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Varicose Veins

Varicose Veins

Medically Reviewed by Jennifer A. Heller, MD, FACS

Assistant Professor of Surgery
Director, Johns Hopkins Vein Centers
Johns Hopkins Medicine
Baltimore, MD

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Overview

What Is It?
Varicose veins result from a chronic dilatation of the veins, a condition called "varicosity." Instead of flowing from one valve to the next, the blood begins to pool in the vein, increasing venous pressure and causing the vein to bulge and twist.

Your body has two types of blood vessels: arteries carry oxygen- and nutrient-rich red blood from your heart to your muscles and organs, while veins return the "used" bluish blood back to your heart. The deep veins located beneath the muscles carry about 90 percent of the blood traveling from your legs back to your chest. The other 10 percent flows through veins located closer to the surface, often visible, and less well supported.

While your leg muscles help your veins pump the blood upward, the real workhorse is an intricate system of one-way valves that prevent the blood from draining back down the leg under the force of gravity. In many people, women in particular, these valves stop working as well as they should, putting additional pressure on the wall of the vein.

Varicose veins results from a chronic dilatation of the veins, a condition called "varicosity." When the vein walls are pushed apart, the valves no longer seal properly, making it difficult for the muscles to push the blood upward. Instead of flowing from one valve to the next, the blood begins to pool in the vein, increasing venous pressure and causing the vein to bulge and twist. The result is varicose veins.

In some people, varicose veins are simply a cosmetic concern. In others, the condition leads to pain and more serious problems. And in some cases, varicose veins can signal a higher risk for other conditions involving the circulatory system. When inflamed or clotted, they become hard and tender to the touch. Increasing pressure may cause itchy skin and aching in the affected limb.

If you suffer from varicose veins, you are not alone. According to the American College of Phlebology, up to 50 percent of American women have varicose veins or a related venous disorder. Spider veins, also referred to as telangiectasia or broken capillaries, are formed by the dilation of a small group of blood vessels located close to the surface of the skin and are most commonly found on the legs and face. They look like red or purple sunbursts or branched or web patterns and only rarely cause pain. Varicose veins differ from spider veins in that they are:

  • larger—usually more than a quarter inch in diameter—and often distended
  • darker purple or blue
  • located deeper than spider veins
  • tend to bulge or twist
  • may be painful
  • can be related to more serious vein disorders

Varicose veins aren't just a cosmetic concern. They can pose a health risk. Sometimes they are associated with:

  • spontaneous bleeding, which occurs as the skin over the varicose veins becomes thin. The vein may be easily injured, even by bedding, clothing or a slight bump, and blood loss can be significant, without any noticeable pain.
  • superficial phlebitis (ST), also called superficial phlebitis, which is an inflammation of a vein just below the surface of the skin. The inflammation may be caused by decreased blood flow through the vein, damage to the vein or blood clotting (known as thromboses). Symptoms include redness and a firm, tender, warm vein. Localized pain and swelling also may occur. ST also increases a patient's risk for deep vein thrombosis (DVT), a potentially serious condition that involves a blood clot in a deep vein.
  • venous leg ulcers, which can result when the enlarged vein does not provide adequate drainage of fluid from the skin; the swollen skin receives insufficient oxygen and an ulcer forms

Certain people seem to be more predisposed to varicose veins than others, including:

  • Women. They are four times more likely than men to develop varicose veins. Up to 50 percent of American women may be affected at some point in their lives, according to the American College of Phlebology.
  • People whose family members have varicose veins. Heredity plays a major role.
  • Older people. Varicose veins affect one out of two people over age 50, and they are more common in women than in men. Also as women age, varicose veins become more visibly pronounced.

In addition, several factors can lead to varicose veins in people who are predisposed to them, including:

  • changes in a woman's hormonal levels, which can be brought on by pregnancy
  • menopause
  • use of birth control pills, estrogen, and progesterone
  • obesity
  • leg injury
  • inactivity
  • strain in the abdominal region, from repeated heavy lifting, pregnancy or constipation (a hemorrhoid is actually a varicose vein)

In addition to hormonal changes, pregnancy causes both an increased volume of blood and increased pressure from the abdomen, which in turn causes veins to enlarge. The good news is varicose veins due to pregnancy often improve within three months after delivery. However, with successive pregnancies, these abnormal veins are more likely to enlarge further.


Diagnosis

Many cases of varicose veins are clearly visible, with the knotted, twisted or bulging darkened veins showing beneath the skin of the thigh and lower legs. And, your legs may be swollen. If you have varicose veins, you may also experience pain in the legs, especially after standing or sitting still for a long time. Some women describe the pain as feelings of fatigue, heaviness, aching, burning, throbbing, cramping or restlessness.

