Varicose veins

Varicose veins, also known as varicoses, are a medical condition in which superficial veins become enlarged and twisted. Although usually just a cosmetic ailment, in some cases they cause fatigue, pain, itching, and nighttime leg cramps. These veins typically develop in the legs, just under the skin. Their complications can include bleeding, skin ulcers, and superficial thrombophlebitis. Varices in the scrotum are known as varicocele, while those around the anus are known as hemorrhoids. The physical, social, and psychological effects of varicose veins can lower their bearers' quality of life.
Varicose veins have no specific cause. Risk factors include obesity, lack of exercise, leg trauma, and family history of the condition. They also develop more commonly during pregnancy. Occasionally they result from chronic venous insufficiency. Underlying causes include weak or damaged valves in the veins. They are typically diagnosed by examination, including observation by ultrasound.
By contrast, spider veins affect the capillaries and are smaller.
Treatment may involve lifestyle changes or medical procedures with the goal of improving symptoms and appearance. Lifestyle changes may include wearing compression stockings, exercising, elevating the legs, and weight loss. Possible medical procedures include sclerotherapy, laser surgery, and vein stripping. However, recurrence is common following treatment.
Varicose veins are very common, affecting about 30% of people at some point in their lives. They become more common with age. Women develop varicose veins about twice as often as men. Varicose veins have been described throughout history and have been treated with surgery since at least the second century BC, when Plutarch tells of such treatment performed on the Roman leader Gaius Marius.

Signs and symptoms

Aching, heavy legs
Appearance of spider veins in the affected leg
Ankle swelling
A brownish-yellow shiny skin discoloration near the affected veins
Redness, dryness, and itchiness of areas of skin, termed stasis dermatitis or venous eczema
Muscle cramps when making sudden movements, such as standing
Abnormal bleeding or healing time for injuries in the affected area
Lipodermatosclerosis or shrinking skin near the ankles
Restless legs syndrome appears to be a common overlapping clinical syndrome in people with varicose veins and other chronic venous insufficiency
Atrophie blanche, or white, scar-like formations
Burning or throbbing sensation in the legs

People with varicose veins might have a positive D-dimer blood test result due to chronic low-level thrombosis within dilated veins.

Complications

Most varicose veins are reasonably benign, but severe varicosities can lead to major complications, due to the poor circulation through the affected limb.

Pain, tenderness, heaviness, inability to walk or stand for long hours
Skin conditions / dermatitis which could predispose skin loss
Skin ulcers especially near the ankle, usually referred to as venous ulcers
Development of carcinoma or sarcoma in longstanding venous ulcers. Over 100 reported cases of malignant transformation have been reported at a rate reported as 0.4% to 1%
Severe bleeding from minor trauma, of particular concern in the elderly
Blood clotting within affected veins, termed superficial thrombophlebitis. These are frequently isolated to the superficial veins, but can extend into deep veins, becoming a more serious problem.
Acute fat necrosis can occur, especially at the ankle of overweight people with varicose veins. Females have a higher tendency of being affected than males
Causes

Varicose veins are more common in women than in men and are linked with heredity. Other related factors are pregnancy, obesity, menopause, aging, prolonged standing, leg injury and abdominal straining. Varicose veins are unlikely to be caused by crossing the legs or ankles. Less commonly, but not exceptionally, varicose veins can be due to other causes, such as post-phlebitic obstruction or incontinence, venous and arteriovenous malformations.
Venous reflux is a significant cause. Research has also shown the importance of pelvic vein reflux in the development of varicose veins. Varicose veins in the legs could be due to ovarian vein reflux. Both ovarian and internal iliac vein reflux causes leg varicose veins. This condition affects 14% of women with varicose veins or 20% of women who have had vaginal delivery and have leg varicose veins. In addition, evidence suggests that failing to look for and treat pelvic vein reflux can be a cause of recurrent varicose veins.
There is increasing evidence for the role of incompetent perforator veins in the formation of varicose veins and recurrent varicose veins.
Varicose veins could also be caused by hyperhomocysteinemia in the body, which can degrade and inhibit the formation of the three main structural components of the artery: collagen, elastin and the proteoglycans. Homocysteine permanently degrades cysteine disulfide bridges and lysine amino acid residues in proteins, gradually affecting function and structure. Simply put, homocysteine is a 'corrosive' of long-living proteins, i.e. collagen or elastin, or lifelong proteins, i.e. fibrillin. These long-term effects are difficult to establish in clinical trials focusing on groups with existing artery decline. Klippel–Trenaunay syndrome and Parkes Weber syndrome are relevant for differential diagnosis.
Another cause is chronic alcohol consumption due to the vasodilatation side effect in relation to gravity and blood viscosity.

