Varicose veins are veins that have become enlarged due to a weakening of the vein walls and to abnormal blood flow. Telangiectasias, also commonly called spider veins, are the smaller version of varicose veins. Veins are the blood vessels that carry blood back to the heart and lungs where it is replenished with oxygen. Arteries bring blood from the heart to the extremities and veins, due to their one-way valves and channel blood back to the heart. The leg has two systems of veins, the deep and the superficial. The superficial veins lie just beneath the surface of the skin while the deep veins travel within the muscles of the leg. Due to the calf muscles, the pumping action of the foot, and the vein valves blood travels in the leg from the superficial to the deep veins to reach the heart. Vein valves, when working properly, are supposed to close behind this moving column of blood preventing it from dropping back down the leg.

When an obstruction is present, or when prolonged pressure is placed on the veins the valves stretch and no longer close properly. The veins in the legs that are close to the surface of the skin enlarge and result in varicose veins and/or spider veins. The exact cause of varicose veins is not known; and what may start as symptoms of tiredness and dull aching in the legs may over time develop into large bulging varicosities or even a thickened, hardening of the underlying leg tissue with brownish skin discoloration and ulcerations. Varicose veins do not happen suddenly; they develop slowly, usually over years.

Varicose veins are the most common vascular problem of the leg and are estimated to affect nearly 40 million people in the United States alone. In most cases, the swelling aching and general discomfort caused by varicose veins can be effectively improved and treated. Depending on how severe the veins are, there are several treatments available. Severe varicose veins may still require surgical removal, but surgery has become less frequent with recent medical advances. For more information about spider veins, click on spider telangiectasias.

Contributing Causes for Varicose Veins While medical science has not yet provided a definite answer as to what causes varicose veins, it is known that varicose veins develop when the walls of the veins or valves are weak. Some people are born with weak valves or veins, while for others disease or injury can cause damage to the vessels. When the valves are no longer able to prevent backflow of the column of blood, abnormal pressure dilates the superficial vein system, causing stagnation and pooling of blood. Women are more likely to suffer from varicose veins than men are in part because hormonal factors such as puberty, pregnancy, menopause and the use of birth control pills and estrogen. Heredity is an important factor, but vein valves can be affected by pregnancy, obesity and in the elderly when the veins tend to lose their elasticity with aging and the muscles supporting the veins weaken.

• Obesity In an overweight person, there is fat accumulated inside the abdomen that causes an increase in intra-abdominal pressure, which reduces venous blood flow in the legs.
• Pregnancy In some women the veins become inflamed during pregnancy, most often due to increased pressure from the uterus on the main veins that drain the legs. Increased levels of progesterone during pregnancy, and also around the time of menstruation cause the blood vessels to relax. Venous dilation begins in the first trimester of pregnancy, due to hormonal changes. Dilation of the vein wall may produce valvular incompetence, or leaking. The impairment or reduction of venous return from the legs increases with the months of pregnancy and combined with increased blood volume typical for pregnancy as well as the increased weight and size of the uterus, contribute to swelling and discomfort in the legs, and the formation of varicose veins.
• Family history there is a definite inherited tendency to developing varicose veins.
• Inactivity, sitting or standing for long periods The pressure inside the veins increases greatly due to gravity. Over time, the increase in pressure in the weak walled veins can result in over-stretched veins, or varicose veins.
• Past vein disease such as phlebitis or chronic venous insufficiency Varicose veins can be caused by inadequate drainage of the deep veins of the legs. When the superficial veins are unable to handle all the venous drainage, the result is dilation of the varicose veins.

Reducing Risk of Development of Varicose Veins It is impossible to prevent an inherited tendency toward developing varicose veins, but it is possible to take measures otherwise to help in prevention. The main goal of prevention is to limit the opportunity to distend, or stretch, the veins. Varicose veins are usually troublesome rather than disabling, but occasionally may have serious consequences. Skin sores and/or ulcers can occur because of the leg tissue not receiving enough blood supply due to the combination of valve failure and gravity over time. The following suggestions may reduce the likelihood of developing varicose veins:

• Regular exercise
• Maintaining a healthy weight
• Avoid standing for prolonged periods
• Get up and move about frequently when traveling by plane or car
• Do not cross legs when sitting
• Wear support stockings regularly
• Avoid sitting in chairs that press against the back of the thighs
• Elevate legs and feet when possible. The elevation should be above the level of the heart; just lying on the bed flat, for example, is not sufficient.

