Veins are blood vessels that return deoxygenated blood from the outer parts of the body back to the heart and lungs. When veins become abnormally thick, full of twists and turns, or enlarged, they are called varicose veins. This happens most commonly in the veins in the legs and thighs. In varicose veins, the thickened, twisting or dilated parts of the vein are called varicosities. Varicose veins can form anywhere in the body, but they are most often located in the legs. Varicose veins tend to be inherited, and become more prominent as a person ages.
The veins in the leg are either superficial or deep. The superficial veins and their branches are close to the skin. Also included in this category are the communicator or perforator veins, which connect the superficial veins with the deep veins. The deep veins are encased by muscle and connective tissue, which help to pump the blood in the veins and back to the heart. The veins have one-way valves to prevent them from developing varicosities. Generally, blood travels from the superficial veins to the deep veins. From there, the blood travels through a network of larger veins back to the heart.
Varicose veins are relatively easy to identify and can be a cosmetic nuisance for many people. They protrude or bulge from under the skin and feel ropey. The legs often ache and feel heavy and itchy. Symptoms can intensify after a long day of standing on the feet. A person may have severe pain upon standing or even have cramps in the legs at night. Varicose veins can be more prominent or first appear during menstruation or pregnancy, and they may be more bothersome during these times.
Some people may have no symptoms of varicose veins at all. Primarily, they are only a cosmetic problem. Varicose veins are prone to developing superficial thrombophlebitis, which is a blood clot along with inflammation of a segment of vein. Blood clots in the superficial veins are easy to detect and troublesome but are usually harmless.
A person may feel an area of tenderness and pain in the varicose vein, along with redness and swelling. The area may also feel hard or firm.
Sometimes such areas can represent infection within the vein, so it is a good idea to visit a health care professional if a person develops any of these symptoms.
This condition is not to be confused with deep vein thrombophlebitis (DVT), which is a blood clot in a deep vein. Deep vein thrombophlebitis (DVT) is more serious because of the clot's potential to travel toward the heart and lodge in the lung (pulmonary embolism). This condition requires emergent admission to the hospital for treatment with blood-thinning medications.
Many theories exist for why varicosities occur in veins, but the consensus is that defective/damaged valves within the veins are the cause. Valves prevent backward flow of blood within the vein. They keep blood in the vein moving toward the heart. It is unclear what causes the valves to work less efficiently. Some experts think inherited problems cause some people to have too few valves or valves that do not function properly. Some people may be born with abnormalities of the vein wall. The resulting weakness may predispose the valves to separate and become leaky, which causes the valves to function poorly so when the person stands up, the blood flow actually reverses and flows down the superficial veins, when it should be flowing up, toward the heart.
When the muscles surrounding the deep veins contract, emptying the deeper veins, a build-up of pressure occurs. This causes even more blood to flow the wrong way from the deep to the superficial veins through faulty valves in the perforator veins. This increases pressure in the superficial veins and causes varicosities.
Many factors can aggravate the varicose veins.
Pregnancy is associated with an increase in blood volume. Also, added pressure on the veins in the legs by the weight of the growing uterus and the relaxation effects of the hormones estrogen and progesterone on the vein walls contribute to the development of varicose veins during pregnancy.
Prolonged standing.
Obesity or distended belly.
Straining: Chronic constipation, urinary retention from an enlarged prostate, chronic cough, or any other conditions that cause a person to strain for prolonged periods of time cause an increase in the forces transmitted to the leg veins and may result in varicose veins. These mechanisms also contribute to the formation of hemorrhoids, which are varicosities located in the rectal and anal area.
Prior surgery or trauma to the leg: These conditions interrupt the normal blood flow channels.
Age: Generally, most elderly individuals show some degree of varicose vein occurrence.
If a person has varicose veins, and has any of these symptoms and signs, see a health care professional.
Inflammation, discoloration, or ulceration of the skin or swelling of the calf or leg is more typical of problems related to the deeper veins, especially a blood clot. Unexplained pain or swelling in a leg particularly suggests a blood clot. Varicose veins by themselves do not usually cause a leg to swell.
Varicose veins alone are relatively harmless, but every now and then they can cause minor problems. If the skin overlying the vein is thin or irritated, minor trauma from a bump or even shaving can tear the vein and cause bleeding. In this case, elevating the leg and applying pressure for several minutes should be enough to stop the bleeding. If it does not, the patient may need to visit a hospital emergency department. If, at any time, the patient feels chest pain or has trouble breathing, this may indicate the presence of a blood clot in the blood vessels of the heart or lungs. The patient should go to a hospital emergency department immediately.
Having varicose veins does not necessarily mean the person will eventually have a blood clot or that a blood clot somehow caused them. In rare instances, however, a clot increases pressure in the veins by blocking blood flow. This elevated pressure will cause backward flow of blood through weakened valves, creating varicose veins. For this reason, the patient should see a health care professional if the leg is swollen or if the patient experiences worsening pain in the leg, or if he or she suddenly develops varicose veins and does not have any of the common risk factors such as pregnancy.
Making the diagnosis of varicose veins is a relatively easy task. They are easy to identify just by their characteristic appearance on physical examination. The health care professional most likely will take a thorough medical history and examination looking not only for the extent of the patient's varicose veins, but also for potential risk factors.
He or she may do any of several simple tourniquet tests to identify points of reverse blood flow. The simplest test uses only a blood pressure cuff. Another useful device aiding in localizing the extent of the problem is a Doppler ultrasound. This handheld device is skimmed over the surface of the leg to map out the veins and faulty valves. This device is similar to those used in pregnancy to identify the developing fetus. Duplex scanning, a similar but more detailed test, can also be done to rule out the presence of clots in the deeper veins. Magnetic resonance venography is another test performed when the Duplex scan test is unclear. This test can even look for blood clots in the deep veins.
