Varicose Veins: Swollen, Twisted, and Treatable

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Medical and self-help techniques can relieve the discomfort and disfigurement of varicose veins.

Audrey stopped wearing skirts, dresses, and shorts after giving birth to her second child. The ropy, bulging veins that had developed in her legs during pregnancy caused her embarrassment, so she hid her legs under slacks. Tom, a truck driver, suffered from aching, protruding veins in one of his legs. His foot and ankle were often swollen and painful, causing him discomfort when he drove for long periods. Susan, a high school teacher, spent much of her day on her feet. The appearance of her legs changed dramatically during her 20 years as a teacher. A network of tiny, purple, swollen veins marred her once smooth skin.

Audrey, Tom, and Susan all have varicose veins, blood vessels that are abnormally swollen and twisted. Although varicose veins usually appear on legs, they can occur on any part of the body. In most cases, varicose veins, which most commonly occur in veins near the surface of the skin, are ugly but do not pose a serious health risk. In rare instances, however, they may be a symptom of damage to deep veins. These deep veins can develop clots that break loose causing an embolism, an obstruction in a main blood vessel that can be fatal.

Varicose veins are one of the most common vascular problems in the United States. About 15 percent of American adults develop them, usually between the ages of 30 and 60. Women are four times more likely to experience them than men. Pregnancy, excess weight, jobs that require long periods of standing or sitting, and heredity may increase a person’s risk of varicose veins.

Varicose veins are not an inevitable part of aging. According to physicians, varicose veins can be prevented in some cases. And medical and self-help techniques can relieve the discomfort and disfigurement of varicose veins easily and safely.

Causes of varicose veins

Veins are thin-walled blood vessels that carry blood from the body tissues back to the heart. There are two principal systems of veins in the body: deep veins, which lie among the muscles and carry about 90 percent of the blood, and surface—or superficial—veins, which are often visible just under the skin. Surface veins do not have the protective muscular surroundings of deep veins and are, thus, weaker and more likely to become varicose.

To ensure upward blood flow against the forces of gravity, veins are divided into sections, with each section separated by one-way, leaflike valves. Blood pressure under the valves opens them, allowing blood to flow in. The valves snap shut to prevent backward seepage. In people with varicose veins, however, the system goes awry. Instead of moving in the direction of the heart, some blood flows backward and pools in the veins. This blood then presses on the veins and causes them to swell and stretch.

Physicians are not certain why valves malfunction. Some people may be born with either an inadequate number of valves or defective valves. Weak vein walls may also damage valves. Veins with weak walls bulge and damage valves by pulling the delicate leaves of the valves apart.

Types and effects of varicose veins

There are three types of varicose veins—primary, spider, and reticular. Primary varicose veins most commonly occur in the back of the calf and anywhere on the inside of the leg. The veins are blue, prominent, swollen, and knotted. Spider veins are shaped like spider legs and appear in clusters of fine red lines. They commonly occur on the feet, ankles, or thighs, and sometimes the face. Reticular veins are generally bluish-green in appearance and crisscross the back of the knee. Varicosities in other parts of the body include hemorrhoids (dilated veins in the anus), esophageal varices (dilated veins in the esophagus), and varicoceles (a condition marked by collections of varicose veins in the scrotum).

In some people, varicose veins cause no symptoms, but others experience a severe ache in the affected area, swelling of the feet and ankles, and persistent itching of the skin. Varicose veins are often progressive, which means that symptoms worsen over time.

If backflow of blood is severe enough to cause tissues to become starved of oxygen and nourishment, the skin covering varicose veins becomes thin, hard, dry, scaly, and discolored, and ulcers (open sores) may form. People with seriously impaired blood circulation also may experience constant swelling in their legs and skin discoloration around their ankles.

Bumping or scratching a large varicose vein may cause severe bleeding. Hemorrhoids can cause rectal bleeding and discomfort and pain during bowel movements. Esophageal varices may result in episodes of vomiting blood, and varicoceles may result in the inability to produce healthy sperm and lead to infertility.

In rare instances, varicose veins may be a symptom of either thrombophlebitis or deep-vein thrombosis. Thrombosis refers to the process of forming a blood clot. In thrombophlebitis, a blood clot forms in an inflamed part of a vein. When clots form in veins near the surface of the body, swelling and redness appear along the affected area of vein. But this condition is not usually life threatening. However, blood clots that form in deep veins—a condition known as deep-vein thrombosis—are more likely to result in a pulmonary embolism, a blood clot that becomes dislodged from a vein, travels to the lung, and blocks the pulmonary artery leading from the heart to the lungs.

Risk factors of Vericose Veins

Several factors may accelerate, if not cause, the development of varicose veins. People—particularly women—with a family history of varicose veins are at greater risk of developing the condition. The female sex hormones estrogen and progesterone weaken vein walls, which may explain the higher incidence of varicose veins among women. Birth-control pills, estrogen treatments, and pregnancy raise a woman’s level of sex hormones, putting her at even greater risk. In fact, nearly 80 percent of all pregnant women develop varicose veins, according to the Mayo Foundation for Medical Education and Research of Rochester, Minnesota. The circulatory changes of pregnancy that are designed to support the growing fetus also increase risk. Varicose veins may surface for the first time or may worsen during late pregnancy, when the uterus exerts greater pressure on the veins in the legs.

