Varicose Veins

Specializing in the Diagnosis
and Treatment of Vascular Disease

Introduction

The condition of superficial venous insufficiency, also known as varicose veins, is a common disorder in western societies. Almost everyone has a friend or family member with varicosities. Thankfully, varicose veins rarely cause serious medical illness, but they can be uncomfortable and may interfere with well being and general feeling of health. This article deals with varicose veins, specifically, what causes them and what some of the treatment options are.

Varicose veins are dilated, elongated superficial veins in the soft tissue under the skin of the legs and above or superficial to the muscle layers. They form when there is a breakdown in the anatomy, which allows normal drainage of veins from the legs back to the heart. In the U.S. more than one in 50 people have varicosities. They tend to run in families and the chance of developing them increases with age. They are more common in women than in men. Women may first notice them when pregnant. Excess weight and long periods of standing may predispose to their development.

Anatomy

To understand varicose veins it helps to know a little about venous anatomy in the legs. Blood travels to the legs through arteries and back to the heart through veins. There are thousands of veins in each leg, but they can be divided into three main types, superficial veins under the skin and above the muscle, deep veins next to arteries in and around the muscles, and connecting veins (perforators) which allow blood to flow from the skin and soft tissues to the large, deep veins. The two largest veins under the skin are the greater and lesser saphenous veins. The greater saphenous starts in the ankle in front of the medial ankle bone and runs up the inside of the leg and thigh to connect at the groin with the main deep vein of the leg, the common femoral vein. The lesser saphenous vein is on the opposite side of the leg, starting at the ankle behind the lateral ankle bone and running up the back of the calf to connect most often with the deep vein at the knee, the popliteal vein. Normal blood flow is from foot to groin and from the superficial veins to the deep veins and then back to the heart.

Blood is propelled from the heart to the legs by the force of the heart pump and the effect of gravity. To get back to the heart, however, blood must travel uphill against gravity and without the heart pumping it forward. This engineering feat is accomplished by making more room in veins. Veins are bigger than the corresponding arteries and are more numerous. Blood is propelled forward by the squeeze of leg muscle contraction, and by the presence of one way valves in veins. These valves prevent backward blood flow down the leg.

Varicose veins develop when valves stop working. The valves may get damaged, for instance by a blood clot or they may degenerate for some reason, or the vein wall may dilate so that the valve edges stop touching each other, allowing falling blood to flow past them back into the leg. Eventually, the weight of the blood from above and the force of the flow from the muscle squeeze combine to damage and dilate the incompetent veins. These veins bulge and elongate, in short becoming visible, unsightly, uncomfortable varicose veins.

Sometimes varicose veins cause no symptoms, but often they are uncomfortable. They make the leg feel heavy and achy. They can cause the leg to swell especially after one is on one’s feet for long periods of time or at the end of the day. People often note that their legs tire more easily and they may get leg cramps at night, disturbing sleep. The bulging veins may actually hurt or feel tender. Symptoms are often worse during menses and during warmer weather.

Other more serious consequences of varicose veins can also occur. The veins under the skin san get inflamed causing a condition called phlebitis. This can happen if a vein is injured, for instance if it is bumped. With phlebitis, a painful clot forms and even after the inflammation goes away, a discolored bump remains. If the skin over the varicose vein gets cut, the vein can bleed. This is not often life threatening but can be frightening.

With time, this degenerative condition invariably worsens. That is varicose veins become larger. Eventually, leg swelling may also occur, and irreversible skin changes can develop in the leg below the knee. The skin can turn a brown color, the soft tissue around the varicose veins can thicken and become hard, and inflammation of the skin can develop, causing an irritating painful or itchy sensation. Ulcerations may form around the ankles.

Diagnosis

To effectively treat varicose veins an accurate venous duplex ultrasound is a necessity. As previously discussed, normally, venous blood flows up hill towards the heart. A venous duplex ultrasound exam evaluates whether each of the major deep, superficial and perforating (communicating) veins is flowing properly. Exams should be performed by a nationally accredited vascular lab by Registered Vascular Technologists as this will insure that patients are receiving quality examinations.

