Varicose Veins and Spider Veins

What are veins and what is their function?

Veins are blood vessels that return blood from all the organs in the body toward the heart. When the different organs use oxygen from the blood to perform their functions, they release the used blood containing waste products (such as carbon dioxide) into the veins. Blood in the veins is then transported to the heart and returned to the lungs, where the waste carbon dioxide is released and more oxygen is loaded by the blood and taken back to the rest of the body by the arteries.

Veins also act as a storage for unused blood. When the body is at rest, only a portion of the available blood in the body circulates. The rest of the blood remains inactive in the veins and enters the active circulation when the body becomes more active and needs the additional blood to carry oxygen to entire body. This storing capacity is due to the elasticity (flexibility to expand) of the walls of the veins.Veins have different sizes depending their location and their function. The largest veins are in the center of the body; these collect the blood from all the other smaller veins and channel it into the heart. The branches of these large veins get smaller and smaller as they move away from the center of the body. The veins closer to the skin surface are called superficial veins. The veins that are deeper and closer to the center of the body are called deep veins. There are also other veins that connect the superficial veins to the deep ones which are called the perforating veins.

What are varicose veins and spider veins?

Veins can bulge with pools of blood when they fail to circulate the blood properly. These visible and bulging veins, called varicose veins, are more common in the legs and thighs, but can develop anywhere in the body.Large varicose veins can be visible, bulging, palpable (can be felt by touching), long, and dilated (greater than 4 millimeters in diameter). Small “spider veins” also can appear on the skin’s surface. These may look like short, fine lines, “starburst” clusters, or a web-like maze. They are typically not palpable. Spider veins are most common in the thighs, ankles, and feet. They may also appear on the face. The medical term for them spider veins is telangiectasias.

Who gets varicose and spider veins?

Varicose and spider veins can occur in men or women of any age, but most frequently affect women in the childbearing years and older people. Varicose veins are very common. Some estimates suggest that about 10%-15% of men and 20%-25% of women suffer from varicose veins. A family history of varicose veins and older age increase one’s tendency to develop varicose and spider veins.

Other risk factors include:

• a sedentary lifestyle
• weight gain
• prolonged standing
• pregnancy

What causes varicose and spider veins?

The causes of varicose and spider veins are not entirely understood. In some instances, the absence or weakness of valves in the veins may cause the poor venous circulation (blood flow in the veins) and lead to varicose veins. Valves inside veins normally act to ensure that blood in the veins does not go the wrong direction (or backwards) away from the large (deep) veins and the heart. They are mainly located in the perforating and some deep veins.

In other cases, weaknesses in the vein walls may cause the pooling of the blood. The walls of the blood vessels can become weaker and less competent than normal, causing the volume of blood in the veins to increase, leading to varicose veins.

Less commonly, varicose veins are caused by such diseases as:

• phlebitis (inflammation of the veins)
• blood clots or any obstruction to blood flow in the veins
• congenital abnormalities of the veins

Venous disease (disease of the veins) is generally progressive and may not be prevented entirely. However, in some cases, wearing support hosiery and maintaining normal weight and regular exercise may be beneficial.

What are varicose vein symptoms?

Many people with varicose veins do not have any physical symptoms. They may, however, have concerns over the cosmetic appearance of the varicose veins.Some of the common symptoms of varicose vein include:

• aching
• cramping
• itching
• swelling
• fatigue

Some people may complain of a dull ache and pressure sensation from varicose veins.Some less common but more severe symptoms of varicose veins may include bleeding, thrombophlebitis (formation of blood clot within the varicose vein), and ulceration of the skin overlying the veins. These complications of varicose veins need to be evaluated by a doctor promptly.

How are varicose veins evaluated (diagnosed)?

Evaluation of varicose veins includes a thorough general physical examination by a doctor. This will include asking about family history of varicose veins, duration, presence of any symptoms, and any worsening or expansion of the varicose veins. The individual’s height, weight, and other medical conditions need to be noted as well.In addition, general inspection and palpation (feeling the veins) as well evaluation for any bleeding or ulcers are typically performed. Standing up for about 5 to 10 minutes can make the veins more visible, and this may further aid the doctor in assessing the extent of the varicose veins.

Can ultrasound be used to evaluate varicose veins?

Ultrasound of the veins can assist in evaluating the varicose veins. Ultrasound can help in delineating the anatomy of the veins involved. Doppler ultrasound (a device which can detect and measure blood flow) may also provide additional information such as the competency of and flow through the valves in the perforating and the deeper veins. This information is especially useful if surgery or other procedures are being considered.

What treatments are available for varicose veins and spider veins?

