Varicose veins: Wikis

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Varicose veins
Classification and external resources

A person affected by varicose veins.
ICD-10 I83., I84., I85., I86.
ICD-9 454-456, 671
OMIM 192200
DiseasesDB 13734
MedlinePlus 001109
eMedicine med/2788
MeSH D014648

Varicose veins are veins that have become enlarged and tortuous. The term commonly refers to the veins on the leg,[1] although varicose veins can occur elsewhere. Veins have leaflet valves to prevent blood from flowing backwards (retrograde). Leg muscles pump the veins to return blood to the heart, against the effects of gravity. When veins become varicose, the leaflets of the valves no longer meet properly, and the valves don't work. This allows blood to flow backwards and they enlarge even more. Varicose veins are most common in the superficial veins of the legs, which are subject to high pressure when standing. Besides cosmetic problems, varicose veins are often painful, especially when standing or walking. They often itch, and scratching them can cause ulcers. Serious complications are rare. Non-surgical treatments include sclerotherapy, elastic stockings, elevating the legs, and exercise. The traditional surgical treatment has been vein stripping to remove the affected veins. Newer, less invasive treatments, such as ultrasound-guided foam sclerotherapy, radiofrequency ablation and endovenous laser treatment, are slowly replacing traditional surgical treatments. Because most of the blood in the legs is returned by the deep veins, the superficial veins, which return only about 10 per cent of the total blood of the legs, can usually be removed or ablated without serious harm.[2][3] Varicose veins are distinguished from reticular veins (blue veins) and telangiectasias (spider veins), which also involve valvular insufficiency,[4] by the size and location of the veins. Many patients who suffer with varicose veins seek out the assistance of physicians who specialize in vein care. These physicians are called phlebologists.

Contents

Symptoms

  • Aching, heavy legs (often worse at night and after exercise).
  • Appearance of spider veins (telangiectasia) in the affected leg.
  • Ankle swelling.
  • A brownish-blue shiny skin discoloration near the affected veins.
  • Redness, dryness, and itchiness of areas of skin - termed stasis dermatitis or venous eczema, because of waste products building up in the leg.
  • Cramps may develop especially when making a sudden move as standing up.
  • Minor injuries to the area may bleed more than normal and/or take a long time to heal.
  • In some people the skin above the ankle may shrink (lipodermatosclerosis) because the fat underneath the skin becomes hard.
  • Restless legs syndrome appears to be a common overlapping clinical syndrome in patients with varicose veins and other chronic venous insufficiency.
  • Whitened, irregular scar-like patches can appear at the ankles. This is known as atrophie blanche.

Stages

  • C0 no visible or palpable signs of venous disease
  • C1 telangectasia or reticular veins
  • C2 varicose veins
  • C3 edema
  • C4a skin changes due to venous disorders: pigmentation, eczema
  • C4b skin changes due to venous disorders: lipodermatosclerosis, atrophie blanche
  • C5 as C4 but with healed ulcers
  • C6 skin changes with active ulcers

Complications

Most varicose veins are relatively benign, but severe varicosities can lead to major complications, due to the poor circulation through the affected limb.

  • Pain, heaviness, inability to walk or stand for long hours thus hindering work
  • Skin conditions / Dermatitis which could predispose skin loss
  • Skin ulcers especially near the ankle, usually referred to as venous ulcers.
  • Development of carcinoma or sarcoma in longstanding venous ulcers. There have been over 100 reported cases of malignant transformation and the rate is reported as 0.4% to 1%.[5]
  • Severe bleeding from minor trauma, of particular concern in the elderly.
  • Blood clotting within affected veins. Termed superficial thrombophlebitis. These are frequently isolated to the superficial veins, but can extend into deep veins becoming a more serious problem.
  • Acute fat necrosis can occur, especially at the ankle of overweight patients with varicose veins. Females are more frequently affected than males.

Causes

The illustration shows how a varicose vein forms in a leg. Figure A shows a normal vein with a working valve and normal blood flow. Figure B shows a varicose vein with a deformed valve, abnormal blood flow, and thin, stretched walls. The middle image shows where varicose veins might appear in a leg.