Another risk factor is obesity. Excess weight puts pressure on surface veins, causing them to weaken. People who have jobs that require them to stand or sit for long periods also are at increased risk of developing varicose veins. Prolonged standing can weaken the walls of veins, and sitting can aggravate inflamed veins.

Diagnosing and treating varicose veins

Physicians use a variety of techniques to diagnose the severity of varicose veins. Varicose veins in the legs are diagnosed from a physical examination performed while the patient is standing. A physician may tie a tourniquet (a tightened band) around the upper part of a patient’s leg, which stops the flow of blood to the leg and makes varicose veins easier to identify. Ultrasound, a diagnostic technique in which very high frequency sound waves are passed into the body, is often used by physicians to measure blood flow in deep and surface veins. Another diagnostic technique known as venography, or phlebography, uses X-ray technology to measure blood flow in deep veins.

Several treatment options are available for people with varicose veins. These treatments provide relief for people suffering from both the cosmetic and medical ill-effects of varicose veins. “There are no real hard and fast rules for treatment because there are many areas where these options overlap,” says Thom Rooke, head of the vascular medicine group at the Mayo Clinic and Foundation in Rochester, Minnesota.

If varicose veins are small, a physician may recommend that a patient wear compression stockings to reduce symptoms. Compression stockings provide support for a vein’s weakened walls and improve circulation. People with more serious cases of varicose veins may require medical treatment or surgery.

Sclerotherapy

One popular medical treatment for varicose veins is sclerotherapy, a process in which a physician injects an irritating chemical directly into the affected veins. The solution blocks varicose veins, closing them off to blood flow. Healthy veins in the region then take over the work of the closed veins. The varicose veins eventually wither and dissolve. Sclerotherapy only treats surface veins and is not effective in treating deep-vein thrombosis.

“Candidates for sclerotherapy are patients with appropriate-sized vessels and without underlying deep-vein disease,” says Stephanie Marschall, a dermatologist and director of laser surgery at Rush-Presbyterian-St. Luke’s Medical Center in Chicago.

“In general, sclerotherapy tends to be for smaller veins and surgery tends to be for larger veins,” says Rooke. “However, the definition of a big vein is changing rapidly as physicians become more aggressive with sclerotherapy. It used to be that we used sclerotherapy for really small veins the size of a hair, but I routinely use sclerotherapy for veins as big around as a pencil or even larger.”

Sclerotherapy is usually painless, although some patients experience a temporary burning or pinching sensation as the solution is injected. Patients must undergo three to six treatment sessions to close up all varicose veins. Sessions are conducted in a physician’s office and last about 30 minutes.

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Following treatment, patients often have bruises on their legs, which usually fade within a month. Blood may leak from the treated veins into the surrounding tissue, which produces brownish discoloration on the skin around the treated vein. This discoloration will eventually fade, though it may take months or even years.

Sclerotherapy does not usually cause scarring or other serious side effects, but in rare cases, a small depressed scar may appear after treatment or a blood clot may develop in a treated vein. Occasionally the treatment will leave a fine network of smaller varicose veins at the site where a larger vein was treated.

The chemical solutions used in sclerotherapy contain high concentrations of salt, which can raise blood pressure and, therefore, may not be safe for people with certain health conditions, such as heart disease. And the solutions have caused allergic reactions in some people, according to the U.S. Federal Trade Commission.

Laser therapy

Laser therapy is another effective treatment for smaller veins and for spider veins in particular. In this process, a physician aims a laser at a vein that is usually less than 0.25 centimeters (one-tenth of an inch) in diameter. The intense beam of light destroys the tiny blood vessel without damaging surrounding tissue.

Laser therapy can be performed in a physician’s office or an outpatient clinic. Patient’s usually require only one or two treatments, which take about 40 minutes. The treatment is painless, although patients may experience a stinging sensation during the procedure.

Following treatment, the skin in the affected area may be sensitive. Patients may feel like they have a sunburn on the treated area for several days following the procedure. The skin may also appear to be slightly bruised. Laser therapy causes scarring and permanent skin discoloration in rare instances.

“There are no lasers available to treat (primary) varicose veins,” Marschall says. “The laser light does not penetrate deeply enough to obliterate the vessel. Laser treatment cannot replace sclerotherapy. Often, we use the two therapies in combination, but sclerotherapy is still the gold standard for the treatment of spider, reticular, and larger varicose veins. The laser certainly hasn’t replaced it.”

Photo therapy

Photo therapy is a treatment that is similar to laser therapy, except that it also can treat deeper veins. Photo therapy uses a pulsed light that produces more heat than a laser to destroy surface veins. The treatment is most effective on spider veins, though it is also used to treat veins too small for sclerotherapy injections.

The photo-therapy procedure can be performed in about 10 minutes in a physician’s office or an outpatient clinic. Patients usually undergo two to five treatments. Following treatment, patients may experience temporary swelling and skin discoloration, the effects of which should disappear in two to four weeks.

