Venous Circulation

Varicose veins are permanently enlarged veins located beneath the skin that have dilated and become tortuous in response to abnormally high venous pressures seen in venous insufficiency. They are typically blue or purple, measure 3-8 mm in diameter, and have a twisted, ropy appearance. They affect an estimated 10% to 60% of the adult population. Varicose veins are not really the problem in themselves, but more a symptom of the underlying venous insufficiency.

To think of varicose veins as the main problem when you have them is sort of like thinking that the problem with getting the measles is only the spots. The spots are an indication that there is an underlying viral infection. If you want to cure the spots, you have to treat the virus. Treating the spots alone is pointless.

The biggest contributing factor in the development of varicose veins is heredity or family history. The risk of developing varicose veins is >90% when both parents have varicose veins, 25% for males and 62% for females if one parent is affected, and 20% when neither parent is affected. Other risk factors include prolonged standing or sitting, pregnancy, hormonal influences, and local trauma. The incidence increases with age.

Varicose veins are irreversibly damaged and are not assisting in blood circulation (in fact they actually impair blood return to the heart). The body will not miss them when they are removed, and they are not suitable for use during heart bypass procedures.

The good news is that varicose veins are generally not a life-threatening or limb-threatening condition. The bad news is that their symptoms will tend to bother you more and more on a daily basis (leg tiredness, heaviness, aching, throbbing, tingling, burning, itching, numbness, swelling, restless legs syndrome, etc.) Whether you should have your veins treated depends upon several things including how severe your venous disease is, how quickly it is progressing, what sorts of other health conditions you have, etc. This decision is best made during consultation, as all the variables can be evaluated and discussed.

Venous insufficiency is usually an “insidiously progressive condition”. This means that they are a little worse this year than they were last year, and will be a little worse next year than they are now. In five or ten years, they will be a much larger problem. Because untreated venous insufficiency tends to progress over time, the appearance continues to deteriorate. You can expect worsening symptoms including leg tiredness, heaviness, aching, throbbing, tingling, burning, itching, numbness, swelling, restless legs syndrome, etc. More serious complications such as dermatitis, phlebitis, blood clots, hemorrhage, and non-healing venous leg ulcers can occur if symptomatic veins are left untreated too long.

When venous insufficiency or varicose veins are left untreated, the high venous pressures cause progressive edema and inflammation in the legs and ankles. This inflammation eventually results in a condition called lipodermatosclerosis, or fibrosis in the skin and subcutaneous tissues. If the veins are still not treated, the skin actually breaks down, forming an open sore or ulcer. Venous ulcers are dreadfully painful and can be open for years at a time. They are difficult or impossible to heal using conventional measures. They usually occur in the ankle or lower leg and can range from dime-size to completely encircling the leg. Venous ulcers affect 4% of people over the age of 65. It is impossible to predict which patients will develop ulcers or how long it will take for them to heal.

Pregnancy does not cause varicose veins in the legs, but each pregnancy makes existing vein problems a great deal worse. If pregnancy did cause leg varicose veins they would be much more common in women than in men. Extensive population studies (including the Edinburgh Vein Study published in 1999) have proven this is not the case.

Elevated hormonal levels, expanding circulating blood volume, and the enlarged uterus all combine to exacerbate any existing venous insufficiency – the underlying cause of varicose veins. This severe venous hypertension creates a state in which new veins are recruited and existing varicose veins become larger and more symptomatic.

The leg pain and edema from these engorged veins tend to make pregnancy terribly uncomfortable. If the source of the venous insufficiency and existing varicose veins are eliminated before the first or any subsequent pregnancy, less damage will have been done to previously normal veins and to surrounding tissues. Treatment of mild disease is more straightforward, leading to shorter operative cases and quicker recovery.

If you are currently pregnant or trying to become pregnant, operative treatment cannot be performed. Wearing compression stockings and elevating your legs are you only options. We therefore recommend varicose veins be treated before becoming pregnant.

Many women develop vulvar or vaginal varices during pregnancy. These can be very painful during pregnancy. They usually diminish after delivery, but can cause pelvic pain during menses, during or after intercourse (dyspareunia), or with prolonged standing for years afterward. These veins originate in the pelvis from refluxing ovarian veins and often contribute to varicose veins in the legs. If you seek treatment for leg veins following pregnancy, tell your physician or ultrasonographer that you had vulvar varices. These can be treated, but may require embolization of the offending ovarian vein.

Effectively treated varicose veins do not come back. The predisposition to form varicose veins cannot be cured, however. Over time, patients may develop new varicose veins in the same or in other areas. Because we treat the “source” of these veins the progression is greatly slowed. New veins that form tend to be less severe and are more easily dealt with. Usually a “touch-up” treatment to remove new veins will be needed periodically.

