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Varicose Veins

Varicose Veins

Varicose veins are very common in all countries. Almost 25% of adults (10 million men and 20 million women) in the US have them; when spider veins are included, the prevalence increases to 80-85% of adults >40yo. Spider veins are often a cosmetic issue, but varicose veins can cause aching, throbbing pain, leg heaviness, fatigue, and swelling. In almost 10% of patients, varicose vein disease can be severe and lead to superficial vein blood clots (thrombophlebitis), bleeding, and skin damage over time (chronic venous stasis, including ulcers and skin infection). The cost of treating vein-related ulcers in the US is reported to be up to $3 billion a year with 2 million work days lost annually.

Risk Factors for Varicose Veins

  • Older age
  • Female gender
  • Family history of varicose veins
  • History of leg injury or surgery
  • History of Deep Venous Thrombosis (DVT)
  • Obesity
  • Pregnancy (current or previous)
  • Lack of exercise and inactivity
  • Job that involves sitting or standing for long periods of time

Venous Insufficiency

There are two systems of veins: a deep system, deep within the muscle and not visible from the outside, and a superficial system, which is just under the skin’s surface within the fatty layer of the skin. Healthy leg veins have one-way valves that open and close to keep blood moving back to the heart. When these valves are damaged or diseased, they don’t close properly, and blood and pressure build up in the lower legs more than normal. This is known as venous reflux or venous insufficiency. When blood pools in the leg veins, the branches of the veins can become swollen and irregular, otherwise known as varicose veins. Increased pressure in the veins can lead to leg swelling (edema). Venous insufficiency is most commonly diagnosed by ultrasound.

Signs and Symptoms

  • Varicose veins
  • Aching or throbbing pain
  • Leg swelling
  • Cramping
  • Heaviness or tiredness
  • Itching or burning
  • Restlessness
  • Shiny, thickened skin
  • Dry, irritated skin
  • Open sores or ulcers
  • Brown, darker-colored skin, possibly with patches of white, lighter-colored skin

Treatment of Venous Insufficiency

Primary management of varicose vein disease, leg swelling, and venous insufficiency is non-surgical. Leg elevation (raising the legs off the ground - ideally but not necessarily above the heart) can help to reduce pressure build-up related to the force of gravity. Leg elevation should be done as often as possible when sitting. Standing for long periods of time is discouraged, while regular leg exercise and weight loss can be helpful. Compression stockings come in various strengths and lengths. The strength or tightness of the stockings ranges from 8mmHg to 50mmHg - the average varicose vein patient should use either 15-20mmHg or 20-30mmHg stockings. Knee-high stockings are the easiest to manage, while thigh-high, pantyhose, or leggings-style stockings provide coverage over the whole leg but are harder to get on and off.

Surgical treatment for varicose veins is considered medically indicated after at least a three-month trial of the above behavioral measures and when the patient is experiencing pain, swelling, or skin complications. The original surgical treatment for varicose veins and superficial venous reflux disease is either tying off the vein at the top of the thigh (ligation) or removal of the vein through two small incisions (vein stripping), which typically causes a lot of bruising. A less invasive way of getting the same functional result is with ablation of the refluxing vein; ablation refers to deliberately shrinking and scarring the affected vein closed. Once the abnormal vein is closed, blood is rerouted through other healthy veins, and the varicose veins should be more empty and flat because pressure build-up in the varicose veins and leg has been reduced. Current ablation techniques either rely on heat (i.e., generated by radiofrequency or laser energy) or non-heat-dependent processes (i.e., adhesive glue or a special chemical) to close the vein. The procedure usually takes 20-30 minutes. The risks of surgery are low (less than one to two percent) and include slow wound healing (especially if there also is leg swelling), minor skin infections or irritation, or clot in the superficial veins (thrombophlebitis). The risk of deep venous thrombosis (DVT) is less than one percent (similar to the risk of DVT if you had a cast on your leg).

An additional procedure that may be recommended to take care of large varicose vein bulges is called phlebectomy; this is done through small (2-3mm) incisions made over the painful varicose veins. The varicose veins are carefully plucked out from under the skin and cut out. This helps make the veins less easily seen and also reduces the chances of the veins getting inflamed (superficial thrombophlebitis). The operation takes 30 to 90 minutes, depending on the number of varicosities being targeted. Like the ablation procedure, it can be done in the office, at a surgery center, or in the hospital, depending on what is needed.

Post-Operative expectations

  • Compression wrap is applied to the leg to achieve stable vein closure and limit bruising. Once this is removed after 1-2 days, you should resume the use of support stockings.
  • Rapid recovery—most patients are walking immediately after the procedure (bedrest is not needed) and can be back to their normal routine within 24-48 hours and to work in 2-3 days.
  • Postoperative ultrasound is done within 3-5 days to confirm that the vein is closed and that there is no clot in the deep veins of the leg
  • Pain medication is only needed for a day or two after surgery. Acetaminophen or ibuprofen is generally strong enough for most patients. A feeling of fullness, bruising, or soreness over the treated area is typical; sharp pain is uncommon. Cool or warm compresses can help.
  • Tightness along the inner thigh, sometimes described as a “rubber band” or “cord,” is expected in the weeks or months following vein ablation due to scar tissue forming in and around the treated vein. This is a normal part of the healing process, and the tissue will gradually soften up with time. Gentle massage and stretching are encouraged. Many patients feel that it helps to rub arnica cream into the area.