Ambulatory phlebectomy

Large varicose veins can be treated with a surgical procedure known as ambulatory phlebectomy. In this procedure, a surgeon makes a series of tiny puncture wounds along the vein and then takes out small segments of the vein. Ambulatory phlebectomy can be performed in one 45-minute session under local anesthesia in a physician’s office or an outpatient center.

The tiny incisions require no stitches. Most patients experience very little pain after the operation and are able to walk immediately following the surgery. The procedure rarely results in scarring. In some instances, however, the surgery leaves tiny white scars where the veins were punctured.

Vein stripping

If varicose veins are painful, ulcerated, or prone to bleed, they may require removal by an operation known as vein stripping. Vein stripping is the only option for removing the saphenous veins—the largest surface veins in the legs—that serve as the major channel for blood among the superficial veins in the leg. “If the valves in the saphenous vein leak all along the vein so that it is what we call incompetent [not working properly] all the way up to the groin, then stripping is usually the only choice,” Rooke says.

The surgery can be done in a hospital or on an outpatient basis. A patient receives a general anesthesia (a drug that produces unconsciousness and stops pain) or an epidural (a local anesthetic injection near the spinal cord that numbs the nerves leading from the spinal cord to the chest and the lower half of the body). A surgeon then makes two small incisions, one in the groin and the other near the ankle. The surgeon cuts and ligates (ties off) the saphenous vein and its branches at the groin incision.

The surgeon then passes a flexible wire through the vein from the ankle incision. When the wire reaches the groin incision, a special metal hook on the end of the wire attaches to the cut end of the vein. The surgeon pulls the wire down to the ankle incision, bringing the entire vein with it. Following a vein-stripping procedure, a surgeon may perform sclerotherapy to treat smaller varicose veins that remain after surgery.

The vein stripping operation usually takes about 30 minutes per leg. The patient must keep the leg or legs bandaged for several weeks following surgery. It usually takes between two to six weeks to recover from the operation.

The surgery leaves scarring on the skin that covered the stripped vein. The procedure can damage nerves along the stripped veins, causing numbness in the leg. This numbness usually improves with time but can be permanent. Rarely, the procedure can result in such complications as infection, pain, bleeding, or deep-vein thrombosis.

“Scarring, the potential for numbness, cost, disability, and the need for general anesthesia are all factors that discourage use of vein stripping,” Rooke says. “Vein stripping is fairly expensive relative to sclerotherapy. Most vein-stripping operations cost between $5,000 and $10,000 for two legs.”

Preventing varicose veins

According to physicians, most people can reduce the risk of developing varicose veins, or lessen the severity of varicose veins, by practicing the following preventive behaviors:

Exercise regularly. Take 30-minute or longer walks several times a week or participate in other aerobic exercises, such as bicycling or jogging, to strengthen leg muscles and improve blood circulation.

Avoid standing for long periods. Sit down frequently and elevate your legs. While standing, shift your weight often from one leg to another. Bounce up and down on the tips of your toes several times an hour. Take a walk if you can. After a day that has required many hours of standing, elevate your legs for about an hour.

Keep your legs elevated when you sit or lie down. When your legs are off the ground, and raised to at least the level of your heart, the veins in your legs have an easier time moving blood back to your heart. Put your feet up when sitting at home, and put a pillow under your feet when you are in bed.

Avoid sitting for long periods. If you must sit most of the day at work, take several breaks from sitting throughout the day and take short walks to improve circulation.

Do not cross your legs when you sit. Crossing your legs can cut off blood circulation and increase your risk of developing varicose veins.

Wear compression hose. Put the stockings on before you get out of bed every morning and wear them all day. Compression hose are available in most pharmacies.

Avoid tight clothing. Clothing that restricts blood flow increases your risk of developing varicose veins.

Don’t wear high heels. High-heeled shoes make you use the muscles in your buttocks, rather than calf muscles, to walk. Walking in high heels does not promote blood flow in the legs. Low-heeled or athletic shoes help strengthen calf muscles and improve circulation.

Keep your weight down. Too much body fat, particularly in the mid-section, can put pressure on your thighs and groin, weakening the walls and valves of the veins in your legs and groin.

Eat foods high in fiber. A high-fiber diet will help you avoid constipation, a condition that puts pressure on the veins in the anus and increases the risk of hemorrhoids.

Avoid too much sun. Overexposure to the sun can damage skin and weaken the walls of surface veins.

Some people may not be able to avoid developing varicose veins. However, people can adopt preventive behaviors to reduce their risk of varicose veins. Although treatment cannot guarantee an end to varicose veins forever, it can improve the appearance and health of a person with varicose veins.

For more information:

American Academy of Dermatology

Telephone: (888) 462-DERM

Web site: http://www.aad.org/ (select “Public Information”).

“Phlebology: The Treatment of Leg Veins” from the North American Society of Phlebology

Telephone: (773) 889-6500

Web site: http://phlebology.org/na04000.htm.

“Tips for Consumers” on varicose vein treatments from the Florida Attorney General’s Office

Web site: http://legal.firn.edu/consumer/tips/tipviein.html.

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