What is Varicose Veins?
Varicose veins are usually easily noticed as they appear as large, twisted veins, about the width of a pencil or larger, that are located just under your skin. These are most common in the legs and are most often associated with veins straight from the heart, called saphenous veins, their branches, or other superficial leg veins. They become more common with age and if your family has a history of them.
Varicose veins are a common sign of a condition called chronic venous disease. Beyond making your legs less attractive, varicose veins can cause an issue called venous reflux. This is when blood doesn’t flow straight back to your heart, but instead, pools in your vein. Doctors usually check for this in the major veins of your leg as a first step in diagnosis.
Varicose veins can lead to a wide variety of issues, ranging from mild leg discomfort to swelling and even wounds that won’t heal. Understanding the risks and symptoms can help with timely treatment and management of these conditions.
What Causes Varicose Veins?
Varicose veins are swollen, bulging veins that often happen in the legs. They are more common in women and can also be influenced by factors like multiple pregnancies, body weight, constipation, and a history of blood clots. People who work in jobs where they’re standing or walking for extended periods may also be more likely to get varicose veins. However, we don’t fully understand all the reasons why some people get varicose veins and others don’t, as both genetics and environmental factors likely play a role but have been less studied.
A recent study attempted to find out more about what causes varicose veins. The researchers used a type of artificial intelligence called machine learning to study nearly 500,000 people in the UK. They found that height might be an unexpected risk factor, and further research was done to investigate this.
Some other factors that the study found might increase the risk of varicose veins include weight, smoking, and high body iron levels. On the flip side, the levels of some minerals, like calcium and zinc, seemed to lower the risk. However, some factors that doctors thought might contribute like high blood pressure, age at menopause, and smoking, did not appear to strongly link with varicose veins in this study. Other less expected factors like drinking coffee, vitamin B12, and magnesium levels were found to be associated with an increased chance of varicose veins.
While the use of contraceptive pills had been thought to contribute to varicose veins, it appears to be a less likely risk factor. Furthermore, the study pointed out that tall people were more likely to develop varicose veins. They also found some possible connections between certain genes and varicose veins, including a gene known to regulate blood pressure. This indicates that our genetic makeup might play a role in the development of varicose veins. So, while we have a better understanding now, more studies are needed to fully understand why people develop varicose veins.
Risk Factors and Frequency for Varicose Veins
Varicose veins, or enlarged veins, are found in around 30% of all people, though this condition is more prevalent in older individuals. This is a worldwide condition and its occurrence is related to lifestyle and physical activity. It’s worth noting that women are more prone to developing varicose veins than men. According to the Framingham Study, which tracked the occurrence of varicose veins within a population over a span of 16 years, they found that between 23 to 30% of men and women developed varicose veins. However, this study did not assess the presence or absence of backflow of blood (venous reflux) in the veins. Every two years, there were about 39.4 to 51.9 new cases of varicose veins per 1000 people, the highest rates were among women in their 40s. Moreover, race plays a role in the prevalence of varicose veins; non-Hispanic white individuals tend to have varicose veins more often than their Asian counterparts.
Signs and Symptoms of Varicose Veins
The venous reflux is usually assessed by the clinical-etiology-anatomy-pathophysiology (CEAP) classification system, which considers the severity of your symptoms. The CEAP categories are broken down as follows:
- C0: No visible or palpable signs of venous disease
- C1: Small, visible veins
- C2: Larger, bulging veins (varicose veins)
- C3: Swelling of the leg
- C4a: Pigmentation or discoloration and eczema
- C4b: Hardening or whitening of the skin
- C5: Healed leg ulcer
- C6: Open, active leg ulcer
However, because science and medicine are constantly evolving, this system is regularly updated. For instance, in 2017, an organization called the American Venous Forum added some new categories. Understanding and using the updated system helps doctors evaluate the full effects of venous disease.
