Symptoms due to varicose veins can be very mild and not significantly alter a person’s lifestyle, to being so severe as to affect mobility and quality of life. Severe chronic venous disease has been shown to have a significant effect on quality of life, in several studies being comparable to that seen in conditions such as congestive cardiac failure and diabetes. Aching, discomfort, and tiredness of the legs are very common symptoms and are usually worse at the end of the day. This symptom has been shown to affect more severely a person’s overall energy levels and ability to do recreational and work activities.
As well as being an unsightly problem, varicose vein is a very common condition that can cause aching and discomfort, and in some cases, more severe symptoms. The presence of dilated and tortuous veins is the most obvious manifestation of underlying venous problems, and varicose veins are a common condition with at least one in three adult Europeans needing treatment, with increasing frequency in older age groups. Women are affected more than men. The condition is more prevalent in the western world and in those with low socioeconomic status. Varicose veins rarely cause serious conditions, but in longstanding cases, there is evidence to suggest that the skin changes and ulceration are a significant burden for a proportion of those affected. The more significant symptoms and problems caused by varicose veins are highlighted below.
Symptoms of Varicose Veins
Tenderness and painful hard knots of veins in the leg are more advanced symptoms and are found near inflamed or clotted veins. These symptoms can make it hard for the individual to fully participate in normal daily activities, and can often cause emotional stress.
In severe cases, a venous leg ulcer may form. This occurs when sustained high blood pressure in the veins cause plasma to separate from the blood and leak into the surrounding tissues. This can cause tissue and skin inflammation, and eventually an ulcer. Although ulcers are most often seen around the ankles, they can occur anywhere in which the vein has been affected.
Common symptoms of varicose veins can include aching pain after sitting or standing for long periods, itching on the skin over the vein, and minor bleeding. Ankle swelling is also a common symptom, as it signifies a more severe form of venous disease. The discoloration of the skin is an indication of long-term varicose veins, and is due to the chronic pooling of blood that has leaked from the affected vein. Often this will take several months to years after other symptoms have developed.
Varicose veins are often associated with certain physical symptoms, the most obvious being the enlarged, visible veins themselves. In addition to the dark purple or blue twisted veins that often occur in the legs, ankles, and feet, there are a number of specific symptoms that people with varicose veins frequently experience. These symptoms can be caused by an unhealthy circulatory/vein system and can be very uncomfortable for the individual affected.
Causes of Varicose Veins
Varicose veins are also common in people who have to stand for long periods of time. The reason for this is that it is more difficult for the blood to flow upwards to the heart in people who have to stand for long periods, as the force of gravity is pulling it down. This also applies to people who have to sit cross-legged for long periods, where it can act to pinch the vein and obstruct blood flow. High heels are yet another factor that can cause varicose veins, as by standing in high heels, you are inhibiting the action of the calf muscles and the blood flow up the vein.
Other than the primary causes listed above, there are other factors that contribute to the causes and effects of varicose veins. Pregnancy causes an increase in the volume of blood in the body yet decreases the flow of blood from the legs to the pelvis. This change is in its greatest effect around the end of the pregnancy and can lead to the formation of varicose veins. Hormonal factors that relax vein walls to increase vein distensibility can cause varicose veins, which is often why they are seen more in women. This can also be due to taking estrogen and progesterone in the form of the contraceptive pill, hormone replacement therapy, or patches and IUDs.
Another main factor of varicose veins is that of a genetic predisposition. One study showed that more than 80% of people with varicose veins have a family history of it. There is no specific gene that causes people to have varicose veins, but they may inherit a tendency for weak vein walls or valves. Varicose veins are seen more commonly in women than men, and about 80% of women have varicose veins in their family.
Arteries are used to bring oxygen from the heart to all areas of the body. Our extremities, arms, and legs are no exception. Below each knee are 2 long saphenous veins that run along the thigh and calf muscles. These are the longest veins in the body and are superficial rather than deep. At each knee, these 2 veins are joined by connecting veins. One of the factors contributing to varicose veins is that the walls of the connecting veins are very thin and can collapse, and over time the valves in the veins become slack. Veins in your legs carry the blood back to your heart so that it can be reoxygenated. The movement of the leg muscles during walking, etc. acts as a pump to push the blood upstream. If the valves in a vein do not meet properly, the blood flows down the vein and distends it.