Varicose veins are more common in women than in men, and are linked with heredity[6]. Other related factors are pregnancy, obesity, menopause, aging, prolonged standing, leg injury and abdominal straining. Less commonly, but not exceptionally, varicose veins can be due to other causes, as post phlebitic obstruction and/or incontinence, venous and arteriovenous malformations[7] See also for differential diagnosis- 1. Klippel-Trenaunay syndrome, 2. Parker-Weber syndrome

Conservative treatment

The symptoms of varicose veins can be controlled to an extent with the following:

  • Elevating the legs often provides temporary symptomatic relief.
  • "Advice about regular exercise sounds sensible but is not supported by any evidence."[8]
  • The wearing of graduated compression stockings with variable pressure gradients (Class I, II or III) has been shown to correct the swelling, nutritional exchange, and improve the microcirculation in legs affected by varicose veins.[9] They also often provide relief from the discomfort associated with this disease. Caution should be exercised in their use in patients with concurrent arterial disease.
  • Diosmin/Hesperidine and other flavonoids.
  • anti-inflammatory medication such as ibuprofen or aspirin can be used as part of treatment for superficial thrombophlebitis along with graduated compression hosiery – but there is a risk of intestinal bleeding. In extensive superficial thrombophlebitis, consideration should be given to anti-coagulation, thrombectomy or sclerotherapy of the involved vein.

Interventional treatment

Active medical intervention in varicose veins can be divided into surgical and non-surgical treatments. Some doctors favor traditional open surgery, while others prefer the newer methods. Newer methods for treating varicose veins such as Endovenous Thermal Ablation (endovenous laser treatment or radiofrequency ablation), and foam sclerotherapy are not as well studied, especially in the longer term.[10][11]

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Surgical treatment

Several techniques have been performed for over a century, from the more invasive saphenous stripping, to less invasive procedures like ambulatory phlectomy and CHIVA.

Stripping

Stripping consists of removal of all or part the saphenous vein main trunk. The complications include deep vein thrombosis (5.3%),[12] pulmonary embolism (0.06%), and wound complications including infection (2.2%). For traditional surgery, reported recurrence rates, which have been tracked for 10 years, range from 5-60%. In addition, since stripping removes the saphenous main trunks, they are no longer available for venous bypass in the future (coronary and/or leg artery vital disease)[13]

CHIVA

CHIVA is an acronym from the scientific paper "Conservatrice et Hémodynamique de l'Insuffisance Veineuse en Ambulatoire"[14] published in France in 1988. CHIVA relies on an hemodynamic impairment assessed by data and evidences depicted through ultrasound dynamic venous investigations. According to this new concept, the clinical symptoms of venous insufficiency are not the cause but the consequence of various abnormalities of the venous system. For example, a varicose vein being overloaded, may be dilated not only because of valvular incompetence (the most frequent) but because of a venous block (thombosis) or arterio-venous fistulae and so the treatment has to be tailored according the hemodynamic features. It generally consists in 1 to 4 small incisions under local anaesthesia in order to disconnect the varicose veins from the abnormal flow due to valvular incompetence which dilates them.[15] The patient is dismissed the same day. This method leads to an improvement of the venous function[citation needed] in order to:

  • Cure the symptoms of venous insufficiency as varicose veins, legs swelling, ulcers.[16][17]
  • Prevent varicose recurrence due to progressive enlargement of collateral veins which replace and overtake the destroyed veins: CHIVA vs Stripping: varicose recurrence divided by 2 to 5 at 10 years.[18]
  • Preserve the superficial venous capital for unpredictable but possible need for coronary or leg artery vital by-pass which increases with ageing.

Lurie[19] in his analysis of Chiva states that "CHIVA definitely falls into a research category and should be continued as such until sufficient evidence of its validity is generated".Unfortunately at this stage, the best available publication of CHIVA outcomes that meets current methodological standards[19] is a study by Carandina et al.[18] where a long term (10 years) randomized trial CHIVA vs stripping restricted to Shunt I varicose configurations ( 30-35% of the varicose confogurations) . That is the reason why the authors estimate that only 30-35% of patients with varicose veins can be treated with CHIVA despite there being some bias in the selection of patients favoring CHIVA.[19]. This study showed that there were recurrent varices in 18% of cases treated by CHIVA vs 38% treated by Stripping which is so far the gold standard treatment of varicose veins.