Severe varicose veins can make your skin itchy or lead to a skin condition similar to eczema or even ulcers on your lower legs. Keep in mind that not all leg discomfort is caused by varicose veins. Any persistent or severe symptoms warrant a visit to your health care professional.

Vein disorders are not always visible. If you can't see any symptoms, or, to help determine the cause and severity of the problem, your health care professional may conduct a noninvasive ultrasound or other vascular test.

Be sure to call your health care professional if swelling becomes incapacitating or if the skin over your varicose veins becomes flaky, ulcerated, discolored or prone to bleeding. In addition, if you have redness, warmth and burning pain in the area of a vein, call your health care professional, because this can be a sign of phlebitis or a blood clot.

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Treatment

Because varicose and spider veins are congested with blood, they really aren't doing their job anymore. Fortunately, there are usually plenty of other, healthy veins to take over. So most of these unwanted veins simply aren't necessary and can be removed. But while invasive treatment is an option, don't rush to the operating room. There are simpler things you can try first, including:

  • Walk regularly, which helps improve muscle tone and circulation.

  • Reduce your body weight.

  • Find several times during the day when you can elevate your legs for 10 to 15 minutes.

  • Wear compression hose or stockings, which can be purchased at most pharmacies. They help your leg muscles push blood upward by concentrating pressure near the ankles. Specially manufactured gradient-compression support stockings are the most effective for controlling symptoms. They may also prevent worsening of the condition and avoid the need for future treatment.

  • Take an over-the-counter anti-inflammatory drug such as aspirin or ibuprofen to alleviate occasional swelling and pain.

If these conservative methods don't work to your satisfaction, you should discuss with your health care professional the possibility of trying one or more corrective measures, such as:

  • Sclerotherapy can be used to treat both varicose and spider veins, but it is usually reserved for people whose varicose veins are small (less than six millimeters). The procedure is performed in a health care professional's office and causes only minimal discomfort. A tiny needle is used to inject the veins with sclerosing (hardening) solution, which irritates the lining of the vein. In response, the vein collapses and is reabsorbed. Multiple branch veins can be treated at the same sclerotherapy session, and the procedure can also be repeated if varicose veins reappear. Complications may include:

    • development of groups of fine, red blood vessels near the injection sites of larger vessels on the thighs, some of which disappear on their own and others require treatment

    • muscle cramps, which go away in 10 to 15 minutes

    • temporary swelling of your feet or ankles

    • red bumps at the sites of the injections, which fade within a few days.

    • bruising, which usually fades after a week or two

    • pigmentation (brown lines or spots) around the treated vein, which usually disappear

    • superficial thrombophlebitis

In addition, if you develop small painful ulcers at the injection site, inform your health care professional immediately.

Although sclerotherapy works well for spider veins, studies show that it is not as effective as surgery for treating varicose veins and that recurrence rates are high.

  • Endovenous chemical ablation, also known as ultrasound-guided sclerotherapy, involves the injection of a chemical irritant—called a sclerosant—into a vein while the doctor watches the process on an ultrasound screen. This process enables treatment of veins that can't be seen because they are further beneath the skin.

  • External laser/light source treatments are generally used only to treat spider veins or very small varicose veins and may be combined with sclerotherapy. A laser or light beam is pulsed onto the veins to seal them and cause them to dissolve. Multiple treatments are usually required.

  • Endovenous radiofrequency ablation involves using radiofrequency to shrink and seal the deeper varicose veins of the legs. This method has replaced surgery for a majority of patients. Usually done in a health care professional's office under local anesthesia, a small catheter is inserted into the damaged vein and delivers radiofrequency energy to the vein wall, causing it to heat. As it warms, it collapses and seals.

Surgery

Surgery is generally used to treat large varicose veins and has been shown to be effective, with most patients reporting satisfaction with their procedure. Surgery for varicose veins can be performed using local, spinal or general anesthesia. Most patients return home the same day as the procedure. Surgical options include:

  • ligation, or tying off of a vein

  • stripping, or removal of a long segment of vein by pulling it out with a special instrument

  • PIN stripping, an updated version of vein stripping that uses a "perforate invaginate (PIN) stripper." The tip of the PIN stripper is sewn to the end of the vein, and as the PIN stripper is removed, the vein is stripped out

  • ambulatory phlebectomy, or removal of veins through a series of tiny incisions; often done in an office under local anesthesia

  • endoscopic vein surgery, which is usually reserved for advanced cases involving leg ulcers. The surgeon inserts a thin video camera into the patient's leg to visualize and close varicose veins and then removes the veins through small incisions.