• Bluish, swollen or bulging veins in the leg when standing
• Throbbing and or burning sensation in legs
• Feeling fatigue or heaviness in leg muscles
• Swelling of ankles at end of the day
• Tenderness or soreness along the vein
• Itching around the ankle region
• Cramps in legs at night

Diagnosis of Varicose Veins Vein disorders are not always visible and diagnostic techniques such as Doppler ultrasound or duplex scanning may be needed to evaluate the extent of the disease. These non-invasive tests are performed after a brief consultation with physical examination and medical history to provide accurate, personalized information about your specific condition and recommendations for treatment options.

• Physical examination
• Medical and family history
• Doppler ultrasound
• Duplex scan

Non-Invasive Testing Non-Invasive testing is done in the vascular laboratory either at the Beachwood office or at the hospital. This is performed to check the blood flow to your lower extremities. Non-Invasive tests are painless and have no risks or side effects. They do not involve the use of needless, x-rays, or dye and no special preparation is required before the test and no observation is necessary afterwards. This allows the test to often be done the same day of the regular office visit, schedule permitting. They are done as an outpatient and all tests take less than one hour to perform. The results are given to Dr. King for evaluation and will be discussed with you, usually by telephone. There are several types of Non-Invasive tests that may be ordered to help with the diagnosis of varicose veins, including most often Doppler ultrasound or duplex scan.

• Duplex Scanning tests provide an image of an artery or vein on a screen. This is very useful for locating bad or leaky valves in a vein, for measuring the size of a blood vessel and its blood flow. For this test, you will need to lie very still after a cold, wet gel is applied to your leg and the technician will move the probe over the vein being studied.

Treatment of Varicose Veins Many patients come for evaluation by Dr. King asking whether their veins require treatment and what type would be best for them. Some patients are simply looking for relief of the discomfort while others are seeking treatment for cosmetic improvement. Both situations are legitimate; the examination and diagnosis determine the best treatment of choice. Veins that are cosmetically unappealing such as spider veins are often treated with sclerotherapy. In the past, surgical treatment such as ligation (tying off a vein) and stripping (removing the vein) were the most commonly recognized treatments for varicose veins. With the medical advances, surgery is necessary in a much lower percentage of patients and usually performed on patients who have significant, large veins or specific types of valve insufficiency such as greater saphenous insufficiency. Good results with relief of symptoms can usually be obtained, but cannot completely prevent further development of new, additional varicose veins.

There are things that patients can do to slow, or stop the progression of varicose veins.

Self Help Treatment

• Exercise regularly; the development and maintenance of muscles in the leg help push the blood up the vein and empty the veins of excess blood
• Elevate the legs while sitting
• When traveling, stop and get out of the car to walk and flex for a few minutes every hour or two, or if on an airplane, walk down the aisle and/or flex feet and extend legs frequently
• Do not cross legs while sitting so that the blood flow will not be hampered
• Maintain suggested healthy weight
• Wear support hose regularly, but especially during pregnancy, postoperatively, when required to stand for long periods, or when confined to bed by illness

Professional Treatment of Varicose Veins The purpose of treatment is relieving the symptoms of aching pain from large varicosities, to achieve the desired cosmetic results by removing large, bulging varicosities and spider telangiectasias, and to prevent the recurrent episodes of superficial thrombophlebitis, bleeding, or ulceration of varicosities. The goals of treatment are to remove the varicosities, achieve the best cosmetic results with minimal scarring, to relieve symptoms, to decrease the recurrence of varicose veins and, of course, to avoid complications.

