Varicose Veins

Etiology

Veins are the blood vessels which return blood from the outer regions of the body back to the heart.  In normal, healthy veins (top picture), one-way valves direct the flow of venous blood upward.  Within muscle compartments, the contraction of muscles compresses deep veins, causing a pumping action, and assists return of blood towards the heart.  Because deep veins are situated within the muscle fascia, they can withstand pressures of up to 5 atm (not uncommon from the pumping action of the musculature). 

The smaller, superficial veins, which lie above the muscle fascia, do not have the same protection as deeper veins, and thus cannot withstand high venous pressures in the same fashion.  In response to increased venous pressure, superficial veins can dilate and become tortuous, manifesting as visible varicosities, just under the skin surface.  Upon dilating, their delicate valve leaflets are unable to close, and blood falls downward with gravity, further worsening the situation.

Elevated venous pressure is most often due to valve incompetency.  Varicose veins are the pathways by which venous blood refluxes back into a congested extremity. By removing these pathways (surgically), venous circulation is improved.  Chronic elevated pressure can also be due to obstruction of outflow (for example from a thrombus or external compression).  In these instances, removal of these pathways is contraindicated, as they are important bypass pathways for blood to flow.

In addition, some patients have an inborn weakness of their vein walls, which could predispose to varicosities.  Other important causes include heredity, prolonged standing (which increases hydrostatic pressures), and pregnancy.

Clinical Presentation

Patients with varicose veins can present with acute complications such as variceal bleeding, dermatitis, thrombophlebitis, ulceration or for purely cosmetic concerns.  Certainly, the approach to a patient with varicosities is like that of any problem and includes a thorough history and physical examination.  Patients who have lived with varicose veins for some time may have become accustomed to their symptoms and may not immediately think to volunteer information, so that a good history should include symptoms of tenderness, pruritis, burning, restless legs, cramps, edema, skin changes, and paresthesias.  Additionally, the student should recognize that the degree of symptoms and extent of the varicosities may not (and often do not) correlate.

Patients with venous insufficiency typically reveal that their pain is better with ambulation (or leg elevation), in contrast to arterial insufficiency, which is the opposite.

The physical exam in these patients is often difficult, because the deep venous system is not able to be examined (auscultated, palpated, inspected, etc.).  One must infer indirectly, by examination of the superficial system.  In addition to inspecting, palpating and percussing areas, the examiner has the following additional tests that can be performed:

Varicose veins are more prevalent in females, and typically begin in childhood (although their visual manifestations tend to occur later).  Although death can occur from bleeding of friable veins, most instances of death are due to the conditions association with thromboembolism.  Thus, when treating a patient with varicose veins, the possibility of associated DVT must always be taken into consideration.

Treatment

As stated previously, varicose veins which exist as bypass tracts for venous obstruction (i.e. move with antegrade flow), should not be treated.  Removing them can cause the rapid onset of pain and swelling, only to create new bypass tracts.

Those varicose veins that are the result of high pressure dilation, carrying retrograde flow, are detrimental as they recirculate oxygen-poor, lactate-rich, venous blood back into an already congested extremity.  The goal of therapy is to ablate these pathways, thereby improving circulation in these areas.

Initial treatment of varicose veins is compression stocking therapy to alleviate increased venous pressures.  If further treatment is required, the current therapies include sclerotherapy, laser and radio frequency ablation, and surgery. 

 Sclerotherapy, the most widely used medical therapy, involves the injection of a sclerosing agent (typically the detergents polidocanol or sodium tetradecyl sulfate or even hypertonic sodium chloride, >20%) into the vessel which destroys the endothelium, producing a fibrotic cord, with the dissolution of all vascular tissue layers.

Laser or pulsed light therapy, although useful for tiny vessels and telangectasias (i.e. on the face), is typically not first line treatment for extremity disease, primarily because the energy required to ablate varicosities has detrimental effects (burns) on the skin.

The surgical approach to small varicosities is normally removal of the vein (phlebectomy) followed by sclerotherapy.  For larger veins, surgery is typically combined with endovenous techniques such as laser and radio frequency ablation.  Surgical skill in the form of a Seldinger over-the-wire or cutdown technique (guided by ultrasound) is used to place lasers through catheters, in order to ablate varicose veins from the inside out.  Laser or radio frequency heats the vessel, destroying it and initiating the fibrotic process.  Phlebectomy (via multiple small incisions) can also be used to remove larger, varicosed veins.