Introduction to Varicose Veins

Varicose Veins The term describes a broad diverse group of conditions associated with enlarged malfunctioning veins. The normal function of a vein is to provide a one way return back to the heart for blood that has been delivered to the tissues by the arteries. The one way system is controlled by plentiful one way valves that only allow unidirectional flow. These valves are little flaps of tissue in the vein tube and can be easily damaged by clot, trauma, pressure and vein dilatation in addition to general ageing and deterioration of the tissues. There is a genetic factor, the familial association can be quite dramatic, this also shows in racial predilection as vein troubles are much more common in European as compared to Asian peoples. Classic Varicose Veins are the blue or purplish enlarged veins typically seen bulging out of the leg. The word "varicose" is derived from the Latin root word "varix," which is translated in English as "twisted" and this relates to the appearance of the large columns of affected trunk veins in the skin. The major deep veins can also become varicose with loss of valve function but they are not visible and can only be detected with techniques such as Duplex Ultrasound which can visualise the deep vessels and measure flow within. These deep incompetent veins can cause significant pressure problems in the lower leg and reflected into the superficial tissues can cause progressive tissue breakdown. There is no evidence that Varicose Veins are caused by standing other than through the pressure effects on potentially weak tissue.

"Popliteal Vein Compression Syndrome" when the knee is fully extended, can possibly provide higher pressures (not measured yet) however this mechanism also works when the leg is extended while sitting or lying down. Gravitational forces increase the pressure affecting the lower leg only when the vein is already varicose unless the individual remains still for prolonged periods. Normal valve function breaks the hydrostatic head into short segments a few cms long rather than the 150 cms plus that occurs when the whole of the long saphenous trunk or the deep veins are incompetentent. Once the valves give way the full hydrostatic pressure from the level of the heart is reflected in the ankle tissues in the upright position. This can lead to fluid and protein leak into the tissues and haemorrhage at the capillary level leaving brown haemosiderin in the skin. If the individual has "Popliteal Vein Compression Syndrome" (20+%) these pressure problems will progress if they are told to rest with the legs up; (the standard recommendation, with the knees extended). As this anatomical finding is so common, 20-25% of the European population, it is best to never spend a long time with the knees in extension whilst in a recumbent position.

The idea of resting with the knee up in extension to improve venous flow is completely wrong for a large proportion of the population. The Knees should be kept flexed slightly, relaxed, at ease at any time there is prolonged inactivity to prevent Popliteal Vein Occlusion.

When standing there is a special muscle developed to allow this, protected from fatiguing the TENSOR FASCIA LATA.

Gravity is the cause of the secondary pressure effects with varicose veins, swelling oedema eczema, ulceration and inflammation. We have observed these effects to occur also with patients immobilised sitting or lying down secondary to the "Popliteal Vein Compression Syndrome" with knee extension.

Pregnancy and Varicose Veins Some pregnant women complain of developing varicose veins. Pregnancy increases the pressure in the veins below the pelvis from an obstructive effect and there are also effects from the hormones produced to stop smooth muscle contraction. These work to allow full development before the birth but they but they also affect the gut, bladder and arteries in addition to the veins which as a result dilate more easily with pressure.

Often the veins recover a lot after pregnancy and this may take at least 6 months. If Varicose Veins start to develop in pregnancy it is worthwhile wearing good compression stockings, often day and night in the latter stages to limit pressure effects. You can get help at our clinic to be fitted with appropriate support.

Symptom Most people notice lumps, discoloration, puffiness or swelling, other symptoms of more significant problems are • Achiness or heavy feeling in one's legs; burning, throbbing, muscle cramping and swelling in the lower legs. • Itching around one or more of your veins in the legs. • Skin ulcers near your ankle, which represent a severe form of vascular disease and require immediate attention.

Ulcers Painful ulcers may form on the skin near varicose veins, particularly near the ankles. Increased pressure of blood within the affected veins which is a cause of the ulcers can cause "water logging"or diffuse oedema and pigmentation with fat necrosis and progressive tissue breakdown. Sometimes there is a brownish pigmentation and hardness of the skin with inflammation (Stasis Change) prior to developing the ulcer. It is important to see a physician immediately if you suspect you are developing an ulcer. In our experience the most common factors are total incompetence of the great saphenous vein or the Popliteal Vein Compression Syndrome orStasis Change related to past DVT with the development of Deep Varicose Veins.

Sudden Swelling of the Leg If you have considerable swelling in the leg (with the enlarging veins becoming tender or inflamed or tightness and discomfort generally) you must see a doctor immediately. Any sudden leg swelling requires urgent medical attention because it may indicate a blood clot —superficially a condition known as thrombophlebitis, in the deep veins more serious, deep vein thrombosis (DVT)

The Varicose Vein condition ranges from enlargement of small skin vessels that look unsightly but often are fed by deeper reticular or abnormal trunk veins to the main deep systems which can also present with malfunctioning valves, often secondary to past deep vein thrombosis (DVT) Management ranges from requiring no more than reassurance and observation, through support therapy with elasticized long sox and hosiery, medication to assist with secondary lymph accumulation, to destruction and ablation of the abnormal vessels. The reasons for destruction of the abnormal veins range from the cosmetic where injection sclerotherapy remains the standard treatment through to treatment of abnormal trunk veins for gravitational related pressure problems where surgery has been the standard and remains so for large complex situations.

In addition management with heat destruction applied with Laser catheters or RadioFrequency (RF) systems is being proven effective. Sclerotherapy in the trunk veins is not as effective but is a useful adjunct to these other procedures when the main vessels have been controlled. RadioFrequency Ablation is now the standard at my Centre for Control of Trunk Veins and Incompetent Perforator Veins. It has been proven to be safe, a little less likely to be asscociated with complications and as effective and durable as my past established use of standard surgery.

In addition to visible enlargement it is usually necessary to trace back through the venous system with Duplex Ultrasound to map the full extent of the abnormality. Often there are deeper abnormal veins which, if not treated, will result in brisk recurrence of the more obvious superficial problem. At present there is little that can be offered to treat the damaged deep central vein system which is why prevention of DVT should remain of high importance, and also early and effective management of DVT Clots occluding major vessels as there is a high incidence of long term pressure problems at the ankle if they do not resolve.

Treatment of trunk, collateral and reticular veins can be guided by the ultrasound findings.

A problem not yet generally discovered which has a very significant effect on varicose vein incompetent perforator occurrence, and is a factor in the generation of varicose veins below the knee is the” Popliteal Vein Compression Syndrome” a condition which occurs when the knee is in full extension and tension develops in the Gastrocnemius muscle bands across the Popliteal Vein, the central vein behind the knee, and occludes it. This condition is common and current guidelines for examination of the Popliteal Vein will fail to discover it. Our investigations demonstrate this is a major issue in venous problems in the lower limb and there is a full discussion on this website.

To have your problem accurately diagnosed and managed you need to find specialist care where ultrasound services are an integral part of the practice and the whole range of treatment modalities are available from the simplest sclerotherapy to complex surgery and endovascular treatment.