Unfortunately, no treatment can prevent veins from becoming varicose. Varicose veins sometimes recur after any form of treatment, but it's not the same vein coming back; it's a different vein becoming affected.

Before undergoing any procedure for varicose or spider veins, be sure to tell your health care professional if you've ever had blood clots in your lungs or legs.

Health care professionals who specialize in the treatment of varicose veins include:

  • general surgeons, physicians with a specialty in performing surgery

  • vascular surgeons, physicians with a specialty in treating blood vessels

  • dermatologists, who specialize in the diseases of the skin

  • phlebologists, who specialize in the field of medicine that deals with vein diseases. In 2005, the American Medical Association officially recognized phlebology as a self-designated specialty for physicians.

Unfortunately, some treatment centers specializing in varicose veins have been caught by the Federal Trade Commission making unfair promises to patients. Keep in mind that no treatment for varicose veins is ever 100 percent effective, and there is never a 100 percent guarantee that other veins in your legs won't become varicose.

Some companies distribute herbs or over-the-counter diet supplements with claims they prevent or cure varicose veins. While some of these supplements claim to have been shown in testing to improve circulation or impact veins in other ways, keep in mind that herbs and supplements are not regulated, and there is no guarantee of quality, safety or efficacy. Also remember that there is no 100 percent cure for or prevention of varicose veins. And keep in mind that it's important to discuss cost of treatments and out-of-pocket expenses because your health insurance may not cover the cost of the procedure.


Prevention

You can't help being a woman, having been born into a family that suffers from varicose veins or even getting older. But there are a few things you can do to head off varicose veins or keep them from becoming more prominent, swollen and distorted, such as:

  • Avoid standing or sitting for long periods in the same position. Take breaks from an office job to get up and move around, or when you're driving for long periods, get out and stretch your legs. If you work in a "standing" profession like teaching or retail sales, stretch and exercise your legs as often as possible to increase circulation and reduce pressure buildup. When possible, wear support stockings as noted below.

  • Try to elevate your legs when resting.

  • Walk for exercise, and do it regularly. Staying fit keeps your leg muscles toned, your blood flowing and your weight under control.

  • Include high-fiber foods in your diet since constipation can contribute to varicose veins. High-fiber foods include fresh fruits, vegetables and whole grains.

  • Wear graduated compression support hose.

  • Use regular sun protection (some unwanted spider veins on the face may be related to sun exposure).

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Facts to Know

  1. About 90 percent of the "used" blood traveling from your legs back to your chest is carried by the deep veins located within the muscles. Vein abnormalities here aren't visible but can be painful or even result in dangerous blood clots.

  2. The other 10 percent of the blood returning to your heart travels through veins closer to the surface; varicose veins here can be visibly swollen, knotted, twisted or bulging.

  3. According to the American College of Phlebology, up to 50 percent of American women have varicose veins or a related venous disorder.

  4. Varicose veins are more likely to occur in older women. Also as women age, varicose veins become more visibly pronounced.

  5. Spider veins, also referred to as telangiectasia or broken capillaries, are formed by the dilation of a small group of blood vessels located close to the surface of the skin and are most commonly found on the legs and face. They look like red or purple sunbursts or branched or web patterns.

  6. Pregnant women often develop varicose veins for a number of reasons: In addition to hormonal changes, pregnancy causes both an increased volume of blood and increased pressure from the abdomen, which in turn cause veins to enlarge. The good news is varicose veins due to pregnancy often improve within three months after delivery. However, with successive pregnancies, these abnormal veins are more likely to remain.

  7. Varicose veins aren't just a cosmetic concern. They can pose a health risk and are associated with the development of skin ulcers; phlebitis, which is an inflammation of the vein; or blood clots.

  8. Though it may require several sessions and the veins may fade only gradually, sclerotherapy, a procedure performed in a health care professional's office, can result in significant improvement in the appearance of spider veins. Studies show that it is not as effective as surgery for treating varicose veins, however, and that recurrence rates are high.

  9. While there are several treatment options for small varicose veins and spider veins, large varicose veins may require radiofrequency closure and/or surgery.

  10. No treatment for varicose veins is ever 100 percent effective, and there is never a 100 percent guarantee that other veins in your legs won't become varicose.


Questions to Ask

Review the following Questions to Ask about varicose veins so you're prepared to discuss this important health issue with your health care professional.

  1. Do I have varicose veins? If so, how severe is my condition?

  2. Can my varicose veins be controlled with lifestyle changes?

  3. What sort of exercise do you recommend?

  4. Are support hose a viable option for treatment? How, exactly, should I wear them? How often and for how long?

  5. If surgery is recommended, are there any less-drastic measures I can try first?

  6. What are the risks and benefits of the treatment options suitable for me? How much will these treatments cost? Will my health insurance cover treatments?

