Varicose veins

Template:Short description Template:Infobox medical condition (new) Varicose veins, also known as varicoses, are a medical condition in which superficial veins become enlarged and twisted. Although usually just a cosmetic ailment, in some cases they cause fatigue, pain, itching, and nighttime leg cramps.<ref name="NIH2019" /><ref name="Mer2019Pro" /><ref>Template:Cite web</ref> These veins typically develop in the legs, just under the skin.<ref name="MLP2019" /> Their complications can include bleeding, skin ulcers, and superficial thrombophlebitis.<ref name="NIH2019" /><ref name="Mer2019Pro" /> Varices in the scrotum are known as varicocele, while those around the anus are known as hemorrhoids.<ref name="NIH2019">Template:Cite web</ref> The physical, social, and psychological effects of varicose veins can lower their bearers' quality of life.<ref>Template:Cite journal</ref>

Varicose veins have no specific cause.<ref name="Mer2019Pro" /> Risk factors include obesity, lack of exercise, leg trauma, and family history of the condition.<ref name="MLP2019" /> They also develop more commonly during pregnancy.<ref name="MLP2019" /> Occasionally they result from chronic venous insufficiency.<ref name="Mer2019Pro" /> Underlying causes include weak or damaged valves in the veins.<ref name="NIH2019" /> They are typically diagnosed by examination, including observation by ultrasound.<ref name="Mer2019Pro" />

By contrast, spider veins affect the capillaries and are smaller.<ref name="NIH2019" /><ref name="WOMEN2016">Template:Cite web</ref>

Treatment may involve lifestyle changes or medical procedures with the goal of improving symptoms and appearance.<ref name="NIH2019" /> Lifestyle changes may include wearing compression stockings, exercising, elevating the legs, and weight loss.<ref name="NIH2019" /> Possible medical procedures include sclerotherapy, laser surgery, and vein stripping.<ref name="Mer2019Pro">Template:Cite web</ref><ref name="NIH2019" /> However, recurrence is common following treatment.<ref name="Mer2019Pro" />

Varicose veins are very common, affecting about 30% of people at some point in their lives.<ref name="Baram_2022">Template:Cite journal</ref><ref name="MLP2019">Template:Cite web</ref><ref name="NHS2007">Template:Cite web</ref> They become more common with age.<ref name="MLP2019" /> Women develop varicose veins about twice as often as men.<ref name="WOMEN2016" /> Varicose veins have been described throughout history and have been treated with surgery since at least the second century BC, when Plutarch tells of such treatment performed on the Roman leader Gaius Marius.Template:Cn

Signs and symptoms

• Aching, heavy legs<ref name=":0">Template:Cite journal</ref><ref name=":1">Template:Cite web</ref>
• Appearance of spider veins (telangiectasia) in the affected leg
• Ankle swelling<ref name=":0" /><ref name=":1" />
• A brownish-yellow shiny skin discoloration near the affected veins
• Redness, dryness, and itchiness of areas of skin, termed stasis dermatitis or venous eczema<ref name=":1" />
• Muscle cramps when making sudden movements, such as standing<ref name=":1" /><ref>Template:Cite journal</ref>
• Abnormal bleeding or healing time for injuries in the affected area
• Lipodermatosclerosis or shrinking skin near the ankles
• Restless legs syndrome appears to be a common overlapping clinical syndrome in people with varicose veins and other chronic venous insufficiency<ref>Template:Cite web</ref>
• Atrophie blanche, or white, scar-like formations
• Burning or throbbing sensation in the legs<ref name=":1" />

People with varicose veins might have a positive D-dimer blood test result due to chronic low-level thrombosis within dilated veins (varices).<ref>Template:Cite web</ref>

Complications

Most varicose veins are reasonably benign, but severe varicosities can lead to major complications, due to the poor circulation through the affected limb.

• Pain, tenderness, heaviness, inability to walk or stand for long hours
• 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. Over 100 reported cases of malignant transformation have been reported at a rate reported as 0.4% to 1%<ref name="Goldman">Goldman M. (1995) Sclerotherapy, Treatment of Varicose and Telangiectatic Leg Veins. Hardcover Text, 2nd Ed.</ref>Template:Dubious
• Severe bleeding from minor trauma, of particular concern in the elderly<ref name=":1" />
• Blood clotting within affected veins, termed superficial thrombophlebitis.<ref name=":1" /> These are frequently isolated to the superficial veins, but can extend into deep veins, becoming a more serious problem.<ref name=":1" />
• Acute fat necrosis can occur, especially at the ankle of overweight people with varicose veins. Females have a higher tendency of being affected than males

Causes

File:Varicose veins-en.svg

How a varicose vein forms in a leg. Figure A shows a normal vein with a working valve and normal blood flow. Figure B shows a varicose vein with a deformed valve, abnormal blood flow, and thin, stretched walls. The middle image shows where varicose veins might appear in a leg.

