Varicose Veins

What causes varicose veins?

Varicose veins occur because of the pressure of blood in the veins is abnormally high. This usually happens because the veins of the legs have leaky valves.

There are two main systems of veins in the legs:

Deep veins: These are the main veins carrying blood from the legs back to the heart. The power for pumping the blood up to the heart comes from the leg muscles as we walk around and squeeze the veins in the leg.

Superficial veins are present under the skin and these are the ones which become large and form varicose veins.

All of these veins contain one-way valves to ensure that the blood flows towards the heart.

Failure of these valves allows blood to flow backwards down the veins and results in an overload of pressure when standing. This excess pressure leads to widening of the veins so that they do not close properly. Blood then flows back into the leg along these veins and causes varicose veins.

Raised pressure in these veins also encourages the development of spider veins and discoloured areas which look like bruises.

These valve abnormalities occur more often in some people than others. Varicose veins and spider veins often run in families and there may be a hereditary component.

Women are more likely to suffer from varicose veins, and up to 50% of women may be affected.

Hormonal factors including puberty, pregnancy, menopause, the use of birth control pills, and HRT affect the disease.

Pregnancy is very often associated with varicose veins. Part of the reason is the high level of hormones in pregnancy, and part is the effect of the large uterus pressing on the veins in the abdomen. Usually these varicose veins disappear after delivery, but some may persist and cause problems.

Many cases are due to age, jobs involving standing for long periods of time, and sometimes because of injury to the vessels.

What are the symptoms?

Very often there are no symptoms at all other than the visible veins.

Cosmetic effects of varicose veins may lead many patients to seek treatment.

Many others can have aching of legs, pain over the large veins, increased tiredness, itching or mild swelling of the legs. These symptoms are not medically serious, but can be treated if they are sufficiently troublesome.

More serious effects are seen in some and these require treatment. These include skin abnormality, with thickening and darkening of skin around the ankles and lower legs, as well as breakdown of skin to form wounds. This is a serious condition and needs treatment of the underlying venous disease.

In some cases, bleeding can occur from the varicose veins or ulcers, but is usually easily controlled by applying pressure on the bleeding point.

What tests are there to investigate varicose veins?

The basic aim of examination in varicose veins is to find out:

1. Which valves are leaky, and

2. What is the condition of the deep veins.

The treatment is entirely based on the answers to these questions.

The easiest way to answer these questions is by a Colour Doppler Ultrasound.

In a few cases, more information is needed after a colour Doppler, and in such cases a CT or an MRI may be necessary. Very rarely a Venogram is required with injection of contrast in to the leg veins. This is done on a special X-Ray machine and requires a needle puncture.

What treatment is available?

The treatment of varicose veins depends upon the problems the patient has and the reason for the varicose veins.

In mild cases without skin changes, swelling or bleeding, where there are no large leaky veins, use of Compression Stockings may be enough. These are stockings made for the purpose of treating veins and are available in different classes and sizes. The use of incorrectly made or wrongly sized stockings can make the treatment useless, so the right stockings must be used.

When the leaky veins are small, Sclerotherapy may be done. This involved injecting a drug into the abnormal vein and blocking it to take away the problems.

When the veins involved are large, they must be blocked at the correct level. This is now done with the use of Endovascular Ablation. This means blocking the abnormal veins in the groin or behind the knee form the inside. This can be done using Laser, RF energy or Glue. These procedures are done under local anaesthesia and may involve no admission or bed rest. Most patients can go home and carry on with normal activities.

Rarely patients have a blockage to a big deep vein which is responsible for the varicose veins. Such cases may require more extensive treatment, including opening of the blocked vein using a Stent.

What are the risks of treatment?

The treatments outlined are very safe and most patients find them easy to go through. The main risk of treatment is clotting of blood in the deep veins (DVT, Deep Vein Thrombosis). Fortunately the risk of this is low, and even lower with treatments that allow patients to walk immediately after treatment.

Other risks with Laser and Radio frequency ablation are there, and include skin burns as well as nerve injury. These are very rare and usually heal well, not requiring any surgery or prolonged therapy.

Glue ablation is very safe. The rare complication of this is allergy to the glue, like there can be allergy to any medication. This is usually easily treated with drugs and goes away in weeks.