Risk Factors for Varicose Veins
Pregnancy causes an increase in the volume of blood in the body, which in turn can cause veins to enlarge. This, in turn, can cause the pressure on the veins to increase, ultimately resulting in varicose veins. Normally, varicose veins that develop during pregnancy may improve within three to twelve months after delivery. However, there is much variation in this finding. Changes that occur during pregnancy often cause permanent damage and will make varicose veins more prominent with each successive pregnancy and with age. Although they may become less pronounced at times when weight is not being carried or during the postmenopausal years, without further treatment, the varicose veins will often enlarge and become more symptomatic with time.
Gender is another strong risk factor, with women being more likely to develop varicose veins than men. Hormonal factors including puberty, pregnancy, menopause, the use of birth control pills, and estrogen and progesterone all have been linked to the development of varicose veins. The great majority of women with varicose veins may recall that their condition developed during pregnancy or following one or another of these hormonal changes in their lifetime. Therapy using hormones might increase the risk of varicose veins developing or worsening, though the extent of this risk is unknown. This higher risk in women may also be because female sex hormones relax vein walls and valves, but this topic needs further research for clarification.
Family history of varicose veins is a strong risk factor. If your parents had varicose veins, chances are overwhelming that you will too. There is a genetic component in the development of varicose veins, evidenced by family trees that show patterns of inherited weak vein valves. Both the presence of varicose veins and certain structural and functional features of the veins have been found to be strongly inherited.
Risk factors that increase your risk of developing varicose veins include age, family history, gender, pregnancy, obesity, and occupation. In terms of age, the incidence of varicose veins increases as people age. Aging causes wear and tear on the valves in your veins that help regulate blood flow. Ultimately, this wear and tear can allow blood to flow back into the veins where it collects instead of flowing up towards your heart. This, in turn, may cause the veins to develop into varicose veins.
Complications of Varicose Veins
Leg Ulcers Despite advances in modern technology, the exact cause of varicose vein-related ulcers remains unknown. 80% of all leg ulcers are due to sustained venous hypertension (high blood pressure in the veins). This is usually caused by damaged valves within the veins. It is thought that the increase in pressure of the blood on the vein wall leads to a release of white blood cells into the area surrounding the vein. This is thought to cause damage to the skin, which forms an ulcer. The remaining 20% are caused by arterial disease, usually connected to smoking and diabetes. These ulcers are usually located on the ankle and are very painful. People who have suffered from varicose veins are at an increased risk of developing ulcers. The occurrence of ulcers depends on the severity of the varicose veins. A European study conducted in 2008 concluded that 15% of people with varicose veins will, at some point in their life, suffer from venous ulceration. This is a type of ulcer that occurs in the veins and is generally due to blood or fluid buildup in the vein and inflammation of the vein. These types of ulcers can be painful and usually drain pus.
Deep Vein Thrombosis (DVT) DVT is an event where blood clots form in the deep leg veins. It can lead to partial or total blockage of the vein. DVT is associated with a likelihood of Pulmonary Embolism (PE). PE occurs when the blood clot detaches from the vein and travels to the lungs. This is potentially life-threatening and requires immediate medical attention. Symptoms of DVT include pain, swelling, and redness of the affected leg. However, in many cases, DVT has no symptoms. Ultrasound is the most common test done to diagnose DVT. It is a painless, risk-free test that uses sound waves to produce an image of the inside of the body. If a blood clot is diagnosed early, it can be treated effectively to avoid developing further complications.
Deep Vein Thrombosis (DVT)
Patients with isolated superficial venous reflux typically have discomfort and aching, which is usually worse at the end of the day. Other symptoms of superficial reflux or obstruction may include swelling, pigmentation or eczema, lipodermatosclerosis (inverted champagne bottle appearance of the leg), atrophie blanche, and superficial thrombophlebitis. In general, patients with some combination of these symptoms or skin changes have venous insufficiency, and it is these patients who are at risk of developing venous ulceration. So, painfully for the patient, it is the venous ulcer that takes the disease from a quality of life issue to a potentially limb-threatening problem. Ulceration of the skin occurs in approximately 1% of the population and 1% of patients with venous disease per year. Ulcers are typically on the medial aspect of the ankle and are often painless; however, the surrounding skin may be inflamed and pruritic. A retrospective blinded study demonstrated that prior to the development of the venous ulcer, patients were symptomatic for up to 6 years, trying on average 3 different forms of treatment. Ulcers have a significant impact on the quality of life, and healing is often slow and difficult. The presence of an ulcer significantly increases the risk of superficial vein thrombosis and DVT, and there is an appreciable risk of ulcer recurrence.
