Circulatory system

What are varicose veins?

Veins are thin vessels that carry blood from body tissues back to the heart. Normally, the valves in the vein keep blood moving toward the heart. Because people move about erect rather than on all fours, gravity pulls blood down into the legs, ankles, and feet. The veins in our legs must work hard against gravity in order to pump blood back up to the heart. Increased pressure in these veins may sometimes break the valves within the veins themselves.

Also known as varicosity or varicosis, varicose veins commonly affect people between the ages of 30 and 70—usually women. Varicose veins are subcutaneous vessels—vessels just below the skin—that have widened, twisted and become painful because of poorly functioning valves within the veins themselves. When valves no longer work properly to prevent the backward flow of blood away from the heart, blood collects in the veins, causing them to bulge and swell. In severe cases, varicose veins can lead to skin changes which can in turn lead to such conditions as eczema, pigmentation, and ulceration or bleeding.¹

Types of varicose veins

Although varicose veins commonly occur in the legs and feet, they can occur in any part of the body, including veins in the lower esophagus, the lining of the stomach, the colon, the rectum, and in men, the scrotum.²

There are two types of varicose veins, primary and secondary.

Primary varicose veins

The most common type of varicose veins, primary varicose veins can often be traced to a specific cause, such as poor circulation, aging, or obesity. Although found most often just under the skin of the legs and feet, primary varicose veins can also occur deep within the limbs. This is accompanied by pain and swelling and may lead to poor circulation in the affected areas. Primary varicose veins can also occur as spider veins—tiny, branching, often problem-free variations of varicose veins.³

Secondary varicose veins

Secondary varicose veins are less common and frequently occur as the result of another disease or medical condition. People with liver disease, for instance, may develop varicose veins in areas other than legs and feet. Secondary varicose veins may affect the rectum, as in the case of hemorrhoids, and the lower end of the esophagus.⁴

Varicose veins may be aggravated by pregnancy, menopause, obesity, aging of tissues, oral contraceptives, and hormone therapy.⁵

What causes varicose veins?

To understand what causes varicose veins, let's first examine the two principal systems of veins in the body.

Deep veins

Deep veins are those which lie among muscle. Deep veins are responsible for carrying 90 percent of blood from body tissues back to the heart.⁶

Surface/superficial veins

Surface veins, also known as superficial veins, are those that are often visible just under the skin. Unlike deep veins, surface veins lack protective muscular surrounding, making them weaker and more susceptible to varicosity.⁷

Generally, varicose veins occur when valves between the deep and superficial veins no longer work properly. A defective valve can allow blood to flow the wrong way because pressure in the deep veins is greater than in the superficial veins. In other words, rather than taking blood from the surface veins, the deep veins may actually pump blood back into the surface veins. This allows blood to remain in the vein, enlarging it and increasing pressure within the surface veins.

Why do valves fail?

It isn't known why valves fail. It could be that there is an insufficient number of valves or that the valve(s) may be defective. Another possibility is that the walls of veins may be weak. When such veins bulge, pulling causes damage to the valves by pulling apart their delicate leaves. The presence of blood clots can also damage valves. Even though clots dissolve, the scar tissue that remains on valves may hinder upon their function, causing them to fail.⁸

This often unleashes a chain reaction: as blood pools and collects in the surface veins and as pressure in the surface veins increases, more and more valves begin to deteriorate. Over time, one valve after another fails. As a result, the surface veins swell from the excess blood and high pressure. This results in varicose veins.⁹

In some instances, it can be the vein itself, and not the valve, that is the cause of varicosis. Such factors as pregnancy, obesity, or periods of prolonged standing may all cause excessive pressure in a leg vein. When this happens, the walls of the vein are likely to bulge, forcing the two halves of the valve too far apart, making them unable to provide a complete blockage during the closing phase. As a result, some blood is allowed to flow downward.¹⁰

What are the risk factors for varicose veins?

Varicose veins are believed to be genetic although they may also be linked to other factors, including:

Thrombophlebitis

The presence of clots in surface veins of the legs can lead to inflammation and can also increase the risk of varicose veins.

Prolonged standing and/or constipation

Each of these can weaken the walls of veins, increasing the risk for varicose veins. Constipation weakens the walls of the veins of the anus, increasing the risk for hemorrhoids.

