Varicose vein and its treatment

Dr. Lukram Sidartha *

Varicose veins are twisted, dilated veins most commonly located on the lower extremities. Varicose veins are generally identified by their twisted, bulging, superficial appearance on the lower extremities. Varicose veins are a common problem, with widely varying estimates of prevalence. In general, they are found in 10 to 20 percent of men and 25 to 33 percent of women.

Varicose veins in legs are veins that are permanently swollen while standing and have a minimum diameter of 3 mm.

Etiology and complications

The etiology of varicose veins is multi factorial and may include: increased intravenous pressure caused by prolonged standing, increased intra-abdominal pressure arising from tumour, pregnancy, obesity, or chronic constipation, familial and congenital factors, secondary vascularization caused by deep venous thrombosis, or less commonly arteriovenous shunting. Shear forces and inflammation have recently been recognized as important etiologic factors for venous disease. Venous disease resulting in valve reflux appears to be the underlying pathophysiology for the formation of varicose veins.

Varicose veins may cause varying degrees of discomfort or cosmetic concern. Skin pigmentation changes, eczema, infection, superficial thrombophlebitis, venous ulceration, loss of subcutaneous tissue, and a decrease in lower leg circumference (lipodermatosclerosis) are possible complications. Although rare, external haemorrhage resulting from the perforation of a varicose vein has been reported.

Diagnosis
CLINICAL PRESENTATION

The clinical presentation of varicose veins varies among patients. Some patients are asymptomatic. Symptoms, if present, are usually localized over the area with varicose veins, however they may be generalized to include diffuse lower extremity conditions. Localized symptoms include pain, burning, or itching. Generalized symptoms consist of leg aching, fatigue, or swelling. Symptoms are often worse at the end of the day, especially after periods of prolonged standing, and usually disappear when patients sit and elevate their legs.

Risk factors include chronic cough, constipation, family history of venous disease, female sex, obesity, older age, pregnancy, and prolonged standing.

WHAT DIAGNOSTIC PROCEDURES ARE AVAILABLE?

The Consilium Radiologicum drew up practice guidelines in Belgium in 2010. In accordance with a prior international consensus (2006) this guide recommends the use of a Doppler ultrasound to realize the diagnosis of the majority of cases of varicose veins (varices). Other examinations (magnetic resonance, tomography, phlebography/venography) may be proposed in exceptional cases (including congenital anomalies).

WHAT TREATMENTS ARE CURRENTLY PROPOSED?

The treatments currently proposed include measures like weight loss, avoiding standing for long periods, lying with the legs raised, physical exercise, compression (stockings, elastic bandages) and medication. In addition a conventional surgical intervention or one of the more recent endovenous techniques (laser, radio frequency, sclerotherapy) may be considered. These latter techniques are either performed alone or in combination with surgery.

Conventional surgical approach

Conventional surgery (also called "stripping") combines the ligature of the junction between the great saphenous vein and the femoral vein or between the small saphenous vein and the popliteal vein with the removal of the stem of the saphenous vein and of the associated insufficient surface veins. There are numerous variations to this technique.

Thermal ablation through endovenous laser treatment

A thin optical fibre is inserted into the vein to be treated: the energy from the laser destroys the vein wall and thereby results in occluding the length of the vein.

Thermal ablation through radio frequency

As with the previous technique a catheter is inserted into the vein and the properties of electromagnetic current are used to create heat, with the same effect as with laser treatment.

Sclerotherapy with foam or liquid via an endovenous catheter

The injection of a sclerosing agent into the vein causes an inflammatory response that results in occlusion. Today the sclerosing solution is usually replaced by a foam emulsion ("foam sclerotherapy").