Leg Ulcers
One of the functions of veins is to return fluid from the tissues to the circulation. Vein problems can lead to increased pressure in the veins and cause damage to the small blood vessels in the skin, allowing the escape of red cells and fluid into the skin. This can lead to inflammation, discoloration, and firmness of the affected skin. If the skin becomes stained brown, red blood cells have been split, releasing the iron which discolors the skin. This is a certain indication that the skin is at risk, and if it is further damaged, an ulcer will occur.
There are no symptoms which predict whether or not a person with varicose veins will go on to develop leg ulcers. However, aching or discomfort in the lower leg or ankle at the end of the day, restless legs at night, and leg pain/discomfort on walking, sometimes with swelling around the ankles, are all suggestive of vein problems which could lead on to develop an ulcer.
The term ulcer refers to a break in the skin, which fails to heal. Chronic venous insufficiency is the most common cause of leg ulcers. Up to one in 50 people will suffer from a leg ulcer at some time in their life, and the majority of these ulcers are due to damaged valves in the veins. Varicose veins are a common sign of vein problems, and if skin changes and/or inflammation occur, this is indicative of severe vein problems.
Bleeding
The occurrence of such bleeding is not only frightening for the patient and their family but can lead to hospitalization and blood transfusions. This can be averted by preventing the veins from becoming too distended. Compression stockings can be helpful if they are worn consistently and are of sufficient strength. Otherwise treatment to remove the veins (usually with the modern techniques of VNUS closure or foam sclerotherapy) can prevent a recurrence of severe bleeding. While it may be difficult to persuade a healthy person to seek treatment in order to prevent a problem which may occur in the distant future, those who have already experienced severe varicose vein bleeding will be very motivated to have the veins treated.
Now we are going to discuss about a very important complication of varicose veins, that is bleeding. This is perhaps the most traumatic and unpredictable complication of superficial varicose veins. The condition usually occurs in the elderly, in whom the skin overlying the veins becomes thin and less elastic. A minor injury to the varicose veins like nicking the vein while shaving or bumping the varicose vein against a table or chair can cause quite severe bleeding. While the bleeding usually stops within a short time, the potential for profuse and severe bleeding is a constant threat. This occurs because high pressure within the varicose veins prevents the bleeding from clotting as quickly as it should. This means that the simple act of shaving can become a life-threatening situation.
Diagnosis and Treatment of Varicose Veins
Diagnostic tests for varicose veins: Uncomplicated varicose veins can be diagnosed through simple physical examination, hence no other test will be necessary. However, many patients with symptoms of chronic venous insufficiency have an extensive history of varicose vein problems often without noticeable progression or an obvious cause. Others with recent onset of symptoms may have severe disease. Detecting the underlying problem in such cases can be difficult, and identifying the correct mode of treatment is essential. An ultrasound study is an accurate way to detect reflux and obstruction within the venous system and is also a good way to diagnose deep vein thrombosis. These tests can assist in formulating the most effective treatment plan for the patients’ specific problems.
Medical history and physical examination: Doctors typically will take a patient’s medical history to help diagnose varicose veins and to learn about any potential aggravating factors. The doctor also will conduct a physical exam to determine the severity of the problem. A hand-held Doppler ultrasound device is a valuable tool for detecting reflux. This form of ultrasound usually is painless and noninvasive. A technician places a small ultrasound probe on the skin over the vein being tested. This test provides information about the direction of blood flow in the vein. This is the ideal diagnostic test as it is directed at identifying the structure of the vein, the primary cause of reflux within the vein. Focused diagnostic information is essential to designing an effective treatment plan for each patient.
