(anatomy) An enlarged tortuous blood vessel that occurs chiefly in the superficial veins and their tributaries in the lower extremities. Also known as varicosity.
Veins, commonly in the legs, which have become distended and twisted as a result of weakening of their walls and valves. Because they protrude, they are ruptured relatively easily. Ruptured veins bleed heavily, but the application of firm pressure usually brings the bleeding under control quickly. Obese individuals, pregnant women, those who regularly stand for prolonged periods, and the physically inactive are particularly susceptible. As long as varicose veins are not associated with other symptoms that may indicate a more sinister condition, a controlled programme of physical exercise may improve circulation and benefit sufferers.
A varix or varicosity is an irregularity or lumpiness. In the body, this means irregularities caused by dilated and distorted veins.
Veins in the legs have valves which normally prevent any backflow of the blood on its way towards the heart. The pressure of the blood tending to distend these veins is greater than in veins elsewhere simply because, for most of most people's waking hours, they are lower than the rest of the body, and vertical. This can put a considerable strain on the valves, each of which supports the column of blood immediately above it, between it and the next valve further up. In ideal normal circumstances the blood is kept moving upwards effectively because of persistent squeezing of veins by actively contracting muscles as we walk about, as well as by other mechanisms which tend continually to draw the blood towards the chest. The superficial veins just under the skin benefit less directly than the deep ones from leg movements — but because they connect to the deep veins, squeezing by the muscles helps to siphon blood from those near the surface, as well as ‘milking’ it up the deep ones.
Thus gravity does not normally cause an accumulation of weighty blood in our lowest parts, as it would in, say, a liquid-filled bicycle inner tube suspended vertically. But there are less than ideal circumstances which cause relative stagnation, particularly in the superficial unsupported veins; blood then leans more heavily on the valves, and in some cases these become damaged and develop leaks. This can occur if there is an obstruction to blood flow up from the legs (such as a heavily pregnant uterus pressing on the veins in the pelvic cavity) and the problem is exacerbated by sitting or standing still. As for many bodily dysfunctions, there is no doubt a combination of innate propensity (weak veins and valves) and risk factors (flow obstruction and immobility). The leakage of valves in turn leads to the irregular bulges on the veins which are known as varicosities, along with enlargement and distortion. The sluggishness imposed on the circulation to the skin and underlying tissues by back pressure from these veins predisposes to discomfort, ulceration, and oedema.
Applying pressure by support stockings to keep the varicose veins from filling is the first line of treatment. But the veins which are affected are fortunately usually dispensible: if they are removed, blood can flow through alternative deeper channels. Effective surgical treatment involves making cuts only at the top and the bottom of the offending vein, which is then removed by using a ‘stripper’. From the top end (say at the knee) a thin flexible rod is passed down the vein to the far end (say at the ankle). The vein is tied around the rod, which has a knob on its end. Pulling from the top then causes the knob to draw the whole length of the vein up before it, ‘crumpling’ it as it comes. Thus the vein is pulled by the stripper from under the skin and out through the upper incision.
A similar problem can occur at other sites. In the lower end of the oesophagus, ‘varices’ may result from back pressure associated with liver disease. In the scrotum a ‘varicocoele’ is a swelling of the veins around the testis. Haemorrhoids represent a comparable condition of the anal veins.
— Sheila Jennett
Veins, commonly in the legs, which have become abnormally distended and twisted as a result of incompetence of internal valves. Varicose veins may bleed heavily if ruptured, in which case the application of firm pressure easily controls the bleeding. As long as varicose veins are not associated with other symptoms, a controlled programme of physical exercise may improve circulation and benefit sufferers.
|Classification and external resources|
A person affected by varicose veins.
|ICD-10||I83, I84, I85, I86|
Varicose veins are veins that have become enlarged and tortuous. The term commonly refers to the veins on the leg, although varicose veins can occur elsewhere. Veins have leaflet valves to prevent blood from flowing backwards (retrograde flow or reflux). Leg muscles pump the veins to return blood to the heart (the calf muscle pump mechanism), against the effects of gravity. When veins become varicose, the leaflets of the valves no longer meet properly, and the valves do not work (valvular incompetence). 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 being a cosmetic problem, varicose veins can be painful, especially when standing. Severe long-standing varicose veins can lead to leg swelling, venous eczema, skin thickening (lipodermatosclerosis) and ulceration. Life-threatening complications are uncommon.
