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Are your leg veins ready for summer?

Source: Harvard Medical School; Published: February, 2006



Treating enlarged leg veins can improve their appearance and reduce the risk of aching, swelling, and more serious problems.

Beach weather may be months away, but if bulging and discolored leg veins make you dread wearing a bathing suit or shorts, winter may be a good time to seek medical help. It's not just a cosmetic consideration: Treating enlarged leg veins can also relieve discomfort and prevent medical complications. A range of nonsurgical and minimally invasive treatments is now available, but to see the full benefits usually takes several weeks or months.


Enlarged leg veins

Veins are responsible for carrying oxygen-depleted blood back to the heart, where it is passed on to the lungs to take up oxygen before being distributed to the rest of the body. The leg veins have the toughest job because they must propel blood a long distance against gravity and the pressure of body weight. To help, they have one-way valves that prevent the blood from flowing backward. When these valves malfunction, blood can leak back down, collect, and swell the veins.


There are two kinds of enlarged veins: varicose veins and spider veins (in medical parlance, telangiectasias). Varicose veins are larger, appear dark blue or purple, and bulge above the skin's surface, often in a twisting pattern. Spider veins are smaller, look like red or blue spider webs, lie close to the surface of the skin, and don't bulge or cause discomfort.


Blood near the leg's surface flows through superficial veins into connector veins before reaching the larger deep veins that are located in muscle tissue. The largest and longest superficial vein is the greater saphenous vein, which extends from the inside of the ankle to the groin. When valves fail along this vein or at the junctions where it meets other veins, blood pools or backs into its branches, causing varicose veins.


Anatomy of a varicose vein


Varicose veins occur mostly in superficial leg veins, the largest of which is the greater saphenous vein. Normally, blood is moved toward the heart by one-way valves, which prevent blood from flowing backward. In a varicose vein, the valves don't close properly, allowing the blood to pool and enlarge the vein.


Why me?

Varicose and spider veins are very common. More than 40% of women over age 50 have them. The causes include:

Heredity. The tendency to develop varicose veins, particularly at a young age, seems to run in families. Some women may simply be born with fewer connector veins, less functional valves, or weaker blood vessel walls.

Prolonged standing. A study of Danish workers published in December 2005 found that women who spend more than 75% of their time on the job standing or walking are almost twice as likely to be treated for varicose veins than women who spend fewer working hours on their feet. The researchers estimate that prolonged standing at work is responsible for more than 20% of varicose vein cases in working-age adults.

Age. The risk of varicose veins rises with age. Blood vessels weaken over time, and so do calf muscles, which help squeeze veins and send blood back toward the heart as we walk. Fewer than 10% of women under age 30 and more than 75% of women over age 70 have enlarged leg veins.

Gender. Women are more likely than men are to have varicose veins, and pregnancy may be the main reason. During pregnancy, the leg veins are subject to more wear and tear, because blood volume and abdominal pressure increase, while hormones cause blood vessels to dilate. The more full-term pregnancies a woman has, the greater her risk for varicose veins.

Weight. Excess weight, particularly around the abdomen, puts added pressure on leg veins. Moderately overweight women are more likely to have varicose veins than lean women, and obese women are at three times the risk. In studies on men, a relationship with weight is less consistent.


Symptoms

Spider veins are mainly a cosmetic issue, but varicose veins can cause many other symptoms besides their characteristic ropy appearance. If you have varicose veins, you may feel a dull ache, heaviness, burning, pressure, or weakness in your legs, particularly after prolonged standing or sitting. You can usually relieve this discomfort by elevating your legs. At night you may develop a painful muscle spasm in your calf (a charley horse). Your feet and ankles may swell, and the skin around the varicose veins may itch, become dry, or develop a rash or a brownish or bluish discoloration.


Larger varicose veins don't necessarily mean more serious symptoms. In fact, some people notice symptoms long before they can see any change in their veins. If troublesome varicose veins are left untreated, they are likely to get worse, sometimes causing complications such as skin ulcers, a ruptured vein, or thrombophlebitis—vein inflammation associated with a blood clot (though not the same as life-threatening blood clots that can develop in deep veins).


Evaluating abnormal veins

A clinician will ask about symptoms and examine the veins and skin surrounding them. To check for reverse blood flow, she or he may briefly block circulation to the vein (using a tourniquet, blood pressure cuff, or hand) and watch what happens when it is released.