Medical History and Physical Examination
This initial assessment should identify noxious (more likely than not contributing to the patient’s symptoms) and contributory conditions (associated, but less likely as the cause for the patient’s symptoms). Specific inquiry about leg swelling, discoloration, long-standing fatigue, achiness, heaviness, night cramps, restless legs, dermatitis, and ulceration is important to identify advanced CVI. Symptoms that usually worsen as the day progresses or with prolonged standing/sitting and improve with leg elevation are more characteristic of venous disease. Other important elements of the history include a family history of venous disease, personal history of DVT, and history of pelvic tumors, abdominal masses or inguinal-femoral hernias. Finally, the impact of the patient’s symptoms on their activities of daily living and functional status should be evaluated. Specific questions should be asked about limitations in work, recreational activities, and impairment of mobility. A physical examination should begin with a general inspection of the patient’s body habit and all parts of the lower extremity. The presence of lower extremity edema or pitting edema should be recorded and the severity and distribution of edema can be graded by classifying the patient’s symptoms with the CEAP scale. An examination of the patient’s gait and maneuvers to identify painful or non-painful ulceration is important.
Diagnostic Tests for Varicose Veins
Various tests may be done to investigate varicose veins and establish the fluid dynamics within the deep and superficial veins. An ultrasound scan may be performed to search for evidence of deep vein thrombosis or results of reflux in the superficial vein system. Colour flow Duplex scans are a highly sensitive and specific type of ultrasound designed to find where a vein is refluxing and which vein it is refluxing into. This test will establish a clear picture for the surgeon of your vein anatomy and will assist in planning any surgical intervention at a later stage. An ultrasound may also be required after any form of treatment for varicose veins to establish its success. Another test that may be performed, especially if there is evidence of skin changes, is a Venogram. This is a test where a radiologist injects a special type of dye called contrast medium into your veins to observe the flow of blood and to take x-rays. This test can establish the precise location of any refluxing valves and will be useful in planning any surgery.
Non-Surgical Treatments
Another non-surgical treatment is sclerotherapy. This method is the most common treatment in Canada. A healthcare provider injects a solution directly into the varicose or spider veins. The solution irritates the lining of the blood vessel, causing it to swell and stick together. Over time, the vessel turns into scar tissue that fades from view. In some cases, the same vein may need to be injected more than once. Sclerotherapy is a minimally invasive procedure that does not require anesthesia and can be done in the physician’s office. The duration of the procedure can range from 15 minutes to more than an hour, depending on the number of veins treated and the difficulty of the procedure. Because the needle used is very thin, patients often do not experience pain, but rather a mild discomfort. Side effects of this treatment are rare, but can include the formation of new veins, and brown lines or spots around the treated area. Telangiectatic matting, which is the new appearance of very small veins, can appear in certain areas of the leg after treatment. This occurrence is usually minor and can be treated with further sclerotherapy.
Compression stockings are often the first treatment tried. They steadily squeeze the legs, helping veins and leg muscles move blood more efficiently. The amount of compression varies by type and brand. A trained professional will fit the stocking to make sure it’s the right size and tightness. Stockings should be worn all day long, ideally taking them off before bedtime. Low-cost stockings sold at the local drug store may not fit well or be as comfortable, and high elastic stockings can be difficult to put on. Using the circular knit and gradient compression, stocking therapy in patients with a prior history of ulceration has been effective in healing and decreasing the recurrence of leg ulcers. Randomized controlled clinical trials have provided the scientific evidence for the efficacy of stocking.
Non-surgical treatments are usually effective for most patients who have varicose veins. The main goals are to relieve symptoms, prevent further complications, and improve the appearance of the legs. Although non-surgical methods do not prevent new veins from appearing, treatment can help keep varicose veins from getting worse.
Surgical Treatments
A clear understanding of the treatment options is helpful in not becoming a ‘victim of the system’ and those with only a cosmetic problem can avoid unnecessary and expensive investigations or treatment. Treatment is also an area where new techniques are frequently being introduced, and a detailed discussion with a specialist is usually required in order to decide the best option.
One of the main problems with varicose veins is that it is not strictly a medical condition but a cosmetic one. This leads to many patients with severe symptoms (including leg ulcers) being denied treatment on the basis that their condition is only cosmetic. Having a detailed understanding of the condition helps patients argue their case with medical providers, and can also be important in order to get insurance cover, as many policies have restrictions on treatment for purely cosmetic conditions.