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 which seal the main leaking vein are available. Alternative techniques, such as ultrasound-guided foam sclerotherapy, radiofrequency ablation and endovenous laser treatment, are available as well. 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.
Secondary varicose veins are those developing as collateral pathways, typically after stenosis or occlusion of the deep veins, a common sequel of extensive deep venous thrombosis (DVT). Treatment options are usually support stockings, occasionally sclerotherapy, and rarely limited surgery.
Varicose veins are distinguished from reticular veins (blue veins) and telangiectasias (spider veins), which also involve valvular insufficiency, 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 or peripheral vascular disease. These physicians are called vascular surgeons, phlebologists or interventional radiologists.
Traditionally, varicose veins were only investigated using imaging techniques if there was a clinical suspicion of deep venous insufficiency, if they were recurrent, or if they involved the sapheno-popliteal junction. This practice is not now widely accepted. All patients with varicose veins should now be investigated using Duplex doppler ultrasound scanning. The results from a randomised controlled trial (RCT) on the follow up of patients with and without routine Duplex scan has shown a significant difference in recurrence rate and reoperation rate at 2 and 7 years of follow up. .
Most varicose veins are relatively benign, but severe varicosities can lead to major complications, due to the poor circulation through the affected limb.
Varicose veins are more common in women than in men, and are linked with heredity. Other related factors are pregnancy, obesity, menopause, aging, prolonged standing, leg injury, abdominal straining, and crossing legs at the knees or ankles. Less commonly, but not exceptionally, varicose veins can be due to other causes, as post phlebitic obstruction or incontinence, venous and arteriovenous malformations See also for differential diagnosis- 1. Klippel-Trenaunay syndrome, 2. Parkes-Weber syndrome
The symptoms of varicose veins can be controlled to an extent with the following:
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.
Several techniques have been performed for over a century, from the more invasive saphenous stripping, to less invasive procedures like ambulatory phlebectomy and CHIVA.
Stripping consists of removal of all or part the saphenous vein (great/long or lesser/short) main trunk. The complications include deep vein thrombosis (5.3%), 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 use as venous bypass grafts in the future (coronary or leg artery vital disease)
Other surgical treatments are:
A commonly performed non-surgical treatment for varicose and "spider" leg veins is sclerotherapy in which medicine (sclerosant) is injected into the veins to make them shrink. The medicines that are commonly used as sclerosants are polidocanol (POL), sodium tetradecyl sulphate (STS), Sclerodex (Canada), Hypertonic Saline, Glycerin and Chromated Glycerin. STS (branded Fibrovein in Australia) and Polidocanol (branded Asclera in the United States, Aethoxysklerol in Australia) liquids can be mixed at varying concentrations of sclerosant and varying sclerosant/gas proportions, with air or CO2 or O2 to create foams. Foams may allow more veins to be treated per session with comparable efficacy. Their use in contrast to liquid sclerosant is still somewhat controversial. Sclerotherapy has been used in the treatment of varicose veins for over 150 years. Sclerotherapy is often used for telangiectasias (spider veins) and varicose veins that persist or recur after vein stripping. Sclerotherapy can also be performed using foamed sclerosants under ultrasound guidance to treat larger varicose veins, including the great saphenous and small saphenous veins. 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. A Cochrane Collaboration review 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. 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. 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. There has been one reported case of stroke after ultrasound guided sclerotherapy when an unusually large dose of sclerosant foam was injected.
The Australian Medical Services Advisory Committee (MSAC) in 2008 has determined that endovenous laser treatment/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." 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%) 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. Myers 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 high frequency ultrasound during the procedure to visualize the anatomical relationships between the saphenous structures. 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 or months after the initial procedure.
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