• Sclerotherapy The procedure called sclerotherapy, or injection sclerotherapy, is irritating to the veins and causes the tiny dilated veins to scar and disappear. This procedure treats the veins that are currently visible and does nothing to permanently alter the venous system or prevent new veins from developing in the future. A chemical solution is injected directly into the veins with a very small needle, irritating and collapsing the lining of the vein. The inner surface of the collapsed vein then grows together and obliterates the vein. This is done in the office, but requires the patient rest and elevate their legs for 48 hours following the procedure. Compression from support hose or elastic bandages (ACE wraps are used for at least several days following treatment.)
  • Instructions you will receive specific instructions from Dr. King and his staff, but in general, plan for someone to drive you home even though anesthesia is not used. This is due to the bulky leg wraps, general temporary discomfort, and occasionally the lingering effects of pain medication. You should wear shorts or bring them to change into for the treatment. Before coming to the office, shave your legs, but do not apply any moisturizers, sunblocks or lotions. You should make arrangements to be off your feet for 48 hours following treatment. Dr. King injects veins on Fridays, and this often makes it easier to arrange to have two days off. Scheduling should be done keeping in mind not only the 48 hours off your feet, but that due to bruising and discoloration, you will likely not want to wear short skirts, bare legs, or bathing suits for several weeks after the sclerotherapy to allow your legs time to heal. Suntanning should be avoided until all the bruises have cleared to lessen the chance of long-term discoloration. Wearing support hose for the duration of the discoloration is also believed to help reduce the chance of long-term discoloration, increase the success rate of therapy and to help seal in the treatment solution.
  • Appearance Sclerotherapy can enhance the overall appearance and reduce symptoms, but it is unrealistic to believe that every vein will disappear. Often two or more sessions will be necessary to achieve the optimum results. The appearance of the legs will be worse before it improves, with bruising and discoloration common and expected for several weeks following treatment.
  • Touch-ups Most patients find that after a year or rarely, in less than a year touch-up sclerotherapy sessions are required for treatment of new varicose veins. Additionally, many find that after a vein stripping and or ligation for serious varicose veins sclerotherapy is useful to clear the remaining residual veins.
  • Recurrence Wearing support hose reduces risks, but there is no guarantee that other, formally healthy veins will not become varicose. Following the recommendations for reducing the risk of developing varicose veins will aid in prevention.
  • Discomfort The injections are similar to insect bites. Check with Dr. King if you have a problem tolerating injections, or a low pain threshold. Ibuprofen, such as in the brand name medications Advil or Motrin are usually adequate for pain relief. Treatment sessions last for 30 minutes.
  • Risks and complications serious medical complications from sclerotherapy are extremely rare when performed by a qualified practitioner. However, complications do occur on occasion. Risks include clots in veins, severe inflammation, adverse allergic reactions to the sclerosing solution, skin injury that could leave a permanent scar. One common complication is pigmentation irregularities or brownish splotches on the affected area of skin that may take months to fade, or less often more than a year to fade. Another problem that can occur is a "matting" appearance where fine reddish blood vessels appear around the treated area, requiring further injections.
    
• Vein Stripping (removal) This surgery is normally considered outpatient, or same-day surgery. The varicosities on the lower leg are removed and/or ligated (tied off). Where sutures are needed, they are placed under the skin with a material that is absorbed. These incisions are then covered with steri-strips, or butterfly bandage. After the operation, gauze and elastic ACE bandages are applied to the leg. Usually there will be some physical restrictions for 2-4 weeks and rest with leg elevation required at home for several days. A follow-up visit with Dr. King in 2 weeks and again at 6 months will be scheduled. Most patients find that within 2-3 months the leg returns fully to normal and the final result of the operation can be assessed. At that point, some sclerotherapy may be desirable to treat the few residual veins for cosmetic purposes.
  
• Vein Ligation (tied off) The treatment of choice when the varicose veins are the result of saphenous system insufficiency in the groin, is to tie off, or ligate, the saphenous vein at the femoral junction to stop and prevent the distortion of engorged valves and leakage down the entire leg.
  
• Custom Compression Hose Elastic support stockings may be useful in keeping the symptoms under control, but they will not cure varicose veins. The compression of the stocking functions similar to the muscles in the leg, squeezing the veins so that the blood is pushed upward. This is especially useful for people who must post-pone surgery, such as pregnant or very obese patients who must lose weight before surgery. Custom fit compression stockings should be prescribed by the doctor and carefully fitted for the best results. It is essential that they give plenty of support to the lower leg without squeezing the calf or thigh and the doctors' prescription ensures exact compression distributed in a graduated manner up the leg. Stockings should be put on as soon as you get out of bed and be worn on all day.
  • Compression stockings are most effectively measured and fitted when leg swelling is at a low point, such as after elevation or in morning.
  • The compression counters, or balances the increased venous pressure in the legs.
  • The compression reduces venous volume in the legs, increases venous flow.
  • The compression supports superficial veins.