Prevention and Lifestyle Changes
Exercise improves circulation, stimulating blood flow from the legs back to the heart. Walking is the best form of exercise for those with varicose veins, as it puts less pressure on the legs and helps move the veins. Other good exercises for varicose veins include swimming and cycling. Exercise can also help to control weight and reduce blood pressure. Low impact activities, such as yoga and the Simmonds arm exercises, can be done at work and help to reduce symptoms. It is important to avoid exercises that put excessive pressure on the legs, such as weight lifting. Research suggests that walking and taking regular breaks to move around can greatly reduce the risk of developing varicose veins. Improvement of muscle tone in the legs can be achieved through regular low impact exercise which will reduce the pooling of blood in the veins. It is important to avoid exercises that put excessive pressure on the legs, such as weight lifting.
Exercise and Physical Activity
Another method to help prevent and reduce varicose veins is to maintain a healthy weight. By doing so, there is less pressure on the legs and the veins. If an individual is currently overweight, losing even a small amount of weight can make a huge difference. This can be achieved through a combination of regular exercise and maintaining a well-balanced diet. By eating foods that are low in sodium and high in fiber, for example, the body can avoid water retention in the legs and maintain healthy digestion. This leads to less swelling and pressure in the veins. Fruits, vegetables, and whole grain foods are good choices, and it is advisable to avoid high-calorie and high-carbohydrate foods. Lastly, it is important to avoid sitting or standing for long periods of time. If the nature of a certain job requires this, try to take small breaks to move around and shift positions. The objective is to avoid prolonged static pressure on the legs.
While there is no known cure for varicose veins, there are ways to help ease the pain and reduce the chances of making the veins worse. Exercising is a good way to keep the blood in the legs from pooling. It is vital to keep the blood moving, as this will put less pressure on the veins. Activities such as walking, yoga, and bike riding are effective and safe ways to get the blood pumping. While aerobic exercises are good for maintaining an overall healthy lifestyle, it is important to ensure that there is not too much strain on the legs. Try to avoid heavy weight lifting or high-impact sports such as basketball and running, as these can actually cause more damage to the veins. If the veins are already at a more severe stage, it is recommended to see a doctor about which specific exercises are best for the individual.
Compression Stockings
An excellent detailed book on varicose veins. I can hardly imagine a more complete book on varicose veins. It starts with easy to understand definitions and anatomy of veins and keeps the reader’s attention throughout with engaging language and analogies. The author does a fine job using photos and drawings to illustrate the topics and reinforce the learning. Written by Dr. Wright who is a practicing vascular surgeon in Melbourne, Australia, you can trust that the medical information is accurate and up to date. This is in contrast to many information sources on the web which contain outdated information or are trying to sell a miracle cure. He goes to some lengths to dispel common myths and misconceptions about varicose veins and does a good job explaining that they are a part of a larger spectrum of chronic venous disease. There is a strong emphasis throughout this book on accurate diagnosis and the idea that proper assessment of venous disease and getting to its root cause will result in more effective and lasting treatment. Dr. Wright’s expertise provides reassurance that diagnosis will not cause more harm than good. In the treatment section, everything from the simplest compression therapy to the most complex surgeries are explained. Treatment is described as being flexible and personalized, which likely seems more hopeful to a patient than a guarantee of any one treatment. At this point Dr. Wright has done his job of providing a very comprehensive resource. Treatment options are listed with advantages and disadvantages and photos and diagrams show the instruments and the before and after pictures. With an already vast understanding of varicose veins compared to what I had before, I was satiated by the 300+ pages of information.
Healthy Diet and Weight Management
Most want to see some kind of clinical proof that ceasing and altering diet can help control their varicose veins. In no way can this help reverse or definitely keep new ones from occurring, but if your varicose veins are just a mild case then this can help defer experiences that are associated with veins that are more severe. Studies have shown that obesity is a risk factor for the development of varicose veins, and just by the act of losing weight, it stands to reason that there would be less pressure on the veins. This is logical, yet now there is positive proof showing that this can help. A study funded by the National Heart, Lung, and Blood Institute and the National Institute of Diabetes and Digestive and Kidney Diseases and published in the December 2009 issue of the Journal of the American College of Cardiology showed that weight loss reduced UEs pressures. Higher UEs pressure in the saphenous vein is one factor that leads to the development of varicose veins. So there you have proof that health and body weight have an effect on prevention of varicose veins.
So it is more than evident that you have varicose veins; however, there is nothing that can be done to reverse them. Maintenance and prevention is the key to reducing the risk of further developing more. Incorporating a healthy diet and maintaining a healthy body weight are the primary ways to ensure that this can be done. In turn, you can decrease the pressure on your veins and increase blood flow