To visualize superficial veins and their valves, your clinician may take a handheld Doppler ultrasound, similar to the one used in pregnancy, and rub it over the surface of the leg. Duplex ultrasound provides further information; it includes a second ultrasound type, called B-mode, that allows your clinician to see how fast, how consistently, and which way the blood is flowing. This procedure can identify the place where blood starts to move backward (reflux) and confirm that deep vein circulation is adequate. Insurance companies require ultrasound studies before they will pay for most vein treatments.


Self-care strategies

Unless symptoms are present, enlarged leg veins do not need any treatment. In many other cases, self-care techniques are sufficient to reduce the pressure in leg veins, encourage proper blood flow, and avoid or delay the need for stronger measures:

Put your feet up. Several times a day, take a 15-minute rest with your legs elevated above the level of your heart so that your veins don't have to work against gravity.

Change leg activity. If you sit or stand for long periods, take frequent brisk walking breaks. Keep your calf muscles strong with physical activities such as brisk walking and resistance training.

Take a pain reliever. Acetaminophen, aspirin, or ibuprofen may relieve mild occasional aching from varicose veins.

Wear compression stockings. Elastic stockings put pressure on leg veins and prevent blood from flowing backward. If symptoms are mild, regular support stockings may suffice. If symptoms are more severe, your doctor will prescribe a graduated compression stocking that applies decreasing pressure from the ankles to the thighs. The stockings should be put on before you get out of bed in the morning. Unless you have already developed certain complications, your insurance company will probably require you to try compression stockings for several months before they authorize more invasive treatment.

Loosen up. Avoid wearing any tight clothing around the waist or legs.


Minimally invasive treatments

You may want to remove or fade varicose veins just because of their appearance. But more aggressive treatment is considered medically necessary only when self-care doesn't relieve symptoms enough for you to carry on normal activities—or when varicose veins have ruptured or caused difficult-to-treat sores or repeated superficial thrombophlebitis.

Several minimally invasive treatments for spider and varicose veins have been developed since 1990. The physician in your community who's most knowledgeable about them may be a dermatologist, interventional radiologist, plastic surgeon, or vascular surgeon. Vein treatment centers may also be available in your area.


Injection therapy (sclerotherapy). This is the most common treatment for spider veins. During an office visit, the physician injects small amounts of an irritating chemical into the vein, causing the lining of its walls to swell and stick together, sealing the vein permanently. Several injections are given during each visit until all the veins have been treated. After each session, you must wear compression stockings for a week or two to keep the vessel closed and minimize bruising and tenderness. Possible complications are allergic reactions to the irritant chemical, stinging or burning at the site of injection, swelling, and skin injury. Once blood is no longer flowing through the vein, scar tissue develops and the vein gradually fades. Brown lines may develop in the treated area, but these usually fade.


Quick fixes: Don't waste your money

So-called varicose vein "cures" are easy to order on the Internet, but beware of unproven claims. Here are a couple of examples:


Creams containing vitamin K. Vitamin K, a nutrient essential for normal blood clotting, is being promoted as a home remedy that purportedly cures varicose veins by repairing holes in leaky blood vessels. But varicose and spider veins aren't caused by leaky blood vessels. The vessels dilate when blood pools in them, but nothing leaks out. Moreover, vitamin K levels aren't abnormally low in women with varicose veins. However, vitamin K cream can help reduce bruising after laser treatment of spider veins.


Herbal supplements. Some companies sell pricey herbal supplements that are supposed to cure varicose veins from the inside out. In March 2005, the FDA warned one company to stop advertising that its supplement, Veinocal, would make 94.6% of varicose veins disappear like magic in days. According to the FDA's warning letter, the company has provided no documentation that the pills are safe or effective. One of the ingredients in Veinocal is horse chestnut seed extract, which has been shown to reduce leg swelling and pain in people who have a condition called chronic venous insufficiency.


Sclerotherapy is generally used only for spider veins or very small varicose veins. The American Academy of Dermatology estimates that most sclerotherapy patients can expect a 50%–90% improvement in spider veins. But new ones can appear in the same area.


