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Varicose Veins and Venous Insufficiency

Varicose Veins and Venous Insufficiency: Overview
Signs, Symptoms and Complications
Causes
Risk Factors
Prevention and Self-help
Compression
When to Seek Medical Advice
Screening and Diagnosis
Complementary and Alternative Medicine
Deep Venous Thrombosis
Treatment

Overview
Venous insufficiency is a very common condition resulting from decreased blood flow from the leg veins up to the heart, with pooling of blood in the veins. Varicose veins are a symptom of venous insufficiency where prominent, elongated veins appear rope-like and bulging just under the skin's surface. The word varicose comes from the Latin root varix, which means "twisted". Any vein in the body may become varicose, but the most common varicose veins occur near the skin surface in your legs. Only humans seem to be affected by this varicose veins, suggesting it is related to our upright posture. Throughout the day our legs remain in the dependent position (standing or sitting) which increases the pressure in the veins of our lower body due to gravity.

More than 25 million Americans (25% of the adult population) suffer from symptomatic superficial venous insufficiency and varicose veins which results in more than 2 million workdays being lost per year. Women seem to have this condition more often but it is also common in men. For many people, varicose veins and spider veins (a common, mild and medically insignificant variation of varicose veins), are not symptomatic and are only a cosmetic concern. However, other people with venous insufficiency can have a variety of discomforting leg symptoms including aching, cramping, burning and pain. Sometimes when longstanding, this condition can lead to more serious problems such as bleeding and ulceration.

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Signs, Symptoms and Complications
You may experience symptoms long before obvious varicose veins appear:

  • Aching, heavy discomfort in your legs sometimes associated with burning throbbing, muscle cramping or swelling in your lower legs.  Some patients describe “restless legs”.  These symptoms can be exacerbated by prolonged standing or sitting.

  • Brownish discoloration around your lower leg and ankle indicates hyperpigmentation (hemodsiderin deposition) from chronic venous pressure and may progress to serious dermatologic conditions known as venous eczema and lipodermatosclerosis.

  • Skin breakdown and ulceration that occurs spontaneously or from mild trauma and fails to heal, represents a severe form of chronic venous insufficiency.  This condition is a feared symptom of chronic venous disease and effects nearly one million Americans annually.  These wounds are often quite painful and difficult to treat and require immediate medical attention.

  • Enlarged veins readily visible under the skin of your legs which may itch or become painful to touch or even bleed.

  • Sudden, severe pain in a varix indicating a blood clot- known medically as superficial thrombophlebitis. This condition, however, does not increase your risk of a deep venous thrombosis.

Varicose veins are dark purple and blue in color and may appear twisted and bulging- like cords.  They are most often found on the backs of the calves or on the inside of the leg, anywhere from your groin to your feet.  Spider veins are smaller, often red or blue in color, and are closer to the surface of the skin than varicose veins. They often have a branching “starburst or web-like” appearance with short, jagged lines.  Spider veins are often found on the legs or the face and can cover either a small or large area of the skin.

Other types of vein abnormalities include:

Reticular veins.

Flat, blue veins which often communicate with spider veins

Telangiectasias.

Fine clusters of blood vessels similar to spider veins, although reddish in color, which are often found on the face or upper body.

Venous lakes.

Pools of blood in the superficial veins.

Occasionally, deep veins (as opposed to the superficial veins) within the legs can become enlarged and sometimes the leg can swell suddenly.  Any sudden leg swelling that may or may not be accompanied by pain and redness warrants urgent medical attention, as this may indicate a serious medical condition known as a deep venous thrombosis.

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NBC 29's Dr. John Hong interviews Dr. Lewis Owens about the treatment of varicose veins.

Causes
The heart serves as the pump for arteries supplying oxygen and nutrients to all parts of the body.  Arteries carry blood from the heart towards the body parts, while veins carry blood back from the body parts to our heart.  In our legs, veins do not have a pump as efficient as the heart and must work against gravity.  The efficient function of veins depends on two important mechanisms.

  • The muscles in our calves to function as a venous pump while we walk or exercise and “squeeze” the toned elastic vein walls forcing blood back towards the heart.

  • Functioning, elaborate network of tiny one-way valves to open as blood flows back towards the heart and close to stop blood from refluxing backwards.