Blood (laboratory) tests are not helpful in making a diagnosis of varicose veins.
Follow-up after a diagnosis of varicose veins is generally necessary only if a person is considering surgery or sclerotherapy. Otherwise, follow up with a health care professional only if severe or worsening symptoms occur.
Treatments are available for varicose veins. Many of them are simple things a person can begin immediately, for example:
Sclerotherapy
Sclerotherapy involves injecting a chemical inside the vein that obliterates it and causes it to scar. Sclerotherapy is not completely successful in alleviating symptoms and preventing the formation of more varicose veins. Complications associated with sclerotherapy include allergic reactions to the chemical used, stinging or burning at the various injection sites, inflammation, skin ulcerations, and permanent discoloration of the skin. Bandages often remain in place for as long as three weeks. Wearing compression stockings is usually recommended after sclerotherapy. Doctors who perform this procedure must have specialized training and experience in order to avoid complications.
Lasers
Lasers are used as a treatment for varicose veins but are frequently used in the treatment of smaller veins, medically referred to as telangiectasias. These veins are small, measuring only up to 1 millimeter in diameter, and represent dilated capillaries. Using lasers to treat these smaller vessels can cause changes in the color or texture of the skin. Multiple treatments are often required. The technique is less helpful in the treatment of larger varicosities.
If a person has superficial thrombophlebitis, a health care professional will usually recommend warm compresses and pain medication. Additional treatment depends on whether the physician thinks the patient may have an infection.
Several surgical procedures are available to relieve varicose veins, but not everyone with varicose veins is a candidate for surgery.
Most of the surgical procedures are performed on an outpatient basis. The surgery involves either vein ligation (tying) or stripping or avulsion (pulling away) of the smaller branches. With any surgery, risks and benefits exist. These should be discussed with the health care professional and with the specialist involved. Recurrence of varicose veins does occur and may be due to incompetent perforator veins or failure to ligate the vein more proximally in the groin.
Avulsion: Avulsion requires many tiny incisions and removal of the varicose veins that have been outlined on the skin.
Stripping: Stripping involves at least two incisions, one at the groin and one at the knee. A tunneling device is placed under the skin between the two points, and the saphenous vein is dragged or pulled out of the tunnel. This technique will leave not only scars from the incisions but also a significant amount of bruising and possibly bleeding. The bleeding is easily controlled by pressure dressings and stops immediately. The bruising is usually noticeable for a few weeks.
For vein stripping, a recovery period of 5-10 days is needed before returning to a regular routine. For just vein ligation, a few days off is more than adequate. A possibility of persistent numbness from damage to the nerves in the skin exists (for this reason, usually only the vein to the knee is stripped, not the vein below the knee). The numbness is only mild in nature and does not cause any future problems.
Endovascular laser therapy
Endovenous laser therapy is a technique that uses a laser to destroy the vein. The procedure is usually performed in a doctor's office and takes about 30-45 minutes. The small laser is passed into the vein with guidance from the ultrasound machine. The laser is then fired up and the entire vein is fibrosed. The laser is fired at multiple locations and the entire procedure is performed with some local anesthesia.
Recovery is rapid and involves minimal pain. The procedure is relatively new and, except for some mild bruising and a numbing sensation, no other effects have been seen in the short term.
Radiofrequency ablation: Ablation is a similar technique to endovascular laser therapy, but it uses heat to destroy the vein. The probe is placed in the vein under ultrasound and, once in position, the vein is heated along the entire length. The procedure is performed under local anesthesia and takes about 30 minutes. Short-term results are excellent using radiofrequency ablation.
Ligation: This was formerly the surgical treatment for varicose veins before the newer treatment modalities described above became available. It usually involved an incision at the groin and tying off of the saphenous vein where it enters the femoral vein. It is tied just at the entrance. The procedure can be performed under local anesthesia.
Varicose veins that a person has now will not go away unless treated, such as sclerotherapy or ligation and stripping. At times, the veins may seem more prominent, such as in warm weather. However, once they appear, they will not go away on their own.
Prevention is the key. The earlier a person starts the lifestyle modifications outlined in the Self-Care at Home discussed previously, the better the chances of preventing new varicose veins from forming. In some cases, varicose veins may be one stage in the continuum of chronic poor vein functioning.
Some people may progress from having no symptoms, to the development of varicose veins, and then on to problems with leg swelling, and finally to ulcers caused by stagnant blood flow. A small number of these people will have deep vein clots as a cause for their signs and symptoms, but most will not. The more severe problems, such as skin ulcers, tend to be very difficult to prevent completely. Once these ulcers occur, they are very difficult to cure. Even when they are eliminated, these ulcers tend to recur.
A deep vein blood clot has the potential to travel through the bloodstream and lodge in the lung. This is called a pulmonary embolism. Pulmonary embolism does not occur from varicose veins. Pulmonary embolism can be life-threatening because the blood clot can interrupt the circulation of blood. Common symptoms of pulmonary embolism are chest pain and shortness of breath.
A person cannot change his or her genes, but a person can keep weight under control, exercise, eat a healthy diet high in fiber, and wear loose comfortable clothing when possible. If an individual is genetically destined to develop varicose veins, they may appear despite all the best efforts.
TED (thromboembolism-deterrent) stockings are the best nonsurgical treatment of varicose veins. They prevent skin breakdown and worsening of the varicosities. Most people have decreased swelling in their feet and less tiredness at the end of the day when using TED stockings.
Signs and symptoms of a blood clot in the leg, or deep vein thrombosis (DVT), occur in the affected leg when a clot obstructs blood flow and causes inflammation. Although some people with DVT do not experience symptoms, signs and symptoms may include:
