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Varicose Veins

Introduction

Varicose veins are enlarged and tortuous veins. They may be visible to the naked eye as bulging blue blood vessels or only visible on ultrasound. Most commonly varicose veins occur in the legs where the effects of gravity are greatest. 

Varicose veins form in the superficial venous system which is responsible for draining 10% of the blood from the leg. The deep system drains 90% of the blood from the leg. 

Apart from their cosmetic appearance, varicose veins can become medically significant due to the 4-9 times higher risk of blood clots and venous leakage causing damage to the skin and underlying soft tissues.

Causes

The fundamental cause of varicose veins is not currently known. Pathology may start with the valves in the vein becoming faulty, which may occur due to recurrent micro-thrombi (clot) formation or due to stretching of the vein wall due to high venous pressure. Varicose veins run in families and additional factors that may contribute include female sex (hormones), pregnancy, obesity and other lifestyle factors such as long periods standing or sitting.

When the venous system is functioning normally, contraction of the lower limb muscles force blood from superficial veins to deep veins and upward past competent valves. In varicose veins, faulty valves remain open instead of closing, allowing back flow and pooling of blood. This is also known as venous insufficiency or incompetence. The venous system remains at high pressure instead of undergoing the normal reduction in pressure that occurs with muscle contraction. Fluid, red blood cells, white blood cells, protein and fibrin, leak out of the veins and capillaries into the surrounding tissue causing tissue destruction and scarring. 

Eventually damage to the tissues and skin changes can occur. In the most extreme cases, chronic ulcers develop, usually at the ankle where hydrostatic pressure is greatest. 

Varicose veins may affect the superficial veins alone or coexist with obstruction or incompetence of the deep veins. 

Signs and Symptoms

For many people varicose and spider veins are of cosmetic concern. Spider veins alone, however, can produce some of the most pronounced symptoms, and are indeed symptomatic in 50% of people.

Aching, pain, throbbing, leg swelling, restless legs, itch, bleeding, and progression to ulceration are also symptoms of presentation. People with varicose veins are also more prone to blood clots (4-9 times increased incidence) called superficial thrombophlebitis and deep vein thrombosis. Symptoms often do not correlate with clinical appearance.

Diagnosis

Your doctor can examine your legs to see the pattern of varicosities but this has little correlation with the anatomical distribution of your disease. A Vascular Duplex Ultrasound is, therefore, necessary.

Vascular Duplex Ultrasound is the gold standard investigation for problem veins. It is important that the distribution of deep and superficial reflux is known before embarking on a treatment regime. In the presence of peripheral arterial disease (poor circulation/blood flow in to the legs) it is also important that an arterial assessment is made.

Treatment

  • Vein tonics.
  • Compression therapy.
  • Endovenous Laser Therapy (EVLT).
  • Ultrasound Guided Sclerotherapy.
  • Sclerotherapy.
  • Surgery.

Related Information

Compression
Endovenous Laser Therapy
Ultrasound Guided Sclerotherapy
Micro-Sclerotherapy
Ambulatory Phlebectomy
Superficial Thrombophlebitis
Ultrasound