Pregnancy

During pregnancy, changes in circulation are designed to help support and nourish the developing fetus. These changes, however, may increase the risk of varicose veins. These may occur for the first time during pregnancy, or they may worsen during the third trimester, when the uterus exerts greater pressure on the veins in the legs.

Birth control pills and hormone therapy

Oral contraceptives and estrogen therapy each raise a woman's levels of sex hormones, placing her at higher risk for varicose veins.

Obesity

Obesity places increased pressure on surface veins, causing them to weaken.

Gender

Women are at greater risk than men, likely because estrogen and progesterone cause blood vessels to relax separating the valves and keeping them from adequately closing to prevent the back flow of blood.

What are the symptoms of varicose veins?¹¹

For many people, varicose veins carry no symptoms aside from the appearance of bulging, rope-like veins beneath the skin. However, some people may experience some of the following:

• pain in the affected areas
• pain in the legs accompanied by fullness, heaviness and aching, particularly at the end of the day or after periods of prolonged standing
• persistent itching of skin under the affect area
• visible, enlarged veins
• mild swelling of the feet and/or ankles due to fluid from stagnant blood leaking through the walls of veins and into surrouding tissues
• discoloration of the skin at the ankles; skin over the affected area may turn a brownish-gray color. Skin in the legs may redden.
• dry, thin, and itching skin in the affected area. Scratching can lead to bleeding, rash, or even a skin ulcer.
• skin ulcers (open sores) in the affected area
• phlebitis (chronic vein inflammation)
• fever
• bulging veins
• twisted veins that have a rope-like appearance

Symptoms are often progressive, becoming worse over time. In addition, because increased progesterone levels are consistent with the development of varicose veins, women may experience more severe symptoms during their menstrual periods. People who experience leg pain because of arthritis, narrowed leg arteries or siatica may believe the pain is due to their varicose veins, when actually the pain may instead be due to one of these conditions.¹²

How are varicose veins diagnosed?

If you experience leg pain or other symptoms as described above, or if you notice any signs of ulceration, you should seek medical attention as soon as possible. Your doctor will use a variety of techniques to determine the severity of your varicose veins. He or she may tie a tourniquet around your thigh or around the upper part of your leg. This will constrict the flow of blood in your leg and make varicose veins easier to identify.¹³

Through what's known as the Trendelenburg test, your doctor can also identify the presence of varicose veins by having you raise your legs above the level of your heart at a 45-degree angle until the veins are emptied. Your doctor will then ask you to quickly lower your legs and stand up. When you stand up, any varicose veins you may have will become immediately noticeable.¹⁴

In rare cases, your doctor may require additional, more detailed tests to rule out other conditions. He or she may recommend an ultrasound, a test in which high frequency sound waves are used to measure blood flow in deep and surface veins, or venography, a test that uses x-rays to measure blood flow in deep veins.¹⁵

Treatment of varicose veins

Because varicose veins are primarily a cosmetic problem, treatment is not always necessary. Wearing compression stockings or support hoisery, maintaining normal weight, and regular exercise may be all that's needed. Compression stockings improve circulation by putting pressure on the leg muscles that squeeze the veins. This improves the flow of blood back to the heart, reducing swelling, achiness, and tiredness. Compression stockings are not curative; they are intended to control the symptoms of varicose veins.¹⁶

More severe cases of varicose veins, particularly those involving ulcers, usually require treatment.¹⁷

Sclerotherapy

Treament typically involves the elimination of "bad" veins, forcing blood flow through healthy veins instead. This is most commonly achieved through a procedure known as sclerotherapy. Using a fine needle, a vascular surgeon or dermatologist injects a solution, typically hypertonic saline or Sotradecol (sodium tetradecyl sulfate), directly into the vein. The solution irritates the lining of the vein and causes it to swell. The blood inside the vein clots, causing the vein to turn into scar tissue and to fade away. Following sclerotherapy and injection of the solution, the vein's surrounding tissue is wrapped in bandages, causing the vein to stick together. Some patients may require more than one sclerotherapy treatment.¹⁸

The pain of sclerotherapy will vary from one patient to another, depending on each person's pain threshold, how extensive the treatment was, the size of the needle used, which parts of the body were treated, and whether complications arise. For many patients, hypertonic saline is the most painful solution, often causing a burning and cramping sensation when it is first injected. Your doctor may add a mild local anesthetic to the solution to help minimize the pain.¹⁹

