Varicose Veins: Causes, Symptoms and Treatment
Chronic Venous Disease is More than a Cosmetic Problem
Dec 11, 2008
Varicose veins are dilated, tortuous veins (the Latin word “varix” means twisted) that are most commonly seen on the legs. They range in size from small "spiders" to finger-sized veins. In the United States, at least 15% of men and 25% of women are affected.
Varicosities can also occur in the esophagus, rectum (hemorrhoids), spermatic cords (varicoceles), and vulva. (London NJ, Nash R. ABC of arterial and venous disease. Varicose veins. BMJ 2000:320(7246):1391-1394)
Causes of Varicose Veins
Varicose veins result from multiple factors which contribute to retrograde blood flow through incompetent venous valves. This creates pooling of blood and increased pressure on vein walls. Known risk factors for varicose veins include:
- Increased intra-abdominal pressure arising from pregnancy, chronic cough, obesity, tumor, chronic constipation, or frequent lifting and straining
- Cirrhosis
- Family history
- Occupations requiring prolonged standing
- Thrombosis (clotting) in primary veins. This shunts more blood through secondary vessels
- Shear forces and inflammation
(Adapted from Jones RH, and Carek PJ. Management of varicose veins. Am Fam Phys 2008;78(11):1289-1294)
Signs and Symptoms of Varicose Veins
- There is no correlation between the visual appearance of varicose veins and the severity of symptoms. Some people with strikingly abnormal veins have no significant symptoms.
- When symptoms are present, they are usually localized to the area of the varicosities. However, people can also experience more diffuse complaints.
- Localized symptoms include pain, burning, or itching.
- Diffuse symptoms consist of swelling, aching or cramping, fatigue, or a sense of leg fullness.
- Complaints are usually worse at the end of the day or after long periods of standing. Conversely, elevation of the legs typically reduces symptoms.
Complications of Varicose Veins
While individuals with varicose veins usually consult physicians because of discomfort or complaints about cosmetic appearance, significant complications can also result from chronic venous disease:
- Changes of skin pigmentation
- Eczema (stasis dermatitis)
- Phlebitis (superficial inflammation)
- Secondary infection
- Thrombosis (clotting)
- Ulceration
- Atrophy of subcutaneous tissue and a decrease in limb circumference (lipodermatosclerosis)
- Hemorrhage from perforation
Treatment of Varicose Veins
Conservative Management
- Treat underlying medical conditions (cirrhosis, congestive heart failure, etc.)
- Avoid prolonged standing or straining
- Elevate affected extremity
- Avoid restrictive clothing
- Exercise (to address obesity and to encourage upward movement of blood via muscular pumping action)
- External compression (20 to 30 mm Hg gradient compression stockings; bandaging; intermittent pneumatic compression device)
- Medications: the use of diuretics to reduce leg swelling caused solely by varicose veins is not effective. European experience with horse chestnut seed extract (Aesculus hippocastanum) has shown benefit in reducing edema. (Diehm C, et al. Comparison of leg compression stocking and oral horse-chestnut seed extract therapy in patients with chronic venous insufficiency. Lancet 1996;347(8997):292-294)
Other Modalities
- Sclerotherapy: Injection of superficial veins with substances that collapse vessels (hypertonic saline, detergent solutions, glycerin). Works well on veins up to 5mm in diameter; deep venous thrombosis and recurrence of varicosities are concerns.
- Endovenous obliteration: Insertion of a long, thin catheter that emits energy (heat, laser, or radio waves) into the vein. The released energy collapses the vessel as the catheter is withdrawn. Bruising, tightness along the vessel, abnormal skin sensation, and recurrence are possible complications.
- Surgery: Incisions are made over the involved veins, and the vessel(s) is then either stripped or avulsed (pulled out in segments). Possible complications include bleeding, infection, bruising, anesthesia reactions, and increased pressure in tributary veins (leading to new varicosities). Surgery is the treatment of choice for venous ulcers, with an 88% chance of healing.
Varicose veins are not uncommon. Choice of a treatment method for symptomatic varicosities depends on the severity of symptoms, cost and insurance reimbursement, patient preference, potential for complications, and availability of trained practitioners.