Venous insufficiency and varicose veins occur when the calf muscle pump system or more commonly the tiny one-way valves malfunction. As you get older, your veins can lose elasticity, causing them to stretch out.  When this happens blood that should be traveling towards your heart may flow (or reflux) backwards.  Blood then pools in your superficial leg veins, and your veins become enlarged or varicose because of the resulting venous hypertension.  The veins appear blue because they contain blood without oxygen which is in the process of being recirculated.

It is not uncommon for women during pregnancy to develop varicose veins for several reasons.  To support the growing fetus during pregnancy, the volume of blood in the body increases and progesterone (which causes blood vessels to dilate) levels are elevated.  These factors, along with an enlarging uterus which can exert great pressure on the veins from your legs, may produce an unfortunate side effect in the mother- venous insufficiency, enlargement of leg veins, and varicose veins. It is not uncommon for varicose veins to appear for the first time during pregnancy but they generally improve without medical treatment within three months after delivery. Unfortunately, however, the condition persists or progresses with each additional pregnancy.

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Risk Factors
Factors that increase your risk of developing varicose veins and venous insuffiency:

Age.

Varicose veins usually appear between ages 30 and 70. It is a disease that progresses and worsens.

Sex.

Women are more likely than men to develop venous insufficiency and varicose veins by a ratio of 60 to 40 percent. Hormonal changes during pregnancy and multiple pregnancies tend to increase the risk.

Genetics.

If other family members had varicose veins, there is a greater chance that you will too.

Obesity.

Being overweight clearly increases venous pressure and thereby increases the risk of venous reflux disease.

Standing or sitting for long periods of time.

The calf muscle pump is not functioning and thus venous blood is not flowing as efficiently.

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Prevention and Self-Help
Varicose veins and venous reflux disease cannot be completely prevented. However, it is well-proven that conservative steps to improve your circulation and muscle tone can reduce the risk of developing varicose veins or getting additional varicose veins.  Some basic recommendations:

Exercise.

Get your legs moving.  This augments your calf muscle pump and thereby improves both you arterial and venous circulation. Charlottesville and Central Virginia residents are fortunate to have a variety of opportunities to enjoy low-impact exercise both outdoors and indoors all year round.

Control your weight.

Losing excess weight removes unnecessary pressure on the veins in your legs, where varicose veins and venous insufficiency are likely to occur.

Watch what you wear.

Avoid high heels.  Low-healed shoes work calf muscles more, which is better for your leg veins.  Don’t wear tight clothes around your calves or groin.  Tight panty-leg girdles, for instance, can restrict circulation.

Elevate your legs.

To improve venous circulation attempt to elevate your legs every three to four hours for 15 minutes to assist gravity and thereby your circulation.  Although crossing your legs has long been thought to aggravate circulatory problems, this has never been clearly proven.

Avoid long periods of sitting or standing.

Make a point of changing your position frequently to use your calf muscles and encourage venous blood flow.

Compression.

One of the most proven and beneficial conservative therapies in treating leg swelling and symptoms associated with varicose veins is compression therapies (see below).

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Compression
Wearing compression stockings is often the first approach to try before moving on to more definitive treatment therapies.  Compression stockings achieve their benefit by augmenting your calf muscle pump function and improving valve apposition.  The stockings steadily squeeze your legs, improve venous tone and improve the efficiency of your venous circulation.  Below knee stockings are the variety most commonly recommended to augment your calf muscles. For most venous disorders there is no advantage to the thigh-high or panty-hose varieties of stockings. For the best effect, stockings should be worn throughout the day during regular activities, and removed at night.

Some people think of compression stockings as being uncomfortable and unstylish, but their negative fashion reputation is no longer deserved.  Venous insufficiency and varicose veins are a medical condition.  Compression stockings, particularly when custom, are very beneficial in treating the symptoms of venous disease.  With new fabrics and technologies, compression stockings today now come in a variety of strengths, styles and colors.  There are several brands including Juzo, Jobst and Medi that have equivalent characteristics. With the variety offered, you are likely to find a stocking you are comfortable wearing.

Compression stockings are sold at most pharmacies and medical supply stores.  However, if your symptoms are significant you may require prescription-strength stockings.  These are created at very specific compression levels.  For example Class 2 compression stockings indicate 30-40 mmHg sequential compression beginning at the ankle level.  The stockings need to be custom fit to the exact measurements of your calf and ankle for maximum benefit and comfort.  Compression stockings are not only beneficial in preventing the progression of existing venous disease but they are also very beneficial in maintaining vein function and appearance long after definitive venous treatment has been performed.