There are many different treatments available for varicose veins. These treatments are offered based upon the size of the varicose veins, the presence of any symptoms, and the location of the veins. Briefly, treatments include:

• compression stockings
• leg elevation while sitting or sleeping
• sclerotherapy (injection of a liquid into the vein)
• laser therapy
• surgery (removal of the varicose veins, or vein stripping)

In general, sclerotherapy and laser therapy are helpful in treating spider veins (telangiectasias), while sclerotherapy and surgery may be a better options for larger varicose veins.

Is treatment always necessary?

No. Varicose and spider veins may be primarily a cosmetic problem. But severe cases of varicose veins, especially those involving ulcers, typically require treatment.

Thousands of people every year consider getting treatment for varicose veins and spider veins. Advertisements for treating venous disease often tout “unique,” “permanent,” “painless,” or “absolutely safe” methods – making it difficult to decide on the best treatment. Check with a doctor if you are uncertain about the safety or effectiveness of any treatment.

Varicose veins Symptoms,Complications and Treatments

Varicose veins are veins that have become enlarged and twisted. Carl Arnold Ruge is credited with having first defined varicose veins as “any dilated, elongated and tortuous vein irrespective of size”. The term commonly refers to the veins on the leg, although varicose veins occur elsewhere. Veins have leaflet valves to prevent blood from flowing backwards (retrograde). Leg muscles pump the veins to return blood to the heart. When veins become enlarged, the leaflets of the valves no longer meet properly, and the valves don’t work. One cause of valve failure is deep vein thrombosis (DVT), which can cause permanent damage to the valves. The blood collects in the veins and they enlarge even more. Varicose veins are 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 has been vein stripping to remove the affected veins. Newer, less invasive treatments, such as radiofrequency ablation and endovenous laser treatment, are slowly replacing traditional surgical treatments. 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.

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.
• 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, especially at the ankles, “atrophie blanche”.

Complications

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

• Pain, heaviness, inability to walk or stand for long hours thus hindering work
• 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. There have been over 100 reported cases of malignant transformation and the rate is reported as 0.4% to 1%.
• Severe bleeding from minor trauma, of particular concern in the elderly.
• Blood clotting within affected veins. Termed superficial thrombophlebitis. These are frequently isolated to the superficial veins, but can extend into deep veins becoming a more serious problem.
• Acute fat necrosis can occur, especially at the ankle of overweight patients with varicose veins. Females are more frequently affected than males.

Etiology/Epidemiology

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 bulging veins that are larger than spider veins, typically 3 mm or more in diameter.

Conservative treatment

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 a pressure of 30–40 mmHg 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.
• 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.
• Diosmin 95 is a dietary supplement distributed in the U.S. by Nutratech, Inc. The U.S. Food and Drug Administration does not approve dietary supplements, and concluded that there was an “inadequate basis for reasonable expectation of safety.”

Interventional treatment

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 laser treatment (EVLT), radiofrequency ablation, and foam sclerotherapy are not as well studied, especially in the longer term.

Surgical treatment

Open surgery has been performed for over a century. 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%.
Non-surgical treatment

Sclerotherapy

A commonly performed non-surgical treatment for varicose and “spider” leg veins is sclerotherapy. It 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 microfoam sclerosants under ultrasound guidance to treat larger varicose veins, including the greater and short 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. A Health Technology Assessment found that sclerotherapy provided less benefit than surgery, but is likely to provide a small benefit in varicose veins without reflux.  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 . There has been one reported case of stroke after ultrasound guided sclerotherapy when an unusually large dose of sclerosant foam was injected.

Endovenous laser and radiofrequency ablation

The Australian Medical Services Advisory Committee (MSAC) in 2008 has determined that endovenous laser treatment 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.” It also found in its assessment of available literature, that “occurence 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 endovenous laser treatment include minor skin burns (0.4%) and temporary paraesthesia (2.1%).The longest study of endovenous laser ablation is 39 months.

Two prospective randomized trials found speedier recovery and fewer complications after radiofrequency obliteration (AKA radiofrequency ablation) compared to open surgery.. Myers 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%. In comparison, radiofrequency ablation has been shown to control 80% of cases of small saphenous vein reflux at 4 years, said Myers. Complications for radiofrequency ablation 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 radiofrequency, with a recurrence rate of 33%, to open surgery, which had a recurrence rate of 23%.Endovenous laser and radiofrequency ablation require specialized training for doctors and expensive equipment. Endovenous laser treatment is performed as an outpatient procedure and does not require the use of an operating theatre, nor does the patient need a general anaesthetic. Doctors must use ultrasound during the procedure to see what they are doing. Some practitioners also perform phlebectomy or ultrasound guided sclerotherapy at the time of endovenous treatment. Follow-up treatment to smaller branch varicose veins is often needed in the weeks after the initial procedure.