Generally, a doctor can initially identify this condition by looking for signs such as swelling, discoloration, and sores (ulcers) on your skin. Symptoms of varicose veins can include:
- Having heavy-feeling legs
- Itchy skin
- Cramps
- Mild tenderness
- Skin discoloration
- Difficulty exercising
- Tired legs
During a physical exam, the doctor may see visibly swollen veins from your thigh to your ankle. There may be noticeable color changes in your skin, primarily around your ankle and calf. A test called the Trendelenburg test may be performed, where your leg is raised, and the veins are watched for filling. If the deeper veins aren’t functioning correctly, the superficial veins of the leg will start to fill. Knowing where the issue lies helps guide the treatment plan.
Testing for Varicose Veins
If your doctor suspects that you have venous reflux, which means blood is flowing back into your veins instead of up towards your heart, based on your symptoms and their examination, they may suggest doing a color duplex venous ultrasound. This is a test that gives details about the structure of your veins and how their valves (the parts that stop blood from flowing backwards) are working. The test can also check for deep vein thrombosis (DVT), a condition where a blood clot forms in the deep veins which could be causing your symptoms.
There are different ways doctors use the results from a duplex ultrasound to determine the severity of varicose veins (bulging, twisted veins often visible on the lower legs). One method is to look at the speed of the blood flow when it’s going backward in the veins (peak reflux velocity). Research had shown this to be a consistent way to classify severity of the varicose veins. Specifically, if blood in the veins is flowing backwards faster than about 27.4 cm per second, it’s a sign of varicose veins.
Another method, contrast venography (an X-ray of the veins), is hardly ever used these days. Instead, doctors often rely on pulsed-wave Doppler images. These images show if blood flow is going backwards after pressure on the calf muscle is released, indicating varicose veins. The amount of this backward flow (reflux) could be easily measured using an ultrasound, done with the probe angled up while looking at a cross-section of the veins.
Treatment Options for Varicose Veins
Sclerotherapy is a technique that uses chemicals to get rid of unwanted veins near the surface of your skin. It’s mainly used on small varicose veins, which are less than 6 mm wide. This method could be a good choice if you’re dealing with symptoms from varicose veins, or if you simply don’t like their appearance. Different types of chemical agents are used depending on the size and type of vein. For instance, an agent called polidocanol is commonly used to treat smaller veins known as reticular and spider veins.
Recently, a substance known as cyanoacrylate glue has become a popular choice for treating varicose veins associated with chronic vein insufficiency. This method is minimally invasive, quick, and does not require anesthesia.
If you’re looking for non-surgical options, compression stockings, leg elevation, and pain relief medicines could help relieve your symptoms. Special stockings that apply gentle pressure on your legs can be particularly helpful if you don’t want to get surgery. But keep in mind that hot weather can make wearing them uncomfortable.
Surgical treatment is another option for dealing with varicose veins. Traditionally, this involves a process called ligation (tying off the veins) and stripping (removing the veins). The specific surgical method used often depends on factors such as the location, size, and extent of the affected veins.
For a saphenous vein stripping procedure, surgical staff will carefully clean and prepare the skin around the affected vein. A tool called a vein stripper is used to remove the vein through small incisions made in the skin. If there’s an ulcer present on the skin, it will be carefully isolated and kept sterile.
In the case of saphenous vein inversion and removal, a small incision is made over the saphenofemoral junction. The vein is then isolated, ligated and removed with the help of a vein stripper. The surgery is carefully performed to minimize the risk of damage to surrounding tissues and potential nerve injury.
High saphenous ligation is another surgical method, which involves tying off the saphenous vein at the saphenofemoral junction. However, this technique is less preferred because of a higher chance of recurrent symptoms and complications.
Ambulatory phlebectomy is a procedure that involves removing the affected superficial vein through small skin incisions.
Another method is transilluminated powered phlebectomy, which involves illuminating the veins, followed by vein maceration (breaking down the vein) and aspiration (sucking out the vein) through a second incision.