Laser for spider veins. Spider veins can also be treated by passing a laser over the surface of the skin. Bursts of laser light shrink the veins, while ice and a topical anesthetic help protect the skin and reduce pain. Laser therapy usually requires two to three treatments in a physician's office and is suitable only for very fine veins. There may be some temporary redness or swelling after the procedure. Like sclerotherapy, laser treatment doesn't prevent new spider veins from appearing near the treated ones.


Laser for varicose veins. Laser energy is delivered to the inside of the vein by a procedure called endovenous laser therapy (EVLT). Guided by ultrasound, the physician punctures the vein and inserts a guide wire to the point where blood begins flowing backward. Then a laser fiber is inserted, and the laser is fired to heat the vein from the inside. The resulting inflammation makes the walls of the vein stick together, eventually forming scar tissue. It takes about three minutes to treat nearly 16 inches of vein this way under local anesthesia in a physician's office.

You can quickly return to normal activities, though you must wear compression stockings for several days. Symptoms may improve in a week or two because of reduced pressure in the vein, but changes in appearance take longer. Two or three months later, the physician will re-examine your legs to see which varicose veins are gone.


"When you dam up the source of the flow in the saphenous vein, varicose veins branching off it will progressively shrink because they're no longer under pressure," explains Dr. Bertrand Janne d'Othee, interventional radiologist at Beth Israel-Deaconess Medical Center in Boston. With the abnormal blood flow cut off, remaining varicose veins can be treated with sclerotherapy (if small) or removed by phlebectomy (see "Surgery," below) if larger.


EVLT has some risks. It produces numb areas near the knees or ankles in about 5% of patients (though feeling almost always returns within a year). In about 7% of cases, the varicose veins reopen within two years. If you are considering EVLT, look for a physician who has experience in performing such procedures under ultrasound guidance. The specific type of laser needn't be a factor in your decision—several are FDA-approved. But ultrasound is necessary to ensure that after the superficial veins are sealed, deeper veins will be able to handle blood flow back to the heart.


"If your deep veins are obstructed, you need your superficial veins to compensate," Dr. d'Othee explains, "just as you need to keep the exit ramps open on a restricted highway so the traffic—in this case the blood flow—can detour onto small parallel roads." The laser fiber is flexible, but it can't be used on stretches of vein with many twists and turns.


Endoluminal radiofrequency thermal heating (VNUS closure procedure). This technique allows physicians to heat the interior of varicose veins with radiofrequency waves instead of lasers. Like EVLT, it can be performed in a physician's office under local anesthesia, but it takes longer, about 20 minutes. Afterward, there may be swelling and pain, and the recurrence rate is about 10%.


Common fears about varicose veins

Fear

Reality

A blood clot will lodge in my lungs.

Pulmonary embolisms come from deeper blood vessels, not the superficial ones that produce varicose and spider veins.

If I get treated, I won't have a vein to use if I ever need bypass surgery.

Twisted and malfunctioning varicose veins aren't suitable for bypass.

If I'm treated to close a varicose vein, my blood will have nowhere to go.

Blood will flow through the deeper leg veins. Keep in mind that the varicose vein was already working poorly.


Surgery

In the 1980s, the only treatment for varicose veins causing serious symptoms was surgery to remove the greater saphenous vein. This procedure, usually called vein stripping, is performed under general anesthesia. Incisions are made at the calf and thigh ends of the varicose vein, the top end is tied off, and a wire is inserted to strip out the vein. You must wear compression bandages or stockings for a few weeks.


With the proliferation of minimally invasive treatments, open surgery for varicose veins is no longer the standard of care in most situations. If your doctor recommends surgical removal, get a second opinion from a physician experienced in treating varicose veins and familiar with a wide range of options.


Ambulatory phlebectomy is a less invasive procedure that can be performed under local anesthesia. Small incisions are made along the length of an abnormal vein and it is pulled out piece by piece. Ambulatory phlebectomy can be used to remove most large varicose veins, but not the upper end of the greater saphenous vein. It may be recommended for removing varicose veins that remain after minimally invasive techniques have closed the saphenous vein.


There are few controlled head-to-head comparisons between surgery and minimally invasive treatments, but prospective studies suggest that the various approaches are equally effective up to two years after treatment. In a British study published in August 2005, patients with varicose saphenous veins on both legs received traditional surgery on one leg and VNUS on the other. Both approaches succeeded, but VNUS was quicker and caused less pain and bruising.