Other

Other surgical treatments are:

•Cryosurgery- A cryoprobe is passed down the long saphenous vein following saphenofemoral ligation. Then the probe is cooled with NO2 or CO2 to a temperature of -850. The vein freezes to the probe and can be retrogradely stripped after 5 sec of freezing.It is a variant of Strippling. The only point of this technique is to avoid a distal incision to remove the stripper.(36)

Non-surgical treatment

Sclerotherapy

A commonly performed non-surgical treatment for varicose and "spider" leg veins is sclerotherapy in which medicine is injected into the veins to make them shrink. The medicines which are commonly used as sclerosants are as follows- Polidocanol 3% or Na-tetradecyl-SO4 liquids are mixed forcibly with air, CO2 or O2 to create foams. It has been used in the treatment of varicose veins for over 150 years.[20] Sclerotherapy is often used for telangiectasias (spider veins) and varicose veins that persist or recur after vein stripping.[21][22] Sclerotherapy can also be performed using foamed sclerosants under ultrasound guidance to treat larger varicose veins, including the great and short saphenous veins.[23][24] A study by Kanter and Thibault in 1996 reported a 76% success rate at 24 months in treating saphenofemoral junction and great saphenous vein incompetence with STS 3% solution.[25] A Cochrane Collaboration review[26] concluded sclerotherapy was better than surgery in the short term (1 year) for its treatment success, complication rate and cost, but surgery was better after 5 years, although the research is weak.[27] A Health Technology Assessment found that sclerotherapy provided less benefit than surgery, but is likely to provide a small benefit in varicose veins without reflux.[28] This Health Technology Assessment monograph includes reviews of the epidemiology, assessment, and treatment of varicose veins, as well as a study on clinical and cost effectiveness of surgery and sclerotherapy. Complications of sclerotherapy are rare but can include blood clots and ulceration. Anaphylactic reactions are "extraordinarily rare but can be life-threatening," and doctors should have resuscitation equipment ready.[29][30] There has been one reported case of stroke after ultrasound guided sclerotherapy when an unusually large dose of sclerosant foam was injected.

Endovenous thermal ablation

The Australian Medical Services Advisory Committee (MSAC) in 2008 has determined that endovenous laser ablation (ELA) for varicose veins "appears to be more effective in the short term, and at least as effective overall, as the comparative procedure of junction ligation and vein stripping for the treatment of varicose veins."[31] It also found in its assessment of available literature, that "occurrence rates of more severe complications such as DVT, nerve injury and paraesthesia, post-operative infections and haematomas, appears to be greater after ligation and stripping than after EVLT". Complications for ELA include minor skin burns (0.4%)[32] and temporary paraesthesia (2.1%). The longest study of endovenous laser ablation is 39 months.

Two prospective randomized trials found speedier recovery and fewer complications after radiofrequency ablation (ERA) compared to open surgery[33][34]. Myers[35] wrote that open surgery for small saphenous vein reflux is obsolete. Myers said these veins should be treated with endovenous techniques, citing high recurrence rates after surgical management, and risk of nerve damage up to 15%. In comparison, ERA has been shown to control 80% of cases of small saphenous vein reflux at 4 years, said Myers. Complications for ERA include burns, paraesthesia, clinical phlebitis, and slightly higher rates of deep vein thrombosis (0.57%) and pulmonary embolism (0.17%).One 3-year study compared ERA, with a recurrence rate of 33%, to open surgery, which had a recurrence rate of 23%.

ELA and ERA require specialized training for doctors and expensive equipment. ELA is performed as an outpatient procedure and does not require the use of an operating theatre, nor does the patient need a general anaesthetic. Doctors must use ultrasound during the procedure to see what they are doing. Some practitioners also perform phlebectomy or ultrasound guided sclerotherapy at the time of endovenous treatment. Follow-up treatment to smaller branch varicose veins is often needed in the weeks after the initial procedure.