Vein stripping

"Stripping" is a surgical prodcedure to treat varicose veins. In fact, it is the only option for removing saphenous veins in the legs. The largest surface veins in the legs, the saphenous veins are the major vessels for carrying blood among the superficial veins in the leg.²⁰

Vein stripping is usually done under general or epidural anesthesia. During stripping, problem veins are eliminated by passing a flexible wire device through the vein at the ankle and removing it through an incision near the groin. By inserting the wire at the ankle incision, passing it through the entire length of the saphenous vein, and drawing it out at the groin incision, the surgeon is able to pull the vein — along with the wire — out.²¹

Recovery usually takes between two to six weeks. Your doctor will ask you to keep your leg(s) bandaged for several weeks following surgery. You should take several short walks. Start with short distances and walk for about five minutes. You can slowly increase time and distance each day. You should also lie down frequently, with your legs elevated above your heart.²²

Ambulatory phlebectomy

Designed to treat larger varicose veins, ambulatory ihlebectomy is a surgical procedure in which a surgeon makes a series of tiny puncture holes along the vein and then takes out small segments of the vein. Ambulatory phlebectomy is usually a 45-minute procedure than can be performed in a doctor's office or in an outpatient clinic. The tiny incisions don't require stitches and most patients experience little or no pain. The procedure is called ambulatory because most patients are able to walk immediately following surgery.²³

Surgery is an important decision. You should consult with more than one doctor before deciding on a method of treatment. Ask each one about his or her experience in performing the treatment you want, as well as about the safety and side effects of the procedure you are considering. You should also discuss any allergies or other drug sensitivities with your doctor. Sotradecol may cause allergic reactions, and in some cases, rather severe reactions. Your doctor will also be able to answer any questions you might have about the suitability of various procedures for treating a particular condition.²⁴ For example, sclerotherapy is not recommended for large varicose veins, varicose veins extending up to the groin, and people who are obese.²⁵

How can I prevent varicose veins?

Here are a few ways you can reduce your risk of developing varicose veins. These practices can also help prevent varicose veins from recurring following treatment.²⁶

Exercise regularly

Taking a 30-minute walk, bicycling, and jogging all help strengthen leg muscles and improve circulation.

Avoid prolonged standing

Sit down often and elevate your legs. While standing, be sure to shift your weight from one leg to the other. Bounce up and down on the tips of your toes several times an hour. If you can, take a walk. After standing for long periods, elevate your legs for about 60 minutes.

Avoid prolonged sitting

If your work requires you to sit for long periods, take several breaks throughout the day. Take short walks to improve circulation. Pump your calves and make small circles with your ankles.

Put your feet up

Elevate your legs when you sit or lie down. When your legs are raised, at least to the level of your heart, you ease the load on the veins in your legs. Put your feet up when you are at home. You can do this by lying on the floor near a bed or a wall and putting your feet up on the wall. Lying in this position for at least 15 minutes each day will allow some of the blood that has pooled in your legs to move out of the legs and back into your body. If you like, you can take a short nap or read a book while you do this exercise. When you are in bed, place a pillow under your feet.

Raise your bed

Using wooden blocks, raise the foot of your bed about two inches. Doing this helps blood flow back to your heart while you sleep.

Avoid crossing your legs

When you sit, try to avoid crossing your legs. Crossing your legs compresses the veins and may affect blood flow in the legs.

Wear compresson stockings

If you have varicose veins or are at risk, wear compression stockings or support hose, available in most drugstores. Put the stockings on as you get out of bed in the morning and wear them all day.

Avoid tight clothing

Tight clothing, tight knee hose, and tight girdles can all restrict blood flow and may increase your risk of developing varicose veins.

Avoid high heels

High-heeled shoes require you to use the muscles in your buttocks, and not your calf muscles, to walk. Walking in high heels does not promote proper circulation in the legs. It's recommended that you wear low-heeled shoes or athletic shoes instead. These help strengthen calf muscles and improve circulation.

Maintain a healthy weight

Try to keep your weight down. Excess body fat, particularly around the waist, can put pressure on the thighs and groin. This weakens the walls and valves of veins in the groin and legs, making you prone to varicose veins.

Increase your fiber intake

Eating foods high in fiber will help you avoid constipation. Constipation puts pressure on the veins in the anus and increases the risk of hemorrhoids.

Increase your vitamin C intake

Increasing your intake of vitamin C, through vitamin supplements, for example, may help strengthen blood vessel walls.

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