varicose veins

Varicose veins are swollen/ enlarged veins that are located on the legs and feet with lumpy, dilated and irregular patterns caused by the veins. It can cause pain, burning and the feeling of heaviness but there is no known cause to the condition. It is suspected that a history of poor venous supply to certain areas of the body or problems with the blood clotting excessively contribute to the presence of the condition.

Epidemiology

In the UK, it was found that less than 50% of the population who have minor problems with diseases affecting the veins (venous) experience visible varicose veins. With women being 20-25% and men being 10-15% [1]
Prevalence increases with age and they develop often in pregnancy [2]
Prevalence is higher in developed countries and more industrialised countries too [3]

Varicose veins

Blue twisting veins superficially (close to skin) seen widely distributed on the leg.

Pathophysiology [4]
- Medical students
  - The specific cause of varicose veins is still being debated.
  - The general agreement is the failure of venous valve closure resulting in the superficial veins becoming dilated, elongated and tortuous.
  - The main factor contributing to the development of varicose veins is sustained venous hypertension.
  - This increases the diameter of the superficial veins resulting in further valve incompetence.
- Patients
  - The specific cause of varicose veins is still being debated.
  - The general agreement is the failure of venous valve (structure that take blood back to the heart against the force of gravity) closure resulting in the superficial (close to the surface) veins becoming dilated, elongated and tortuous (twisted).
  - The main factor contributing to the development of varicose veins is sustained venous hypertension.
  - This increases the diameter of the superficial veins resulting in further valve incompetence.

Varicose veins

Extensive varicosities seen on the leg; crowded blue veins on the thigh

Causes [5]
- Increased blood pressure in the veins that can run in the family
- Pregnancy- hormonal changes and uterus increases pressure in veins
- Ageing
- Standing for long periods of time
- Obesity
- Leg injury

Risk factors [6]
- Older age
- Standing or sitting for long periods of time
- Sedentary lifestyle (inactive)
- History of varicose veins or deep vein thrombosis (formation of blood clots causing obstruction)
Presentation [7]
- Tense and palpable (able to be touched)
- May progress to enlarged, more obvious signs
- Can cause tiredness, fatigue, pressure, pain and hypersensitivity in the legs
- Can impact the inner ankle (medial malleolus) region when discolouration occurs
- Ulcer formation after small injuries
- Thin bleeding sacs may form with pain and rupture after small levels of trauma

Investigations [8]
- Clinical examination of the appearance of the legs and ask for a history of varicose veins, pregnancy, deep vein thrombosis history, body mass index and history of leg injury
- Referral to a specialist may be needed if the varicose veins cause pain and discolouration of the legs
- A test called a duplex ultrasound scan will be needed. This uses high-frequency sound waves in a device to create an image of the veins investigated, helping the veins affected to be focused on in management

Differential diagnosis [9]
- Telangiectasia- red, small thread- shaped veins
- Venulectasia- blue, networks of vessels

Varicose veins

Purple discolouration of varicosities on pale skin

Management [7]
- Medical students
  - Treatment aims to relieve symptoms, improve leg appearance, and prevent complications of varicose veins.
    - Compression stockings and local wound care are used as needed in the treatment.
  - Minimally invasive therapies (e.g., sclerotherapy) and surgery are indicated for prevention of recurrent variceal thrombosis, skin changes, and cosmetic reasons.
    - Sclerotherapy induces thrombophlebitic reaction to occlude the vein, but recannulation may occur in many cases.
    - Surgery involves ligation or stripping of veins, providing short-term symptom relief, but long-term efficacy is poor with recurrent varicose veins.
    - Thermal ablation using laser or radiofrequency is another minimally invasive option for treatment.
  - Despite treatment, new varicose veins may develop, and treatment may need to be repeated indefinitely.
- Patients
  - Treatment aims to relieve symptoms, improve leg appearance, and prevent complications of varicose veins.
    - Compression stockings and local wound care are used as needed in the treatment.
  - Minimally invasive (in the body) therapies (e.g., sclerotherapy) and surgery are indicated for prevention of recurrent variceal thrombosis (blood clot formation), skin changes, and cosmetic reasons.
    - Sclerotherapy induces thrombophlebitis reaction (reaction that causes a blood clot to form) to block the vein, but recannulation (process of inserting a tube to free blockages) may occur in many cases.
    - Surgery involves ligation (tying around a blood vessel) or stripping of veins (removal of veins), providing short-term symptom relief, but long-term efficacy is poor with recurrent varicose veins.
    - Thermal ablation (destruction of tissue) using laser or radiofrequency is another minimally invasive option for treatment.
  - Despite treatment, new varicose veins may develop, and treatment may need to be repeated indefinitely.

Complications
- Blood clots- obstructions of the blood vessels
- Inflammation or swelling of the veins (phlebitis)
- Bleeding due to injury or trauma [8,10]

Varicose veins

Dilated varicose veins which appear on legs in a ‘worm-like’ distribution

Myths
- Varicose veins only have visible symptoms (cosmetic symptoms)
- The condition only affects elderly people
- Only women experience the symptoms of varicose veins
- If you cross your legs, it increases your chances of varicose veins
- Varicose veins will come back after treatment [11,12]

Questions to ask your doctor
- What causes varicose veins?
- How can I get support for my varicose veins if I feel insecure about them?
- How do I decide which treatment to use to treat my varicose veins?
- What happens if my varicose veins return?
- How long will treatment take to show improvement in the appearance of varicose veins?