References

  1. ^ Varicose veins Mount Sinai Hospital, New York (external reference link broken)
  2. ^ Merck Manual Home Edition, 2nd ed.
  3. ^ NHS Direct
  4. ^ Weiss RA, Weiss MA (October 1993). "Doppler ultrasound findings in reticular veins of the thigh subdermic lateral venous system and implications for sclerotherapy". J Dermatol Surg Oncol 19 (10): 947–51. PMID 8408914. http://openurl.ebscohost.com/linksvc/linking.aspx?genre=article&sid=PubMed&issn=0148-0812&title=J%20Dermatol%20Surg%20Oncol&volume=19&issue=10&spage=947&atitle=Doppler%20ultrasound%20findings%20in%20reticular%20veins%20of%20the%20thigh%20subdermic%20lateral%20venous%20system%20and%20implications%20for%20sclerotherapy.&aulast=Weiss&date=1993. 
  5. ^ Goldman M. Sclerotherapy, Treatment of Varicose and Telangiectatic Leg Veins. Hardcover Text, 2nd Ed, 1995
  6. ^ Ng M, Andrew T, Spector T, Jeffery S (2005). "Linkage to the FOXC2 region of chromosome 16 for varicose veins in otherwise healthy, unselected sibling pairs.". J Med Genet 42 (3): 235–9. doi:10.1136/jmg.2004.024075. PMID 15744037. 
  7. ^ Claude Franceschi Physiopathologie Hémodynamique de l'Insuffisance veineuse in Chirurgie des veines des Membres Inférieurs, page 49, 1996, AERCV editions 23 rue Royale 75008 Paris France. Varicose veins could also be caused by elevated levels of homocysteine in the body can degrade and inhibit the formation of the three main structural components of the artery, collagen, elastin and the proteoglycans. Homocysteine permanently degrades cysteine disulfide bridges and lysine amino acid residues in proteins, gradually affecting function and structure. Simply put, homocysteine is a 'corrosive' of long-living proteins, i.e. collagen or elastin, or life-long proteins, i.e. fibrillin. These long-term effects are difficult to establish in clinical trials focusing on groups with existing artery decline.
  8. ^ Campbell B (August 2006). "Varicose veins and their management". BMJ 333 (7562): 287–92. doi:10.1136/bmj.333.7562.287. PMID 16888305. 
  9. ^ Curri SB et al. Changes of cutaneous microcirculation from elasto-compression in chronic venous insufficiency. In Davy A and Stemmer R, editors: Phlebology '89, Montrouge, France, 1989, John Libbey Eurotext.
  10. ^ "Open Surgery Is Still The Best Technique To Ablate The Great Saphenous Vein," Vascular, Vol. 14 (November 2006), Suppl. 1, p. S. 25
  11. ^ Systematic review of foam sclerotherapy for varicose veins.Jia X, Mowatt G, Burr JM, Cassar K, Cook J, Fraser C. Br J Surg. 2007 Aug;94(8):925-36
  12. ^ van Rij AM, Chai J, Hill GB, Christie RA (December 2004). "Incidence of deep vein thrombosis after varicose vein surgery". Br J Surg 91 (12): 1582–5. doi:10.1002/bjs.4701. PMID 15386324. 
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  14. ^ claude Franceschi, Cure CHIVA, 1988, Editions de L'Armançon, 21390 Precy-Sous-Thil France
  15. ^ [1]
  16. ^ Maeso J, Juan J, Escribano J, et al. (November 2001). "Comparison of clinical outcome of stripping and CHIVA for treatment of varicose veins in the lower extremities". Ann Vasc Surg 15 (6): 661–5. doi:10.1007/s10016-001-0009-8. PMID 11769147. 
  17. ^ Zamboni P, Cisno C, Marchetti F, et al. (April 2003). "Minimally invasive surgical management of primary venous ulcers vs. compression treatment: a randomized clinical trial". Eur J Vasc Endovasc Surg 25 (4): 313–8. doi:10.1053/ejvs.2002.1871. PMID 12651168. 
  18. ^ a b Carandina S, Mari C, De Palma M, et al. (February 2008). "Varicose vein stripping vs haemodynamic correction (CHIVA): a long term randomised trial". Eur J Vasc Endovasc Surg 35 (2): 230–7. doi:10.1016/j.ejvs.2007.09.011. PMID 17964822. 
  19. ^ a b c Lurie F (February 2009). "Venous haemodynamics: what we know and don't know". Phlebology 24 (1): 3–7. doi:10.1258/phleb.2008.008055. PMID 19155334. 
  20. ^ Goldman M, Sclerotherapy Treatment of varicose and telangiectatic leg vein, Hardcover Text, 2nd Ed, 1995
