A varicose vein is an abnormal swelling or tortuosity of a superficial vein of the legs. Age, number of pregnancies, and heredity have been, implicated as the significant risk factors in the development of varicosities. In the U.S., the incidence of varicose veins shows that across all ages, females have a higher incidence of varicosis, and that incidence increases with age.
There is ongoing research regarding the pathogenesis of varicose veins. Apoptosis, or programmed cell death, plays a crucial role in cell turnover, control of cell numbers, and elimination of abnormal cells. Apoptosis is normally occurring in healthy veins to remove senescent or abnormal cells. This process does not occur to any significant degree in varicose veins, thus predisposing the vessel wall to varicosity development.
CONTRIBUTORS OF DISEASE
Certain hormones are also believed to be contributory to varicosity development. Progesterone surges during the menstrual cycle and is exacerbated during pregnancy, appearing to have a dilating effect on veins.
Another factor called relaxin, which acts to reduce smooth muscle cell tension in the vein wall, is being investigated. These substances promote vein elongation which causes tortuosity (twists and turns) and dilation leading to venous valvular incompetency.
All patients with varicose veins can be categorized according to the CEAP classification recommended by the American Venous Forum. Patients are assigned to class according to the severity of venous disease, from mild venous changes {Class 1) to skin changes with active ulceration (Class 6).
Varicose disease is a spectrum. Obviously there are the cosmetic concerns associated with varicosis. In the advanced stages of disease, however, patients have considerable functional disability from pain, swelling, and/or ulceration.
Vascular exams with a duplex ultrasound scanner are performed on patients to qualitatively assess reflux or reversal of flow secondary to incompetent venous valves. The location of venous reflux to specific superficial or deep vein segments, or the perforating veins, and the degree of reflux impact for the treatment are then recommended. Air plethysmography or APG is another diagnostic, but a less utilized test to quantitate, the degree of reflux.
TREATING VARICOSIS
Primary varicose veins and superficial venous insufficiency is curable by a variety of methods to be outlined. However, deep venous insufficiency is treatable, but not curable. This stresses the importance of pre-treatment testing to select out the patients who can be treated for cure versus those patients who will be maintained by conservative measures. The indications for treatment are leg pain, fatiguability, heaviness, recurrent superficial phlebitis, external bleeding, and appearance.
Non-operative management of varicose veins includes sclerotherapy and laser. Both treatments are primarily applied to varicose veins with vessels less than 3mm in size. There are several types of lasers currently being marketed for this purpose and beyond the scope of this brief review.
Sclerotherapy as a technique dates back to the 1930s. It involves injecting a sclerosing agent of hypertonic saline, sodium morrhuate, or sodium tetradecyl sulfate with a very fine needle directly into the vessel. The sclerosant irritates the vein wall lining causing it to swell and adhere obliterating the lumen with clot. A single vessel may have to be injected several times depending on its size. Immediately after injecting the extremity, it is wrapped in a pressure dressing for one to three days. This may be followed by incision and drainage of entrapped blood at two weeks after the injection with reapplication of compression.
VEIN REMOVAL
Surgical removal of varicose veins is indicated for: axial flux in the saphenous system; large size of varicosities (4 mm). New technology has resulted in many minimally invasive techniques for vein removal.
The traditional varicose , vein "stripping" involves l complete removal of the saphenous vein (greater or lesser saphenous) when the main trunk exhibits valvular reflux. Alternatively, some , physicians believe that high ligation or tying off the saphenous vein when it is incompetent at the saphenofemoral junction in the groin should suffice.
Incompetent saphenous vein tributaries or branch vessels, historically have been removed by the stab avulsion technique with preservation of the competent saphenous vein. This is accomplished by making a small incision over the varicosity, lifting the vessel with a crochet hook, and blindly following the vessel distally and proximally with hemostats as far as possible before tying off the vein, and cutting it. These same incompetent venous branch vessels can be successfully treated by endoscopically "clipping" the side branches of the saphenous. A small incision is made and a scope is passed along the course of the saphenous vein in the subcutaneous fat, and branches of the saphenous are directly seen and serially clipped with a staple device. The newest method of venous tributary ablation has been marketed as transilluminated powered phlebectomy or Trivex procedure. By inserting a light source along the saphenous through a small incision, the veins are transilluminated and visualized through the skin. Then, a powered surgical instrument containing a rotating blade is inserted through a counter incision to cut away at the vein and simultaneously suck it out.
The later two methods are excellent advances over the traditional stab avulsion technique because they allow directed therapy rather than blind removal of veins with hemostats. They allow the surgeon to use a minimal number of incisions to remove a larger number of veins. This translates into shorter surgeon operative times, less post procedure pain for the patient, and improved cosmesis.
OTHER OPTIONS
On a final note, patients that are not surgical candidates or those who do not desire surgery can receive significant symptomatic relief of pain and swelling from compression stockings. These garments are prescribed at various pressure according to severity of the varicose disease. They work by creating a pressure gradient from the ankle to the upper leg with the highest pressure at the ankle. This gradient helps blood in the veins to flow in the right direction back to the heart. Thus, there is a decrease in blood pooling in the veins which leads to less venous distention and pain and swelling in the extremity.
Other conservative measures such as elevation of the legs, daily exercise, avoidance of prolonged standing, meticulous skin care with emollients are advocated regimens for vein patients. Some patients with venous disease experience itchiness, and over-the-counter products like Benadryl or hydrocortisone cream, or calamine lotion help.
Varicose veins should be considered a symptomatic manifestation of venous disease and not merely a cosmetic problem. It is a considerable problem in Western culture and affects all ages, men and women. Fortunately, we are living in the best of times where treatment options are burgeoning.
This column is provided by the Richmond County Medical Society and appears on the second Monday of the month in the Health & Fitness section. Questions may be sent to the column in care of the Advance.