Treatment

Prescription Compression Stockings is the most conservative approach. Compression stockings work by applying pressure against the bulging veins, pushing the blood up hill. Compression stockings may help to relieve the discomfort of varicose veins. Prescription compression stockings are fit to the individual by a medical professional and squeeze harder at the foot than at the knee, helping to propel blood upward to the heart.

Vein Stripping is a procedure in which incisions are made in the groin and at knee level. The leaking saphenous vein is disconnected from the deep vein and major branches in the groin. A plastic catheter is then passed down the inside of the vein to the level of the knee. There the catheter is brought out of the vein and the surgeon pulls the vein from the tissue under the skin. Pressure is placed on the thigh to lessen bleeding from the torn branches of the stripped vein. The incisions are closed and the leg is wrapped. This procedure is done as an outpatient procedure under general or spinal anesthesia. One usually uses narcotic pain medicines for a couple of days and misses about one week of work due to discomfort. The patient can walk the day of surgery. Leg bruising disappears in about four weeks.

Radiofrequency Endovenous Ablation (VNUS) is a new alternative to vein stripping. With this technique a special catheter is inserted inside the saphenous vein at the level of the knee, perhaps through one small incision. The catheter has prongs at the tip that conduct radiofrequency energy which heats up and seals the vein as the catheter is removed. The catheter is passed up the saphenous vein to a position near its attachment with the deep vein. The Catheter position is watched under ultrasound. Fluid with local anesthetic is then injected around the vein to protect the skin and nerves near the vein from the radiofrequency heat. Next, the radiofrequency heat is turned on, and the catheter is slowly brought down the vein from groin to knee. This causes the leaking vein to shrivel up and the vein is no longer capable of carrying blood. The vein is not removed. This procedure is done with local anesthetic sometimes supplemented by sedation. It, too is an outpatient procedure. Narcotic medicines are rarely required. Most often an over the counter pain medicine provides relief. Bruising is unusual, and the patient can sometimes return to work the next day. More information on the VNUS Closure Procedure can be obtained at www.vnus.com.

Sclerotherapy is the injection of a detergent into the vein which causes the cells on the vein wall to detach, The vein walls will then attach together if they are pushed together by an external wrap. Sclerotherapy is an office procedure best used on smaller varicose veins after the larger leaking veins in the leg have been treated. For optimal results you will need to obtain compression stockings and bring them to your sclerotherapy treatment.

Frequently Asked Questions:

What are the most common symptoms of varicose veins? Varicose veins may or may not be symptomatic. Symptoms may include dull leg ache, night cramps, leg fatigue, and leg heaviness

What is the recovery time for vein stripping? Most patients miss one week of work due to pain. Bruising will subside in about four weeks.

What is the recovery time for radiofrequency venous ablation? Most patients return to work in 1-2 days. Over the counter medications usually provide sufficient pain relief.

If it is determined that I would I benefit from surgery what is the time frame from my consultation to surgery? Frequently pre-authorizations/determinations are required. This involves sending the physician’s clinic notes along with the ultrasound data to the insurance review department. This process may take up to 8 weeks depending on the insurance company.

What is the purpose of compression stockings? Compression stockings work by squeezing the leg and forcing the blood uphill.

Where can I get compression stockings? Stockings may be purchased at many medical supply stores. We have a list of dealers.

Will my insurance pay for my stockings? Generally no, however, you should check with your insurance company. If you have medical savings account or cafeteria plan stockings are eligible expenses.

What is the recovery time for sclerotherapy? With sclerotherapy one can return to work the same day, however, for optimal results compression stockings should be worn following the procedure.

Can I schedule a sclerotherapy session as my first visit? No. Our protocol for patients with vein problems include an ultrasound exam followed by a physician consultation. If sclerotherapy is to be performed it will performed as part of a subsequent visit. For optimal results obtain and bring your compression stockings to your sclerotherapy treatment.

Is sclerotherapy covered by my health insurance company? Generally no, however, some insurance companies may approve sclerotherapy if the patient has first undergone surgical intervention. If sclerotherapy is performed by itself with no surgical intervention, then most insurance companies will not cover it. Approval of sclerotherapy involves sending the patient’s clinical information to the insurance company for medical review. This process may take up to 8 weeks. If the insurance company denies coverage for sclerotherapy, there are self-pay options available.