File:Blausen 0891 VaricoseVein.png

Comparison of healthy and varicose veins

Varicose veins are more common in women than in men and are linked with heredity.<ref>Template:Cite journal</ref> Other related factors are pregnancy, obesity, menopause, aging, prolonged standing, leg injury and abdominal straining. Varicose veins are unlikely to be caused by crossing the legs or ankles.<ref>Template:Cite web</ref> Less commonly, but not exceptionally, varicose veins can be due to other causes, such as post-phlebitic obstruction or incontinence, venous and arteriovenous malformations.<ref>Template:Cite book</ref>

Venous reflux is a significant cause. Research has also shown the importance of pelvic vein reflux (PVR) in the development of varicose veins. Varicose veins in the legs could be due to ovarian vein reflux.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> Both ovarian and internal iliac vein reflux causes leg varicose veins. This condition affects 14% of women with varicose veins or 20% of women who have had vaginal delivery and have leg varicose veins.<ref>Template:Cite journal</ref> In addition, evidence suggests that failing to look for and treat pelvic vein reflux can be a cause of recurrent varicose veins.<ref>Template:Cite journal</ref>

There is increasing evidence for the role of incompetent perforator veins (or "perforators") in the formation of varicose veins.<ref>Template:Cite journal</ref> and recurrent varicose veins.<ref>Template:Cite journal</ref>

Varicose veins could also be caused by hyperhomocysteinemia in the body, which can degrade and inhibit the formation of the three main structural components of the artery: collagen, elastin and the proteoglycans. Homocysteine permanently degrades cysteine disulfide bridges and lysine amino acid residues in proteins, gradually affecting function and structure. Simply put, homocysteine is a 'corrosive' of long-living proteins, i.e. collagen or elastin, or lifelong proteins, i.e. fibrillin. These long-term effects are difficult to establish in clinical trials focusing on groups with existing artery decline. Klippel–Trenaunay syndrome and Parkes Weber syndrome are relevant for differential diagnosis.Template:Citation needed

Another cause is chronic alcohol consumption due to the vasodilatation side effect in relation to gravity and blood viscosity.<ref>Template:Cite book</ref>

Diagnosis

Clinical test

Clinical tests that may be used include:Template:Citation needed

• Trendelenburg test – to determine the site of venous reflux and the nature of the saphenofemoral junction

Investigations

Template:See Traditionally, varicose veins were investigated using imaging techniques only if there was a suspicion of deep venous insufficiency, if they were recurrent, or if they involved the saphenopopliteal junction. This practice is now less widely accepted. People with varicose veins should now be investigated using lower limbs venous ultrasonography. The results from a randomised controlled trial on patients with and without routine ultrasound have shown a significant difference in recurrence rate and reoperation rate at 2 and 7 years of follow-up.<ref>Template:Cite journal</ref>

Stages

The CEAP (Clinical, Etiological, Anatomical, and Pathophysiological) Classification, developed in 1994 by an international ad hoc committee of the American Venous Forum, outlines these stages<ref name="pmid24868066">Template:Cite journal</ref><ref name="pmid15622385">Template:Cite journal</ref>

• C0 – Perthes test – no visible or palpable signs of venous disease
• C1 – telangectasia or reticular veins
• C2 – varicose veins
• C2r – recurrent varicose veins
• C3 – edema
• C4 – changes in skin and subcutaneous tissue due to Chronic Venous Disease
• C4a – pigmentation or eczema
• C4b – lipodermatosclerosis or atrophie blanche
• C4c – Corona phlebectatica
• C5 – healed venous ulcer
• C6 – active venous ulcer
• C6r – recurrent active ulcer

Each clinical class is further characterized by a subscript depending upon whether the patient is symptomatic (S) or asymptomatic (A), e.g. C2S.<ref name="Bailey&Love">Template:Cite book</ref>

Treatment

Treatment can be either active or conservative.

Active

Treatment options include surgery, laser and radiofrequency ablation, and ultrasound-guided foam sclerotherapy.<ref name="Baram_2022" /><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> Newer treatments include cyanoacrylate glue, mechanochemical ablation, and endovenous steam ablation. No real difference could be found between the treatments, except that radiofrequency ablation could have a better long-term benefit.<ref>Template:Cite journal</ref>

Conservative

The National Institute for Health and Clinical Excellence (NICE) produced clinical guidelines in July 2013 recommending that all people with symptomatic varicose veins (C2S) and worse should be referred to a vascular service for treatment.<ref>Template:Cite web</ref> Conservative treatments such as support stockings should not be used unless treatment was not possible.