Diagnosis

Clinical test

Clinical tests that may be used include:

Trendelenburg test – to determine the site of venous reflux and the nature of the saphenofemoral junction
Investigations

Traditionally, varicose veins were investigated using imaging techniques only if there was a suspicion of deep venous insufficiency, if they were recurrent, or if they involved the saphenopopliteal junction. This practice is now less widely accepted. People with varicose veins should now be investigated using lower limbs venous ultrasonography. The results from a randomised controlled trial on patients with and without routine ultrasound have shown a significant difference in recurrence rate and reoperation rate at 2 and 7 years of follow-up.

Stages

The CEAP Classification, developed in 1994 by an international ad hoc committee of the American Venous Forum, outlines these stages

C0 – Perthes test – no visible or palpable signs of venous disease
C1 – telangectasia or reticular veins
C2 – varicose veins
C2r – recurrent varicose veins
C3 – edema
C4 – changes in skin and subcutaneous tissue due to Chronic Venous Disease
C4a – pigmentation or eczema
C4b – lipodermatosclerosis or atrophie blanche
C4c – Corona phlebectatica
C5 – healed venous ulcer
C6 – active venous ulcer
C6r – recurrent active ulcer

Each clinical class is further characterized by a subscript depending upon whether the patient is symptomatic or asymptomatic, e.g. C2S.

Treatment

Treatment can be either active or conservative.

Active

Treatment options include surgery, laser and radiofrequency ablation, and ultrasound-guided foam sclerotherapy. Newer treatments include cyanoacrylate glue, mechanochemical ablation, and endovenous steam ablation. No real difference could be found between the treatments, except that radiofrequency ablation could have a better long-term benefit.

Conservative

The National Institute for Health and Clinical Excellence produced clinical guidelines in July 2013 recommending that all people with symptomatic varicose veins and worse should be referred to a vascular service for treatment. Conservative treatments such as support stockings should not be used unless treatment was not possible.
The symptoms of varicose veins can be controlled to an extent with the following:

Elevating the legs often provides temporary symptomatic relief.
Advice about regular exercise sounds sensible but is not supported by any evidence.
The wearing of graduated compression stockings with variable pressure gradients has been shown to correct the swelling, increase nutritional exchange, and improve the microcirculation in legs affected by varicose veins. They also often provide relief from the discomfort associated with this disease. Caution should be exercised in their use in patients with concurrent peripheral arterial disease.
The wearing of intermittent pneumatic compression devices has been shown to reduce swelling and pain.
Diosmin/hesperidin and other flavonoids.
Anti-inflammatory medication such as ibuprofen or aspirin can be used as part of treatment for superficial thrombophlebitis along with graduated compression hosiery – but there is a risk of intestinal bleeding. In extensive superficial thrombophlebitis, consideration should be given to anti-coagulation, thrombectomy, or sclerotherapy of the involved vein.
Topical gel application helps in managing symptoms related to varicose veins such as inflammation, pain, swelling, itching, and dryness.
Procedures

Stripping

Stripping consists of removal of all or part the saphenous vein main trunk. The complications include deep vein thrombosis, pulmonary embolism, and wound complications including infection. There is evidence for the great saphenous vein regrowing after stripping. For traditional surgery, reported recurrence rates, which have been tracked for 10 years, range from 5% to 60%. In addition, since stripping removes the saphenous main trunks, they are no longer available for use as venous bypass grafts in the future.

Other

Other surgical treatments are:

CHIVA method is a relatively low-invasive surgical technique that incorporates venous hemodynamics and preserves the superficial venous system. The overall effectiveness compared to stripping, radiofrequency ablation treatment, or endovenous laser therapy is not clear and there is no strong evidence to suggest that CHIVA is superior to stripping, radiofrequency ablation, or endovenous laser therapy for recurrence of varicose veins. There is some low-certainty evidence that CHIVA may result in more bruising compared to radiofrequency ablation treatment.
Vein ligation is done at the saphenofemoral junction after ligating the tributaries at the saphenofemoral junction without stripping the long saphenous vein, provided the perforator veins are competent and DVT is absent in the deep veins. With this method, the long saphenous vein is preserved.
Cryosurgery – A cryoprobe is passed down the long saphenous vein following saphenofemoral ligation. The probe is then cooled with NO₂ or CO₂ to −85 °F. The vein freezes to the probe and can be retrogradely stripped after 5 seconds of freezing. It is a variant of stripping. The only purpose of this technique is to avoid a distal incision to remove the stripper.