Because a genetic predisposition is the biggest risk factor for the development of varicose veins, the can appear at any age. Other risk factors such as age, pregnancy, physical trauma, prolonged standing or sitting at work, etc. do increase the incidence of varicose veins over time. We frequently see and treat patients as young as teenagers and as old as the 80’s or even 90’s. Older patients are usually treated for advanced disease that has been neglected for many years such as bleeding varicose veins or venous leg ulcers.

Varicose veins are not very attractive. Vanity, however, is usually only a minor reason people seek treatment. The major reason people seek treatment is usually because they are tired of the aching, pain, burning, tiredness, heaviness, itching, Restless Legs Syndrome sensations, night cramps, edema, eczema, hyperpigmentation, venous leg ulcers, and bleeding…

We frequently have patients come to our office who have had stripping done in the past. Despite the rather severe morbidity, vein stripping fails to relieve the patients’ venous reflux 50-65% of the time. Varicose vein recurrence is quite common after stripping. Vein stripping has earned a bad reputation, and justifiably so. Fortunately, these operations are largely of historical interest only; and have been replaced by recently developed minimally-invasive procedures including the radiofrequency “closure” procedure and endovenous laser ablation. Vein stripping is now utilized only rarely when endovenous radiofrequency and laser techniques are impossible.

When varicose veins return after a stripping procedure, they are quite a mess. Effective treatment is more complex, but routinely accomplished. Careful evaluation of the “new” varicose veins with duplex ultrasound is critical. Treatment is performed with the same techniques – endovenous thermal ablation, sclerotherapy, phlebectomy, etc. Good results are expected.

While the deep venous system can develop venous insufficiency (reflux), the deep veins are supported by the leg muscles and bones and never become “varicose.” The superficial system lacks this support system and is consequently prone to varicose vein formation.

Heart disease and venous disease are not related. The causes of venous disease (hereditary predisposition to venous disease, prolonged standing, pregnancy, hormonal influences, local trauma, etc.) are completely different than those related to heart disease (hereditary predisposition to heart disease, elevated cholesterol, smoking, high blood pressure, diabetes, stress, etc.). Weak vein valves do not increase the likelihood of heart valves to fail.

Poor circulation is a rather vague term that includes arterial problems and venous problems. Arterial disease leads to reduced flow of the blood carrying oxygen and nutrients down the leg to the tissues. Venous disease causes poor flow of blood carrying cellular waste back up the leg to the heart. The severe lack of arterial blood bringing oxygen and nutrients can cause tissue death, which can lead to amputation. Poor venous flow does not pose this risk.

Enlarged veins on the back of the hands and feet are quite normal. They are visible only because the overlying skin is thin, and there is very little subcutaneous fat in these areas. They are typically more prominent in slender people. Treatment is generally not indicated in these cases.

Endovenous Laser Ablation with the CTEV laser is approximately 98% effective in treating refluxing veins. There is therefore an approximately 2% chance that a treated vein will “recannulate” or come back, requiring additional treatment. This is easily identified with a postoperative duplex examination and re-treated.

As mentioned above, the biggest risk factor for developing refluxing or varicose veins is genetic predisposition. There is no way to change your genetic makeup. This means that you may or may not develop new venous disease at some point in the future. If new venous reflux develops over time, it can be easily treated.

Historical vein treatments such as vein stripping were extremely painful, left disfiguring scars, and were only minimally effective. The cure was definitely worse than the disease. Current techniques have fortunately revolutionized the treatment of venous disease.

Vein stripping was introduced by Dr. William Keller in 1905 and has changed little in the last 100 years. Numerous studies of vein stripping have confirmed it to be only about 35-50% effective – certainly not very good odds. In addition, varicose vein surgery has historically been carried out by non-specialist consultants or relegated to junior staff (residents) to perform the procedure. As such, many surgeons have little interest in keeping up to date with the latest techniques. Many are even still using Dr. Keller’s stripping procedure.

Endovenous thermal ablation (endovenous radiofrequency and endovenous laser) bears little resemblance to its historical predecessor. Radiofrequency ablation was FDA approved in 1999, and endovenous laser ablation was FDA approved in 2002. The Cool-Touch Endovenous Laser (CTEV) was FDA approved in 2004 – 99 years after Dr. Keller introduced vein stripping.

A lot has changed over the last 99 years. The minimally invasive endovenous laser procedures are 95-98% effective in treating the refluxing veins (200%-300% better than the stripping procedures they replaced). The new endovenous ablation procedures are also much less painful than vein stripping. Patients were typically off work 6-8 weeks after a stripping procedure. Our patients usually go back to work in 3-4 days. Many patients do not even require the prescribed Darvocet.

Unfortunately, many doctors and nurses still advise patients not have their veins treated. This is because effective treatment of venous disease has only been available for a short time, and many health care professionals are unaware of the latest developments. We welcome phone calls from your healthcare providers with questions or concerns, so we can explain the difference in the treatment options that we offer and those options available when they were in training.