Treatment of Varicose Veins

What are Varicose Veins?

If you’re over 40, you probably see them; those little purple veins that suddenly seem to appear on your legs. Veins are the soft, thin-walled tubes that return blood from the arms and legs to the heart. Because veins work against the force of gravity, they have valves that allow forward blood flow, but not reverse. Your legs and arms have two major types of veins: superficial and deep. The superficial veins are near the surface of the skin and are often visible.

varicose veins

The deep veins are located near the bones and are surrounded by muscle. Connecting the deep and superficial veins is a third type of vein, the perforator vein. Contraction (squeezing) of the muscles in the arms and legs with exercise helps blood flow in the veins. Varicose veins are enlarged, bulging superficial veins that can be felt beneath the skin, generally larger than 3-mm in diameter.

They are usually located on the inside of the calf or thigh and develop due to weakness of the vein wall and loss of valve function. Under the pressure of gravity, they continue to enlarge, and in the course of time, they may become elongated, twisted, pouched and thickened. Spider veins or telangiectasia are tiny dilated, veins, usually less than 1-mm in diameter, located at the surface skin layers. Spider veins cannot be felt. Veins larger than the spider veins, but still under 3-mm are called reticular veins.

Symptoms of varicose veinsCausesRisk Factors
Varicose veins may be entirely symptom-free and cause no health problems. Treatment in such cases is often for cosmetic purposes. When symptomatic, varicose veins may cause ankle and leg swelling, heaviness or tension, aching, restlessness, cramps and itching. Varicose veins are more often symptomatic in women than in men. Signs of chronic venous disease include skin pigmentation (usually rusty brown), and loss of the soft texture of the skin and underlying tissue in the ankle area (called induration). Itching is perhaps the most consistent symptom of varicose veins in men. Women most often complain of leg heaviness, tension and aching.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 and abdominal straining. Varicose veins are unlikely to be caused by crossing the legs or ankles. Less commonly, but not exceptionally, varicose veins can be due to other causes, as post phlebitic obstruction or incontinence, venous and arteriovenous malformations.

The most important factors leading to the development of varicose veins include:

• Heredity

• Prolonged standing

• Increasing age

• Heavy lifting

• Prior superficial or

deep vein clots

• Female gender

• Multiple pregnancies

Less physical activity, a higher

blood pressure and obesity have

also been linked with the presence

of varicose veins in females.

Treatment of Varicose Veins

Treatment options for varicose veins include conservative management, external laser treatment, injection sclerotherapy, endovenous interventions, and surgery.

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The indications for treatment are largely based on patient preference. Choice of treatment is also affected by symptoms, cost, potential for iatrogenic complications, available medical resources, insurance reimbursement, and physician training, as well as the presence or absence of deep venous insufficiency and the characteristics of the affected veins.Vascularsurgical intervention for venous insufficiency may be indicated in patients with aching pain and leg fatigue, ankle edema, chronic venous insufficiency, cosmetic concerns, early hyperpigmentation, external bleeding, progressive or painful ulcer, or superficial thrombophlebitis.

CONSERVATIVE MANAGEMENT varicose veins
CONSERVATIVE MANAGEMENT varicose veins
CONSERVATIVE MANAGEMENTConservative treatment options include avoidance of prolonged standing and straining, elevation of the affected leg, exercise, external compression, loosening of restrictive clothing, medical therapy, modification of cardiovascular risk factors, reduction of peripheral edema, and weight loss. External compression devices (e.g., bandages, support stockings, intermittent pneumatic compression devices) have been recommended as initial therapy for varicose veins; however, evidence to support these therapies is lacking.

Typical recommendations include wearing 20 to 30 mm Hg elastic compression stockings with a gradient of decreasing pressure from the distal to proximal extremity. Multiple medications have been proposed as treatments for varicose veins.

The use of diuretics is not supported by medical literature. Horse chestnut seed extract (Aesculus hippocastanum) has been used in Europe and has been shown in randomized, double-blind, placebo-controlled trials to reduce edema.  Butcher’s broom (Ruscus aculeatus) has also been used; however, clinical data to establish its safety and effectiveness are lacking.