  7. How should I follow up with home treatment to any corrective measures undertaken in the office, hospital or clinic?

  8. What if I am pregnant or plan to become pregnant?

  9. Could my varicose veins cause more serious problems?

  10. Am I at high risk for a blood clot or pulmonary embolism? How can I prevent these?

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Key Q&A

  1. What causes varicose veins?

    Both your leg muscles and valves within your veins work to get the used blood from your legs back up to your heart. When the valves stop working as well as they should—which can be caused by heredity, abdominal pressure, increased pressure from prolonged standing, obesity, hormonal changes, aging and a number of other factors—the blood pools in the vein, stagnating there and causing the vein to bulge or twist.

  2. Are varicose veins dangerous, or just more of a cosmetic issue?

    Although they can be painful and unsightly, in most cases, superficial or visible varicose veins don't lead to further complications. If you are concerned, your health care professional can conduct some painless tests to determine the severity of the problem and ascertain if any of the deeper veins are affected.

  3. My varicose veins are visible, but not very bothersome. Do I need to have them removed?

    Probably not. If only surface veins are affected, the condition is usually harmless. You would probably be feeling more pain or other symptoms if deeper veins were abnormal, which can lead to more serious problems. However, you may want to talk to your health care professional about these concerns.

  4. My legs always seem to be tired and achy. Do I have varicose veins?

    Leg pain can be caused by a number of factors or conditions. If the pain seems to be brought on by standing or sitting for prolonged periods, you could have varicose veins. But if you have no visible symptoms, the only way to determine the cause of your pain is to have some tests done by your health care professional.

  5. I'm pregnant and have developed varicose veins. Will they go away?

    Varicose veins due to pregnancy often improve within three months after delivery. However, with successive pregnancies, these abnormal veins are more likely to remain.

  6. My general practitioner doesn't think my superficial varicose veins are problematic, but I'd like to have them removed for cosmetic reasons. Who should I see?

    The best idea is probably to get a referral from your health care professional or from a friend or family member who has been successfully treated. The types of health care professionals best suited to treating varicose veins are most likely vascular or general surgeons, dermatologists and phlebologists.

  7. Will my varicose veins come back if I have them removed?

    Once the vein is removed, it's gone forever. However, you very well could develop varicosity in other veins.

  8. I saw an advertisement for a "vein clinic" that made all sorts of promises about permanently making my varicose veins disappear with no risk or pain. What's that all about?

    Keep in mind that no medical treatment is ever 100 percent risk-free and cannot be 100 percent guaranteed. While it's true that once a varicose vein is removed surgically, it will not reappear, that doesn't mean you will forever be free of varicose veins. Other veins can develop problems. Remember that surgery is a rather drastic measure. The less drastic corrective measures such as sclerotherapy or laser treatments are by no means 100 percent effective 100 percent of the time. And none of the corrective measures can be guaranteed to be totally pain-free.

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Organizations and Support

For information and support on Varicose Veins, please see the recommended organizations, books and Spanish-language resources listed below.

American Academy of Dermatology
Website: http://www.aad.org
Address: P.O. Box 4014
Schaumburg, IL 60618
Hotline: 1-866-503-SKIN (7546)
Phone: 847-240-1280
Email: mrc@aad.org

American College of Phlebology
Website: http://www.phlebology.org
Address: 101 Callan Avenue, Suite 210
San Leandro, CA 94577
Hotline: 1-866-634-8346
Phone: 510-346-6800

American Society for Dermatologic Surgery
Website: http://www.asds.net
Address: 5550 Meadowbrook Dr., Suite 120
Rolling Meadows, IL 60008
Phone: 847-956-0900

Society of Interventional Radiology
Website: http://www.sirweb.org
Address: 3975 Fair Ridge Drive, Suite 400 North
Fairfax, VA 22033
Hotline: 1-800-488-7284
Phone: 703-691-1805
Email: info@sirweb.org

Beautiful Again: Restoring Your Image and Enhancing Body Changes
by Jan Willis

VNUS Medical Technologies
Website: http://www.vnus.com/InformacionParaPacientes/
Address: VNUS Medical Technologies
5799 Fontanoso Way
San Jose, CA 95138
Hotline: 1-888-797-8346
Phone: 408-360-7200
Email: info@vnus.com

Medline Plus: Varicose Veins
Website: http://www.nlm.nih.gov/medlineplus/spanish/varicoseveins.html
Address: US National Library of Medicine
8600 Rockville Pike
Bethesda, MD 20894
Email: custserv@nlm.nih.gov