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When to Seek Medical Advice
Self-help efforts such as leg elevation, compression and the other listed preventive measures can help ease the pain and discomfort of varicose veins and may slow the progression.  But if you are concerned about the appearance and symptoms associated with your veins and the self- care measures have not improved your venous condition from getting worse, see your physician.

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Screening and Diagnosis
In order to make a diagnosis of chronic venous insufficiency your physician will carefully examine your legs to assess your vascular health.  He or she will look for evidence of the above described signs and symptoms.  You should carefully describe the character and duration of your symptoms- particularly when they occur such as with prolonged standing or sitting.  Your primary care doctor may then recommend that you be further evaluated by a physician who specializes in vein conditions such as a vascular surgeon or interventional radiologist. 

Prior to a complete diagnosis you may require a comprehensive venous duplex ultrasound study.  This exam can be thought of as an extension of your physical exam to completely assess your vein anatomy and venous blood flow changes in your legs.  This study will carefully look at all the veins in your legs (both the superficial and deep vein systems) and evaluate the caliber of the veins, function of the valves and identify any evidence of previous blood clots.  This study is very important prior to planning or performing any definitive treatment.

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Complementary and Alternative Medicine
You may be tempted to try one of the many herbal supplements that claim to be able to prevent venous reflux disease and varicose veins. The active ingredient in most of these products is horse chestnut. Although as vascular surgeons intimately involved in wound care and venous disease we do not rule out the possibility of this herb having an effect on veins, there are no good studies that have shown any significant benefit on eliminating varicose veins or relieving the symptoms they cause.

Additionally, there are concerns about the purity of herbal supplements and the large amounts needed for their effects.  The manufactures of these products are not closely regulated by the Food and Drug Administration.

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For More Info

Deep Venous Thrombosis

Deep Vein Thrombosis (DVT)

DVT is a vascular disorder resulting from the formation of a blood clot (thrombus) inside a deep vein of the upper or lower extremities. Most frequently, a DVT will occur in the leg or thigh when a blood clot either partially or completely blocks the flow of blood in the vein. Patient symptoms can include pain, swelling, and discoloration.

Post-Thrombotic Syndrome (PTS)

PTS is an under-recognized, but relatively common sequela, or aftereffect, of having DVT if treated with blood thinners (anticoagulation) alone, because the clot remains in the leg. Contrary to popular belief, anticoagulants do not actively dissolve the clot, they just prevent new clots from forming. The body will eventually dissolve a clot, but often the vein becomes damaged in the meantime. A significant proportion of these patients develop permanent irreversible damage in the affected leg veins and their valves, resulting in abnormal pooling of blood in the leg, chronic leg pain, fatigue, swelling, and, in extreme cases, severe skin ulcers. While this use to be considered an unusual, long-term sequela, it actually occurs frequently, in as many as 60-70 percent of people, and can develop within two months of developing DVT. There is increasing evidence that clot removal via interventional catheter-directed thrombolysis in selected cases of DVT can improve quality of life and prevent the debilitating sequela of post-thrombotic syndrome.

Pulmonary Embolism (PE)

Left untreated, a deep vein thrombosis (DVT) can break off and travel in the circulation, getting trapped in the lung, where it blocks the oxygen supply, causing heart failure. This is known as a pulmonary embolism, which can be fatal.

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Treatment
In the last decade many novel advances have occurred in the field of vascular surgery and interventional radiology to effectively treat venous insufficiency without a hospital stay or long uncomfortable recovery periods.  Minimally invasive techniques generally allow patients with symptomatic vein disease and varicose veins to be dealt with on an outpatient basis and return to their normal activities often within 2 to 3 days.  People who have varicose veins or venous conditions that have not responded to self-help or preventive measures may be a candidate for definitive treatment.  The anatomy of the venous system of the leg is very complex with many overlapping and collateral pathways.  This is why a careful evaluation and diagnosis by a specialist in vein diseases such as a vascular surgeon or interventional radiologist is strongly recommended. 

At CRL Surgical our Total Vein Care program consist of a team of board certified vascular physicians and interventional radiologists who provide comprehensive care to patients with all types of vein problems. We have extensive experience in the latest techniques and because each patient has unique venous anatomy, each treatment regimen is individualized to achieve the optimal results.

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