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.<ref>Template:Cite journal</ref>
• The wearing of graduated compression stockings with variable pressure gradients (Class II or III) has been shown to correct the swelling, increase nutritional exchange, and improve the microcirculation in legs affected by varicose veins.<ref>Template:Cite conference</ref> They also often provide relief from the discomfort associated with this disease. Caution should be exercised in their use in patients with concurrent peripheral arterial disease.
• The wearing of intermittent pneumatic compression devices has been shown to reduce swelling and pain.<ref name="Yamany Hamdy 2021 p.">Template:Cite journal</ref>
• Diosmin/hesperidin and other flavonoids.
• 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.Template:Medical citation needed
• Topical gel applicationTemplate:Vague helps in managing symptoms related to varicose veins such as inflammation, pain, swelling, itching, and dryness.

Procedures

Stripping

Stripping consists of removal of all or part the saphenous vein (great/long or lesser/short) main trunk. The complications include deep vein thrombosis (5.3%),<ref>Template:Cite journal</ref> pulmonary embolism (0.06%), and wound complications including infection (2.2%). There is evidence for the great saphenous vein regrowing after stripping.<ref>Template:Cite journal</ref> For traditional surgery, reported recurrence rates, which have been tracked for 10 years, range from 5% to 60%. In addition, since stripping removes the saphenous main trunks, they are no longer available for use as venous bypass grafts in the future (coronary or leg artery vital disease).<ref>Template:Cite journal</ref>

Other

Other surgical treatments are:

• CHIVA method (ambulatory conservative haemodynamic correction of venous insufficiency) is a relatively low-invasive surgical technique that incorporates venous hemodynamics and preserves the superficial venous system.<ref name=":2">Template:Cite journal</ref> The overall effectiveness compared to stripping, radiofrequency ablation treatment, or endovenous laser therapy is not clear and there is no strong evidence to suggest that CHIVA is superior to stripping, radiofrequency ablation, or endovenous laser therapy for recurrence of varicose veins.<ref name=":2" /> There is some low-certainty evidence that CHIVA may result in more bruising compared to radiofrequency ablation treatment.<ref name=":2" />
• Vein ligation is done at the saphenofemoral junction after ligating the tributaries at the saphenofemoral junction without stripping the long saphenous vein, provided the perforator veins are competent and DVT is absent in the deep veins. With this method, the long saphenous vein is preserved.
• Cryosurgery – A cryoprobe is passed down the long saphenous vein following saphenofemoral ligation. The probe is then cooled with NO₂ or CO₂ to −85°F. The vein freezes to the probe and can be retrogradely stripped after 5 seconds of freezing. It is a variant of stripping. The only purpose of this technique is to avoid a distal incision to remove the stripper.<ref>Template:Cite journal</ref>

Sclerotherapy

A commonly performed non-surgical treatment for varicose and "spider leg veins" is sclerotherapy, in which medicine called a sclerosant is injected into the veins to make them shrink. The medicines that are commonly used as sclerosants are polidocanol (POL branded Asclera in the United States, Aethoxysklerol in Australia), sodium tetradecyl sulphate (STS), Sclerodex (Canada), hypertonic saline, glycerin and chromated glycerin. STS (branded Fibrovein in Australia) liquids can be mixed at varying concentrations of sclerosant and varying sclerosant/gas proportions, with air or CO₂ or O₂ to create foams. Foams may allow more veins to be treated per session with comparable efficacy. Their use in contrast to liquid sclerosant is still somewhat controversialTemplate:Medical citation needed, and there is no clear evidence that foams are superior.<ref name="CD001732">Template:Cite journal</ref> Sclerotherapy has been used in the treatment of varicose veins for over 150 years.<ref name="Goldman" /> Sclerotherapy is often used for telangiectasias (spider veins) and varicose veins that persist or recur after vein stripping.<ref>Pak, L. K. et al. "Veins & Lymphatics," in Lange's Current Surgical Diagnosis & Treatment, 11th ed., McGraw-Hill.Template:Page?</ref><ref>Template:Cite journal</ref> Sclerotherapy can also be performed using foamed sclerosants under ultrasound guidance to treat larger varicose veins, including the great saphenous and small saphenous veins.<ref>Template:Cite book</ref><ref>Template:Cite journal</ref>

There is some evidence that sclerotherapy is a safe and possibly effective treatment option for improving the cosmetic appearance, reducing residual varicose veins, improving the quality of life, and reducing symptoms that may be present due to the varicose veins.<ref name="CD001732" /> There is also weak evidence that this treatment option may have a slightly higher risk of deep vein thrombosis. It is not known if sclerotherapy decreases the chance of varicose veins returning (recurrent varicose veins).<ref name="CD001732" /> It is also not known which type of substance (liquid or foam) used for the sclerotherapy procedure is more effective and comes with the lowest risk of complications.<ref name="CD001732" />

