Varicose Veins

This is a common condition affecting the veins of the lower extremities. Women are affected by varicose veins nearly twice as frequently as men but it is not at all uncommon for men to be affected.  Studies have shown that non-Hispanic Whites are affected more commonly than Hispanics, African-Americans or Asians.

The anatomy of the veins of the leg is basically that of two parallel systems that extend from the foot to the groin. The deep veins are located within the muscles of the legs. The superficial veins are located just beneath the skin. These superficial veins called the "greater saphenous vein" (on the inside of the thigh) and the "lesser saphenous vein" (behind the knee and extending down the back of the calf) are not necessary for the normal functioning of the leg. In fact, these are the veins that are removed from the leg to create a "bypass" for blocked arteries of the heart or some other portion of the body.

When these superficial veins become large, bulging, and "tortuous", they are called varicose veins. The condition results from a weakness of the valves within the veins. This weakness can be hereditary, acquired due to occupations associated with prolonged standing, or due to an injury to the venous valves of the leg.

Risk factors associated with varicose veins:

A positive family history of varicose veins
Prolonged standing or sitting
Leg injury
Obesity
Increasing age

Factors considered to NOT contribute to varicose veins:

Hypertension
Allergies
Cancer
Diabetes
Wearing high heel shoes
Dietary fat or carbohydrate intake
Alcohol consumption
Exercise

Types of Varicose Veins:

Varicose veins can be relatively mild in appearance (although even the “mild” form can be painful) such as what are called “telangiectasias” or “spider veins (see photo 1), or they can be huge veins which are easily visible – sometimes being so large that they can be seen bulging through a pair of pants (see photo 2).

Photo 1: Telangiectasias of the leg. These are usually treated with injection therapy in the office setting. Lasers have also been used to eliminate "spider veins" with variable success.
Photo 2: Huge varicose veins arising from the long saphenous vein (also called the greater saphenous vein). These are usually best treated by removal of the vein (see post-op photo) and the bulging varicosities which are branches of the main vein. These are caused by incompetence of the valves within the vein. The valves can become incompetent due to hereditary factors, trauma or phlebitis.
		Post-op photo taken three weeks after surgery. The veins were removed via the two small incisions seen in this photo and two other small incisions (one at the ankle and one in the groin crease) which can not be seen in this photo. This type of surgery is performed in an ambulatory setting and no hospitalization is required. When the veins are not quite as severe, a laser may be used to close the long saphenous vein in the thigh. This can be performed without any skin incision.

Symptoms of varicose veins:

In addition to the cosmetic considerations associated with varicose veins, there are definite and sometimes very painful leg symptoms associated with varicose veins. These symptoms include:
Aching of legs
Itching of legs and feet
Heaviness of legs
Tiredness of legs
Cramping of legs at night
Swelling of legs
Restlessness of legs at night

Stasis Pigmentation and Stasis Ulceration: Over the course of years, varicose veins can lead to leg swelling ("edema"), brown discoloration of the skin of the leg around the ankles (called "stasis pigmentation"), or actual breakdown of the skin (called "stasis ulceration").  The swelling of the lower legs  or “edema” can be caused by leakage of fluid (essentially water) out of the varicose veins because these bulging veins are under high pressure.    With prolonged pressure associated with untreated varicose veins, there is actual leakage of  blood cells into the tissues of the lower leg.  The skin becomes brown in color due to deposition of hemoglobin within the tissues.  This “stasis pigmentation” can be associated with itching and thickening of the skin (see photo 4).  With time, the skin can become so damaged and fragile that actual “stasis ulceration” can occur (see photo 5).  This condition can be extremely painful and, although it rarely leads to limb loss, it is a cause of significant disability and discomfort.
		Photo 4: Stasis pigmentation due to severe venous insufficiency due to both varicose veins and incompetence of the valves within the deep system of leg veins.
			Photo 5: Severe stasis pigmentation and venous insufficiency leading to eventual stasis ulceration of the skin. This was successfully treated with a skin graft.

Treatment of Varicose Veins

Since the superficial veins in the legs are usually not necessary for normal functioning of the lower extremities (this is the vein that is removed for bypass of blocked arteries in the heart, for example), these veins can be removed without any consequence. One situation where superficial varicose veins of the lower extremities cannot be removed is when the deep veins of the leg are blocked due to previous episodes of phlebitis. In this instance, the superficial veins should not be removed because this may result in significant swelling of the lower extremity. Prior to removing varicose veins of the legs, the patient's surgeon should evaluate the deep system of veins within the leg (usually with ultrasound evaluation) to be certain that the deep system is not blocked. Most varicose vein surgery can be performed in the outpatient setting. The following outlines some of the most common treatment options for treatment of lower extremity varicose veins:

Sclerotherapy: This is a nonsurgical treatment used to eliminate small varicose veins and spider veins. It involves injecting a sclerosant solution into the vein which causes the vessel to collapse and disappear. This procedure is performed in the office and generally requires several visits to eliminate all of the spider veins since most people have multiple areas of spider veins on their lower extremities.

Foam sclerotherapy: Foam sclerotherapy is a procedure in which the sclerosing solution is mixed with air to create a "foam". This foam is injected into the spider veins and small varicose veins to cause the vessel to collapse and disappear.

Laser treatment (transcutaneous): Laser treatments can be used for removing spider veins of the lower extremities. This involves no injections and is performed in an office setting.

Endovenous laser treatment: Endovenous laser treatment is performed under local anesthesia in an office setting. During this procedure, a laser catheter is inserted into a large varicose vein in the thigh and laser energy is used to seal the vein closed. This is a variant on surgical phlebectomy (in which a large saphenous vein of the thigh is actually removed from the patient). The advantage of the laser treatment is that it can be performed in the office under local anesthesia and recovery is faster than if the entire vein is removed using surgical techniques.

Microphlebectomy: This is a surgical procedure in which small clusters of varicose veins are removed through tiny (1/8 inch) incisions under local anesthesia in the office setting. It is frequently used in conjunction with EVLT or surgical removal (phlebectomy) of the saphenous vein in the thigh.

Spider veins pre-sclerotherapy		Spider veins post-sclerotherapy