Catheter-based endovenous ablations use a small flexible tube (catheter) introduced into the vein to destroy it from the inside, using either heat or radiofrequency.
Remember, each of these treatment options has its set of advantages and potential drawbacks. Be sure to discuss with your doctor the method that would be best suited for your condition and preferences.
What else can Varicose Veins be?
Here are some medical conditions that can be confused with each other due to having similar symptoms:
- Lymphedema
- Deep vein thrombosis
- Cellulitis
- Stasis dermatitis
What to expect with Varicose Veins
Unfortunately, there is no known cure for varicose veins. This means that even if you have surgery to remove them, they could come back. People who get venous ulcers, which are sores that occur when the vein doesn’t provide enough drainage in a particular area of your skin, often have a high level of sickness and can experience a lower quality of life.
What might be some relief is that unlike the veins that are deep inside you, if a clot forms in one of your superficial veins (the veins that are close to the surface of your skin), it’s unlikely to travel and cause a pulmonary embolism, which is a dangerous and potentially life-threatening condition.
Without treatment, varicose veins can look unpleasant, and this is often the primary reason why most individuals choose to seek treatment.
Possible Complications When Diagnosed with Varicose Veins
People with varicose veins might experience a few challenges or complications. These could include venous ulcers, which are open sores that can appear when the leg veins don’t return blood back towards the heart as well as they should. Another common symptom is physical discomfort or pain. Furthermore, aesthetic concerns, also known as “poor cosmesis”, may arise due to the visible and pronounced nature of these veins.
Although more research is needed to confirm these findings, a study from Taiwan showed that people with varicose veins might have a higher risk of developing deep vein thrombosis (DVT) and pulmonary embolism (PE). DVT is a serious condition where blood clots form in the deep veins of the body, usually in the leg. PE occurs when a blood clot travels to the lungs, which can be life-threatening.
Patients with varicose veins were found to be at a higher risk of developing DVT (6.6 versus 1.2 per 1000 person-years; hazard ratio, 5.30)
The risk of developing PE was also found to increase (0.48 versus 0.28 per 1000 person-years; hazard ratio, 1.73).
However, more studies are required to further validate this correlation; we must make sure that other factors such as smoking and obesity aren’t influencing the results.
Further complications could include superficial thrombophlebitis, a condition where a blood clot forms in a vein just below the skin. This might come with prolonged pain and bleeding. Another possible complication is superficial vein thrombosis, which is a blood clot in a vein close to the skin’s surface.
Common complications of varicose veins:
- venous ulcers
- pain
- poor cosmesis
- deep vein thrombosis (DVT)
- pulmonary embolism (PE)
- superficial thrombophlebitis
- superficial vein thrombosis
Recovery from Varicose Veins
In surgery for varicose veins, an important step is applying a ‘compression dressing’ after the operation. This is much like a very tight bandage used to decrease blood flow and inflammation. Despite this, experts can’t quite agree on precisely how important this step is. Similarly, in treatment for ‘venous ulcers’ (sores caused by poor blood flow in veins), it’s advised to use a certain amount of pressure in the bandage around the ankle and below the knee, but again, there’s no clear guideline on this.
One common practice after varicose vein surgery or laser remedies is wearing compression stockings. However, there isn’t a unanimous agreement among medical professionals regarding how necessary these stockings are and how long patients should wear them.
One study even investigated the use of compression therapy after a specific varicose vein treatment using an advanced type of laser technology. The researchers found that wearing compression stockings for more than two days after the procedure did not greatly influence the results. These findings contradict the customary advice that patients should use compression therapy for a week or more. But it’s important to note that this study applied to lasers with a less commonly used, low wavelength.
Preventing Varicose Veins
Wearing graduated compression stockings can help improve blood flow. It’s also beneficial to maintain a healthy weight. Regular exercise also promotes overall health and supports good circulation.