bleeding from a varicosity, superficial thrombophlebitis and acute or chronic DVT in the setting of active or healed varicose veins. Without intervention, some of these complications may progress to severe, non-reversible conditions such as chronic ulceration and DVT or VTE. In the following section, we will discuss the best methods of treating varicose veins and venous insufficiency currently available.
Intervention and Treatment Options
The costs related to time off work and loss of mobility are likely to be significantly higher. It is likely that these figures are an underestimation and that the true cost is much higher. It is also likely that with the increasing longevity of the population in recent years, the incidence and prevalence of both venous ulceration and late sequelae from deep venous thrombosis, such as post-thrombotic syndrome, will increase. Measures to abrogate or halt the progression of CVS are likely to have a major impact on the overall health of the population and healthcare costs. With the rapid changes in endovenous technology and methodology, it is likely that minimally invasive methods of managing varicose veins will take a more prominent role in the management of this condition. Early referral to vascular specialists will enable successful intervention to take place before there is irreversible skin damage. A cost utility analysis of early referral and intervention vs long-term compression treatment in patients with severe venous disease would also be an interesting topic for future research.
Chronic venous diseases (CVD) are one of the most prevalent health issues in westernized countries and are the cause of significant morbidity due to its association with long-term discomfort, swelling, and adverse skin changes. In addition, they are aetiologically related to venous ulceration and the post-thrombotic syndrome. Chronic venous insufficiency and varicose veins now consume a significant portion of healthcare resources and result in functional disability, with a major socioeconomic impact. In 1994, the cost of managing venous leg ulceration in the UK had been estimated at £400 million per annum, with direct healthcare costs in Italy in 1998 being estimated at £6151 per patient over a 3-year follow-up period.
Conservative Management Approaches
The more recent option of lifestyle changes with regular, moderate exercise may offer a more acceptable conservative approach. Patients involved in the Tampere varicose vein study were given a regular home exercise regimen, resulting in improved venous leg pump function in those who complied. Measures were gauged using air plethysmography and foot venous pressure measurements. While the exact definition of moderate exercise was not provided, a similar home exercise regimen in a UK patient group would likely involve the use of a Nintendo Wii Fit exercise program, as demonstrated in the study by Rose and Butterfield in 2010. This involves a wide variety of aerobic exercises and balance games of varying intensities. Though no direct studies have been conducted, recommendations would suggest this is a more cost-effective and acceptable method than compression therapy, with potential for engaging the elderly population and improving general health.
Recommendation for the conservative management of varicose veins in the United Kingdom, as recommended in the 2006 NICE guidelines, remains compression therapy, form-fitting stockings, and regular, moderate exercise. This method is practiced for at least 3-6 months before moving onto more invasive methods. Stockings come in various pressures, with differences in effectiveness, though generally 30-40mmHg is recommended. The use of compression may bring symptomatic relief for a few select patients; however, compliance is generally poor, and stockings are considered cosmetically unacceptable by some in the working population. An active high street pharmacist reported that patients often return the stockings to him after use, claiming that they are too difficult to put on. Cognitive-behavioral therapy was deemed ineffective in increasing patient compliance with compression therapy in a 2014 study.
Minimally Invasive Treatment Procedures
Laser and Intense Pulsed Light (IPL) treatments work at the surface of the skin to remove thread veins and small varicose veins. A laser causes less pain and bruising than sclerotherapy and is effective and visible in 2/3 treatments. IPL has been shown in studies to improve patients’ symptoms and is as effective as sclerotherapy for varicose veins. The closure procedure is a new intravenous method that utilizes a diode laser. It is minimally invasive, just requiring a small amount of local anesthetic and only leaves a small entry mark. The vein is targeted with a precise wavelength of laser light to cause the vein to contract and then seal shut. Over time, it will then be absorbed by the body. This procedure is a less traumatic alternative to surgical intervention with a lower risk of complications and is as effective in the treatment of larger veins.
Sclerotherapy involves the injection of a solution into the affected veins. The solution irritates the lining of the vessels, causing it to stick together and clot. Over time, the vessel turns into scar tissue that fades from view. This treatment is effective on the majority of varicose veins, however between 10-20% of veins injected fail to respond to the treatment. Also, the procedure generally does not affect the symptoms associated with the condition, and again there is a lack of evidence regarding the long-term effects of sclerotherapy for varicose veins. In more recent times, foam sclerotherapy has been used for veins where traditional methods may be less effective, like in bigger veins, where a catheter can be used to generate foam from the solution to maximize contact with the vein.
Varicose veins are most commonly treated with compression stockings, which apply a defined level of compression to the affected limb. Despite being low risk and relatively inexpensive, there is still no concrete evidence to suggest that it is an effective long-term solution for varicose veins. For those who do not wish to undergo invasive treatments or who are unable to obtain funding through healthcare, this may be a suitable long-term solution.
Surgical Intervention for Severe Cases
Ambulatory phlebectomy is a further method of surgical removal of superficial varicose veins in which several minimal incisions are made, and a special hook is used to remove the veins. Only the parts of the vein causing the reflux are removed, and there is no need for any stitches. This method has the benefit of leaving very small or no scars and can be done under local anesthesia.
Vein ligation and stripping is considered to be the gold standard for the removal of large varicose veins in the medical world. The surgery is performed as a day case for most patients. It is done by surgically tying off the main varicose vein in the upper leg and the saphenous vein through small incisions, and then pulling the vein out using a special tool. The removal of the vein causing the reflux is what makes it a very effective method. However, the pulling out of the vein can cause discomfort for the patients, and they are often left with some bruising and discomfort in the region for a few weeks. This surgery has been proven to give the best long-term results for the removal of the problem veins and can help to prevent the varicose veins from causing further complications.
Surgical intervention is generally only considered if all other management options have been exhausted. If the varicose veins are causing a large amount of discomfort, swelling, and open sores, then this is a strong indication for surgical intervention. There are a number of different techniques used for the removal of varicose veins, including vein ligation and stripping, ambulatory phlebectomy, endoscopic vein surgery, and the newest method of laser-assisted ablation surgery.