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.<ref>Finkelmeier, William R. (2004) "Sclerotherapy", Ch. 12 in ACS Surgery: Principles & Practice, WebMD, Template:ISBN.</ref><ref>Template:Cite journal</ref> There has been one reported case of stroke after ultrasound-guided sclerotherapy when an unusually large dose of sclerosant foam was injected.<ref>Template:Cite journal</ref>

Template:Anchor Endovenous thermal ablation

There are three kinds of endovenous thermal ablation treatment possible: laser, radiofrequency, and steam.<ref>Template:Cite journal</ref>

The Australian Medical Services Advisory Committee (MSAC) in 2008 determined that endovenous laser treatment/ablation (ELA) 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."<ref>Medical Services Advisory Committee, ELA for varicose veins. MSAC application 1113, Dept of Health and Ageing, Commonwealth of Australia, 2008.</ref> It also found in its assessment of available literature, that "occurrence 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 ELA include minor skin burns (0.4%)<ref name="Elmore">Template:Cite journal</ref> and temporary paresthesia (2.1%). The longest study of endovenous laser ablation is 39 months.<ref>Template:Cite web</ref>

Two prospective randomized trials found speedier recovery and fewer complications after radiofrequency ablation (ERA) compared to open surgery.<ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> Myers<ref>Template:Cite journal</ref> 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%. By comparison ERA has been shown to control 80% of cases of small saphenous vein reflux at 4 years, said Myers. Complications for ERA 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 ERA, with a recurrence rate of 33%, to open surgery, which had a recurrence rate of 23%.Template:Citation needed

Steam treatment consists in injection of pulses of steam into the sick vein. This treatment which works with a natural agent (water) has results similar to laser or radiofrequency.<ref>Template:Cite journal</ref> The steam presents a lot of post-operative advantages for the patient (good aesthetic results, less pain, etc.)<ref>Template:Cite journal</ref> Steam is a very promising treatment for both doctors (easy introduction of catheters, efficient on recurrences, ambulatory procedure, easy and economic procedure) and patients (less post-operative pain, a natural agent, fast recovery to daily activities).<ref>Template:Cite journal</ref>

ELA and ERA require specialized training for doctors and special equipment. ELA is performed as an outpatient procedure and does not require an operating theatre, nor does the patient need a general anaesthetic. Doctors use high-frequency ultrasound during the procedure to visualize the anatomical relationships between the saphenous structures.Template:Citation needed

Some practitioners also perform phlebectomy or ultrasound-guided sclerotherapy at the time of endovenous treatment. This is also known as an ambulatory phlebectomy. The distal veins are removed following the complete ablation of the proximal vein. This treatment is most commonly used for varicose veins off of the great saphenous vein, small saphenous vein, and pudendal veins.<ref>Template:Cite book</ref> Follow-up treatment to smaller branch varicose veins is often needed in the weeks or months after the initial procedure.

Medical Adhesive

Also called medical super glue, medical adhesive is an advanced non-surgical treatment for varicose veins during which a solution is injected into the diseased vein through a small catheter and under the assistance of ultrasound-guided imagery. The "super glue" solution is made of cyanoacrylate, aiming at sealing the vein and rerouting the blood flow to other healthy veins.<ref>Template:Cite web</ref>

Post-treatment, the body will naturally absorb the treated vein which will disappear. Involving only a small incision and no hospital stay, medical super glue has generated great interest within the last years, with a success rate of about 96.8%.<ref>Template:Cite web</ref>

A follow-up consultation is required after this treatment, just like any other one, in order to re-assess the diseased vein and further treat it if needed.Template:Citation needed

Echotherapy Treatment

In the field of varicose veins, the latest medical innovation is high-intensity focused ultrasound therapy (HIFU). This method is completely non-invasive and is not necessarily performed in an operating room, unlike existing techniques. This is because the procedure involves treating from outside the body, able to penetrate the skin without damage, to treat the veins in a targeted area.<ref>Template:Cite news</ref> This leaves no scars and allows the patient to return to their daily life immediately.

Epidemiology

Varicose veins are most common after age 50.<ref>Template:Cite book</ref> It is more prevalent in females.<ref>Template:Cite web</ref> There is a hereditary role. It has been seen in smokers, those who have chronic constipation, and in people with occupations which necessitate long periods of standing such as wait staff, nurses, conductors (musical and bus), stage actors, umpires (cricket, javelin, etc.), the King's guards, lectern orators, security guards, traffic police officers, vendors, surgeons, etc.<ref name="Bailey&Love" />

External links

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