EXTERNAL LASER TREATMENTMultiple laser machines that deliver various wavelengths of light through the skin and into the blood vessels are available to treat varicose veins. The light is absorbed in the vessels by hemoglobin, leading to thermocoagulation.

laser treatment

Types of lasersinclude pulsed dye, long pulsed, variable pulsed, neodymiumdoped yttrium aluminum garnet (Nd:YAG), and alexandrite lasers. Potentially, any small, straight vein branch is amendable to external laser ablation. However, laser therapy has typically been used on telangiectasias and smaller vessels rather than on larger veins. Long-pulsed lasers have been shown to completely clear veins with diameters less than 0.5 mm. For veins with diameters of 0.5 to 1.0 mm, improvement but not clearance is achieved.

ENDOVENOUS OBLITERATION OF THE SAPHENOUS VEINA newer treatment for varicose veins is to insert a long, thin catheter that emits energy (most commonly heat, radio waves, or laser energy). The released energy collapses and scleroses the vein. A variety of techniques and protocols are used. Because it is easier to insert a catheter through a vein in the same direction that the valves open, the catheter is most commonly inserted into a more distal portion of the vein and threaded proximally. Energy is released from the catheter tip. As the catheteris pulled out, the vein lumen collapses. Bruising, tightness along the course of the treated vein, recanalization, and paresthesia are possible complications.
SCLEROTHERAPY Sclerotherapy involves injecting superficial veins with a substance that causes them to collapse permanently. A needle is inserted into the vein lumen and a sclerosing substance is injected. The substance displaces the blood and reacts with the vascular endothelium, sealing and scarring the vein.

SCLEROTHERAPY Varicose veins
A variety of products are used, including hyperosmotic solutions (e.g., hypertonic saline), detergent solutions (e.g., sodium tetradecyl sulfate), and corrosive agents (e.g., glycerin). Injections typically work better on small (1 to 3 mm) and medium (3 to 5 mm) veins; however, a precise diameter used to make treatment decisions is lacking.

Although sclerotherapy is a clinically effective and cost-effective treatment for smaller varicose veins, concerns about the development of deep venous thrombosis and visual disturbances, and the recurrence of varicosities have been noted.

SURGERYHistorically, surgery is the best known treatment for varicose veins, especially when the greater saphenous vein is involved. However, literature does not consistently support surgery as the definitive treatment option.  Most surgical techniques involve using multiple smaller incisions to reduce scarring, blood loss, and complications.

Surgical management may reduce the risk of complications of varicose veins. Surgical correction of superficial venous reflux reduces 12-month ulcer recurrence. In addition, surgical management of venous ulcers leads to an 88 percent chance of ulcer healing, with only a 13 percent risk of ulcer recurrence over 10 months.

The simplest surgical procedure is ligation, which involves tying off the enlarged vein in portions of the leg, thigh, and groin.
Potential complications include recurrence and worsening of intravenous pressure in tributary veins.

Phlebectomy and stripping are probably the best known procedures; however, they are more of a collection of procedures than single techniques. For phlebectomy, the varicose vein is mapped and marked on the skin using visual skin changes or duplex Doppler ultrasonography while the patient is standing.

The patient is then placed in a supine position, and a series of perpendicular 1- to 2-mm stab incisions are made over the vein several centimeters apart. The saphenous

vein is identified in the groin, brought to the surface via a small incision, and ligated. Thevein is hooked and brought to the surface at the next incision site. It is then pulled and

dissected proximally and distally at each incision site to release it from the surrounding tissues and to sever any connections to tributary or deeper perforating veins. This

process is repeated distally. The vein can be removed in a long strip or in multiple smaller pieces depending on the size and shape of the vessels, as well as the patient’s vascular pathology.

Alternatively, the greater saphenous vein can be ligated and incised at the groin. A stripper is inserted into the vein near the knee and moved proximally.

The stripper is then attached to the proximal end of the vein and pulled distally, removing it.

 

Prevention

Varicose-veins-prevention
You can’t do anything about your heredity, age or gender. However, you can help delay the development of varicose veins or keep them from progressing.

  • Be active. Moving leg muscles keeps the blood
  • Keep your blood pressure under control. Work
  • with your doctor.
  • To temporarily relieve symptoms, lie down and
  • raise your legs at least six inches above the level
  • of your heart. Do this for ten minutes a few times
  • each day.
  • Maintain a normal body weight.
  • Wear prescription compression stockings as
  • specified by your doctor.
  • See a qualified doctor who can diagnose the cause
  • of your varicose veins, the sources of venous reflux
  • in your legs and offer a variety of treatment options.


REFERENCES:  wikipedia.org,  www.aafp.org,  vasculardisease.org

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Treatment of Varicose Veins