Varicose veins are veins that have become enlarged and tortuous. The term commonly refers to the veins on the leg,although varicose veins can occur elsewhere.When veins become varicose, the leaflets of the valves no longer meet properly, and the valves do not work. This allows blood to flow backwards and they enlarge even more. Varicose veins are most common in the superficial veins of the legs, which are subject to high pressure when standing. Besides cosmetic problems, varicose veins are often painful, especially when standing or walking. They often itch, and scratching them can cause ulcers. Serious complications are rare. Non-surgical treatments include sclerotherapy, elastic stockings, elevating the legs, and exercise. The traditional surgical treatment (vein stripping) removes the affected veins. Newer, less invasive treatments which seal the main leaking vein on the thigh are available. Alternative techniques, such as ultrasound-guided foam sclerotherapy, radiofrequency ablation and endovenous laser treatment, are available as well. Because most of the blood in the legs is returned by the deep veins, the superficial veins, which return only about 10 per cent of the total blood of the legs, can usually be removed or ablated without serious harm.Varicose veins are distinguished from reticular veins (blue veins) and telangiectasias (spider veins), which also involve valvular insufficiency,by the size and location of the veins.
Signs and symptoms
Aching, heavy legs (often worse at night and after exercise). Appearance of spider veins (telangiectasia) in the affected leg. Ankle swelling. A brownish-blue shiny skin discoloration near the affected veins. Redness, dryness, and itchiness of areas of skin, termed stasis dermatitis or venous eczema, because of waste products building up in the leg. Cramps may develop especially when making a sudden move as standing up. Minor injuries to the area may bleed more than normal and/or take a long time to heal. In some people the skin above the ankle may shrink (lipodermatosclerosis) because the fat underneath the skin becomes hard. Restless legs syndrome appears to be a common overlapping clinical syndrome in patients with varicose veins and other chronic venous insufficiency. Whitened, irregular scar-like patches can appear at the ankles. This is known as atrophie blanche.
Varicose veins are more common in women than in men, and are linked with heredity. Other related factors are pregnancy, obesity, menopause, aging, prolonged standing, leg injury, abdominal straining, and crossing legs at the knees or ankles. Less commonly, but not exceptionally, varicose veins can be due to other causes, as post phlebitic obstruction and/or incontinence, venous and arteriovenous malformations.
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.” The wearing of graduated compression stockings with variable pressure gradients (Class II or III) has been shown to correct the swelling, nutritional exchange, and improve the microcirculation in legs affected by varicose veins.They also often provide relief from the discomfort associated with this disease. Caution should be exercised in their use in patients with concurrent arterial disease. Diosmin/Hesperidine 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.
Active medical intervention in varicose veins can be divided into surgical and non-surgical treatments. Some doctors favor traditional open surgery, while others prefer the newer methods. Newer methods for treating varicose veins such as Endovenous Thermal Ablation (endovenous laser treatment or radiofrequency ablation), and foam sclerotherapy are not as well studied, especially in the longer term.
Several techniques have been performed for over a century, from the more invasive saphenous stripping, to less invasive procedures like ambulatory phlebectomy and CHIVA.
Stripping consists of removal of all or part the saphenous vein main trunk. The complications include deep vein thrombosis (5.3%),pulmonary embolism (0.06%), and wound complications including infection (2.2%). For traditional surgery, reported recurrence rates, which have been tracked for 10 years, range from 5-60%. In addition, since stripping removes the saphenous main trunks, they are no longer available for venous bypass in the future (coronary and/or leg artery vital disease)\
Other surgical treatments are:
Ambulatory phlebectomy Vein ligation Cryosurgery- A cryoprobe is passed down the long saphenous vein following saphenofemoral ligation. Then the probe is cooled with NO2 or CO2 to a temperature of – 850. The vein freezes to the probe and can be retrogradely stripped after 5 sec of freezing.It is a variant of Stripping. The only point of this technique is to avoid a distal incision to remove the stripper. Non-surgical treatment
A commonly performed non-surgical treatment for varicose and “spider” leg veins is sclerotherapy in which medicine is injected into the veins to make them shrink. The medicines that are commonly used as sclerosants are polidocanol (POL), sodium tetradecyl sulphate (STS), Sclerodex (Canada), Hypertonic Saline, Glycerin and Chromated Glycerin. STS and Polidocanol(branded Asclera in the United States) liquids can be mixed with air or CO2 or O2 to create foams. Sclerotherapy has been used in the treatment of varicose veins for over 150 years.Sclerotherapy is often used for telangiectasias (spider veins) and varicose veins that persist or recur after vein stripping.Sclerotherapy can also be performed using foamed sclerosants under ultrasound guidance to treat larger varicose veins, including the great saphenous and small saphenous veins. A study by Kanter and Thibault in 1996 reported a 76% success rate at 24 months in treating saphenofemoral junction and great saphenous vein incompetence with STS 3% solution. A Cochrane Collaboration review concluded sclerotherapy was better than surgery in the short term (1 year) for its treatment success, complication rate and cost, but surgery was better after 5 years, although the research is weak.