Vain About Veins?

If you're over 40, you probably see them — those little purple veins that suddenly seem to appear on your legs. They make us realize we are getting older. Are we just being vain about our appearance, or are they a serious problem? Let's look first at what veins are.

Veins are soft, thin-walled tubes which enable the return of blood from the legs and arms to the heart, against the forces of gravity. This is possible by the presence of valves inside that allow forward flow but not backward flow. Your legs and arms have two major types of veins: superficial and deep. The superficial veins are near the surface of the skin and often you can see them. The deep veins are near the bones and are surrounded by muscle. Connecting the deep and superficial veins are the perforator veins. Contraction (squeezing down) of the muscles in the arms and legs through exercise helps with blood flow in the veins.

Varicose veins are large, bulging surface veins, felt under the skin, generally larger than one-eighth inch in width, and usually located at the inside part of the calf or thigh. They develop due to weakness of the vein wall and because the valves no longer work. Under the pressure of gravity they continue to expand and, in the course of time, they may become longer, twisty, pouched, and thickened.

Spider veins or teleangiectesiae are tiny, dilated veins that you cannot feel, and are usually located at the surface skin layers. Veins that are larger than spider veins but smaller than varicose veins are called reticular veins.

Varicose Veins Are Very Common
Vein problems are among the most common chronic conditions in North America and Western Europe. They are less common in the Mediterranean Basin, South America, India, and even less so in the Far East and Africa. In one study from southern California, vein problems were present in 33 percent of women and 17 percent of men, without racial or ethnic differences. Varicose veins were almost as frequent in women as in men; however, spider veins were more frequent in women. A large U.S. survey, the Framingham study, reported that 27 percent of the American adult population has some type of vein disease in the legs. It is estimated that at least 20 to 25 million Americans have varicose veins.

Symptoms of Varicose Veins
Varicose veins may be entirely symptom-free and cause no health problems. Treatment in such cases is cosmetic. When symptomatic, varicose veins may cause ankle and leg swelling, heaviness or fullness, aching, restlessness, cramps, and itching. Varicose veins are more often symptomatic in women than in men. Signs of chronic venous disease include skin discoloration (usually rusty brown) and loss of the softness of the skin and tissue in the ankle area (induration). Itching is perhaps the most consistent symptom of varicose veins in men. Women most often complain of leg heaviness, fullness, and aching.

Risk Factors for the Development of Varicose Veins
The most important factors leading to the development of varicose veins include:

• Heredity
• Prolonged standing
• Increasing age
• Heavy lifting
• Prior superficial or deep vein clots
• Female gender
• Multiple pregnancies

Less physical activity, higher blood pressure, and obesity have also been linked with the presence of varicose veins in females.

Causes of Varicose Veins
The causes of varicose veins may be primary, secondary, or congenital (from birth). Varicose veins of primary cause develop as a result of a weakness in the wall of the vein. Varicose veins can have a hereditary factor and often occur in several members of the same family. Varicose veins that develop after a trauma or a deep vein clot are of secondary cause. Congenital varicose veins are due to flaws in the natural development of the venous system, and usually are part of a vascular malformation in the limb with which the child was born. (See Keeping in Circulation, Fall 2004, Volume 4, Number 3.) In addition to varicose veins, these individuals may also have an enlarged and longer limb and often have birthmarks (port-wine stains), as in Klippel Trenaunay Syndrome (KT Syndrome). Regardless of cause, defective valves may cause venous blood to stagnate in the leg, leading to high blood pressure in the vein. This may result in further enlargement of the varicose veins, increasing the likelihood of symptoms as well as complications such as skin changes and ulcers at the ankles. Blockage of the veins in the pelvis may severely aggravate the effects of varicose veins, thus requiring a separate treatment.

Diagnosis of Varicose Veins
The diagnosis of varicose veins is made primarily by physical examination. The accuracy of physical examination is improved with the aid of hand-held Doppler ultrasound. The most accurate and detailed test is duplex ultrasonography. This test enables an ultrasound image of the vein to detect any venous blockage caused by blood clots, and to determine whether the blood is flowing well and whether the vein valves are working properly. Measurement of the venous function of the leg may be obtained with other tests such as plethysmography.

Complications of Varicose Veins
Without treatment, varicose veins may cause pain or aching, leg swelling, skin color changes, hardened skin and subcutaneous tissue (lipodermatosclerosis), and eczema. In advanced cases, breakdown of the skin may cause bleeding from varicose veins and large varicosities may develop blood clots, a condition called superficial phlebitis or thrombophlebitis. Patients with varicose veins may also develop chronic skin ulceration around the ankle.

Treatment of Varicose Veins
The treatment of primary varicose veins may be conservative, minimally invasive, or invasive, depending on the extent of the varicosity. Prescription elastic compression stockings may reduce the symptoms of varicose veins, prevent leg swelling, and decrease the risk of blood clots. However, in hot environments the use of elastic stockings may be impractical. Sclerotherapy (injections of the veins), entailing injection of a sclerosing solution into spider veins, reticular, or small varicose veins, is a minimally invasive outpatient procedure. This blocks the veins that are not working. The best results are in legs with localized areas where the valves do not work.

Ambulatory phlebectomy is also a minimally invasive outpatient procedure that can be performed under local, epidural, or general anesthesia. Varicose veins are removed with small hooks, by tiny skin incisions. Stitches are not used, and the tiny incisions are pulled together with fine paper-tape. Recovery is brief and uneventful.

Venous stripping is the standard treatment for bad valves in the great saphenous vein, the largest surface vein, which goes down the inner side of the leg. Usually the thigh part of the great saphenous vein is stripped (removed). After stripping, multiple fine, skin incisions are made to allow removal of the varicose veins. The entire surgery is safely performed under general, epidural, or local anesthesia.

A new procedure using a laser or radiofrequency technique involves placing a catheter into the saphenous vein through a tiny incision in the knee. The tip of the laser fiber or radiofrequency probe is advanced in the vein through the groin and the vein is sealed by heat with the device. The blood then flows through the remaining open veins properly returning back to the heart. This technique avoids the surgery of the saphenous vein stripping. Varicose veins still need to be treated with ambulatory phlebectomy or sclerotherapy.

What You Can Do:
You can't do anything about your heredity, age, or gender. However, you can help delay the development of varicose veins or keep them from increasing.

• Be active. Moving leg muscles keeps the blood flowing.
• Keep your blood pressure under control. Work with your doctor.
• Give your legs a break! Lie down and raise your legs at least six inches above the level of your heart. Do this for ten minutes a few times each day.
• Strive for a normal weight.

About the Authors: Konstantinos Delis, PhD, FRCSI, is the Marco Polo Fellow of the European Society for Vascular Surgery currently at the Mayo Clinic in Rochester, Minnesota.

Peter Gloviczki, MD, FACS, is Professor of Surgery, and Chair, Division of Vascular Surgery, and Director, Gonda Vascular Center, Mayo Clinic, Rochester, Minnesota. Dr. Gloviczki is also president of the Vascular Disease Foundation.