  21. ^ "Veins & Lymphatics," L. K. Pak et al., in Lange's Current Surgical Diagnosis & Treatment, 11th ed., McGraw-Hill,
  22. ^ Tisi PV, Beverley C, Rees A (2006). "Injection sclerotherapy for varicose veins". Cochrane Database Syst Rev (4): CD001732. doi:10.1002/14651858.CD001732.pub2. PMID 17054141. 
  23. ^ Paul Thibault, Sclerotherapy and Ultrasound-Guided Sclerotherapy, The Vein Book / editor, John J. Bergan, 2007.
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  25. ^ Kanter A, Thibault P (July 1996). "Saphenofemoral incompetence treated by ultrasound-guided sclerotherapy". Dermatol Surg 22 (7): 648–52. doi:10.1016/1076-0512(96)00173-2. PMID 8680788. http://openurl.ebscohost.com/linksvc/linking.aspx?genre=article&sid=PubMed&issn=1076-0512&title=Dermatol%20Surg&volume=22&issue=7&spage=648&atitle=Saphenofemoral%20incompetence%20treated%20by%20ultrasound-guided%20sclerotherapy.&aulast=Kanter&date=1996. 
  26. ^ http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD001732/abstract.html
  27. ^ Rigby KA, Palfreyman SJ, Beverley C, Michaels JA (2004). "Surgery versus sclerotherapy for the treatment of varicose veins". Cochrane Database Syst Rev (4): CD004980. doi:10.1002/14651858.CD004980. PMID 15495134. http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD004980/abstract.html. 
  28. ^ Michaels JA, Campbell WB, Brazier JE, et al. (April 2006). "Randomised clinical trial, observational study and assessment of cost-effectiveness of the treatment of varicose veins (REACTIV trial)". Health Technol Assess 10 (13): 1–196, iii–iv. PMID 16707070. http://www.hta.ac.uk/execsumm/summ1013.htm. 
  29. ^ William R. Finkelmeier, Sclerotherapy, Ch. 12, ACS Surgery: Principles & Practice, 2004, WebMD (hardcover book)
  30. ^ Scurr JR, Fisher RK, Wallace SB (2007). "Anaphylaxis Following Foam Sclerotherapy: A Life Threatening Complication of Non Invasive Treatment For Varicose Veins". EJVES Extra 13 (6): 87–89. doi:10.1016/j.ejvsextra.2007.02.005. 
  31. ^ Medical Services Advisory Committee, ELA for varicose veins. MSAC application 1113, Dept of Health and Ageing, Commonwealth of Australia, 2008.
  32. ^ Elmore FA, Lackey D (2008). "Effectiveness of ELA in eliminating superficial venous reflux". Phlebology 23 (1): 21–31. doi:10.1258/phleb.2007.007019. PMID 18361266. http://openurl.ebscohost.com/linksvc/linking.aspx?genre=article&sid=PubMed&issn=0268-3555&title=Phlebology&volume=23&issue=1&spage=21&atitle=Effectiveness%20of%20endovenous%20laser%20treatment%20in%20eliminating%20superficial%20venous%20reflux.&aulast=Elmore&date=2008. 
  33. ^ Rautio TT, Perälä JM, Wiik HT, Juvonen TS, Haukipuro KA (June 2002). "Endovenous obliteration with radiofrequency-resistive heating for greater saphenous vein insufficiency: a feasibility study". J Vasc Interv Radiol 13 (6): 569–75. doi:10.1016/S1051-0443(07)61649-2. PMID 12050296. http://openurl.ebscohost.com/linksvc/linking.aspx?genre=article&sid=PubMed&issn=1051-0443&title=J%20Vasc%20Interv%20Radiol&volume=13&issue=6&spage=569&atitle=Endovenous%20obliteration%20with%20radiofrequency-resistive%20heating%20for%20greater%20saphenous%20vein%20insufficiency:%20a%20feasibility%20study.&aulast=Rautio&date=2002. 
  34. ^ Lurie F, Creton D, Eklof B, et al. (January 2005). "Prospective randomised study of endovenous radiofrequency obliteration (closure) versus ligation and vein stripping (EVOLVeS): two-year follow-up". Eur J Vasc Endovasc Surg 29 (1): 67–73. doi:10.1016/j.ejvs.2004.09.019. PMID 15570274. 
  35. ^ Kenneth Myers, An opinion —surgery for small saphenous reflux is obsolete!" Australian and New Zealand Journal of Phlebology, Vol 8, Number 1 (December 2004)

(36)Shouten R, Mollen RM, Kuijpers HC. A comparison between cryosurgery and conventional stripping in varicose vein surgery: perioperative features and complications. Ann Vas Surg 2006;20:306-311.

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