What they are, what favors the appearance of varicose veins, What symptoms may occur with varicose veins, What varices be treated?
What are they?
They are dilations of the superficial veins which are often tortuous and occur mainly in lower limbs (World Health Organization).
Are they frequent?
There are numerous epidemiological studies, typically included within a much delimited geographic or labor frame; we show a prevalence ranging between 15% and 56% of the general population. These significant differences are due to what each author has considered as varices.
If we include in this term the spider veins (telangiectasia), reticular varicose veins and major expansions the number is closer to the higher percentage, but instead, if we only consider the prevalence of large varices it is closer to 15%. If instead of taking into account their aspect grouped by clinical severity we will find that 44% of these varices are irrelevant to health and only 12% have true clinical impact (pain, edema, skin lesions, bleeds, phlebitis ...).
Extrapolating the data to Spain we suspect that between 6 and 23 million people suffer from some form of varicose veins and at least 5 million would require medical or surgical treatment. In the age group between 30 and 70, which includes most of the working population, 40% have some form of varicose veins, 15% clinically relevant and 1.5% do develop venous leg ulcers.
What favors the appearance of varicose veins?
Several factors support or increase the risk of developing varicose veins:
Age. It is the major risk factor and affects both men and women. At age 70 a 70% of the population has some of the types of the varices described versus only 20% at age 25.
Heredity. Carriers of varicose veins have a family history twice as often as non-carriers.
Obesity. Plays an adverse role in both sexes equally.
Multiple pregnancies. Among groups of women aged 37, one without having suffered pregnancy and the other two pregnancies, there are four times more varicosities in the pregnant group than in the other.
The Genre. Although the women consultation is 9 times more frequent than men for varicose veins, when truncal they are equally common in both sexes, however spider veins are more common in women.
Oral contraceptives. May promote the development of varicose veins but not very significantly and, instead, appear to protect against the phlebitis and pulmonary embolism.
Hernias. In themselves they do not favor the appearance of varicose veins but if there is a frequent association between both diseases.
The type of work. Especially in occupations with prolonged orthostatic (long standing) and waiters, bakers, hostesses, teachers, ...
Orthopedic problems. As with the hernias, there is a significant association with varicose veins, especially in women.
Social class. Varicose veins are more common in lower-middle class and industrial workers.
Constipation. It is possibly one of the frequent causes in affluent societies and addicted to junk fast food.
By what mechanisms do varicose veins develop?
The key element in the emergence and development of varicose veins is the deterioration or failure of the valves that exist along the veins. No matter if you first saw a widening of the vein or if it was the valve failure, the truth is that there are some pathological mechanical phenomena such as: increased blood pressure on various segments of the vein wall, out of fluid outside the vein (plasma leakage), it will change the exchange between intra-and extravascular systems and increased capillary permeability produced edema, local increase CO2 and lactic acid, release of histamine, serotonin and prostaglandins ... This chain of events is responsible for the subsequent symptoms of varicose veins. This will promote increased permeability edema and release of metabolites will lead to local pain and inflammation.
What symptoms can occur with varicose veins?
Following the progressive functional disability explained in the preceding paragraph signs change as the disease progresses. Usually we use an international classification into four grades:
It is characterized by rapid onset of venous network of the legs, varicose veins can be seen generally in antero outer thighs, behind knees and inside of legs but are asymptomatic.
Varicose veins begin to cause trouble because the hydrostatic equilibrium has broken, they are: heaviness and fatigue, especially when standing for a long time (orthostatic) and the end of the day it relieves by walking, with exercise or when they raise their limbs, pain, especially along the routes varicose veins in lower legs and ankles, their intensity can be very variable, cramps, especially in the calves and at night, pruritus, or itching of ankles and dorsum of the foot that can gateway to infection from scratching lesions, edema (swelling of legs) that are initially in ankles and feet and can ultimately affect the leg, initially subsides with rest, but over time they tend to be chronic and not disappear.
They are characterized by the appearance of subcutaneous deposits of red cells that are characterized by brown spots on the skin. The degeneration of the skin and fat that occurs under it leads to local inflammatory reactions that end up producing hardened and painful areas (subcutaneous fibrosis).
Ulcers appear at this stage, usually in the vicinity of the ankle, they are very painful and are slow to heal.
How should we explore a person who we suspect has varicose veins?
It should be done with completely bare legs, with the patient in orthostatic (standing). Simple inspection will reveal the existence of an extensive superficial venous network, shape and location; they also value the appearance of the skin (blemishes, eczema, indurated areas, ulcers, infections ...), the presence of edema and whether there are differences between one limb and another. Palpation will show us the tension increased in the varicose vein and the presence or absence of pain. At the level of the perforating veins left buttonhole appreciate them passing through the muscle fascia. There are a series of exploratory maneuvers (Schwartz Tredelemburg, Bernstein and PERT) that have become obsolete following the introduction of echo-Doppler.
What are the best tests to diagnose some varicose veins?
The echo-Doppler is Especially useful. With this system we can explore all the deep and superficial routes of the venous limb. Both lying and standing should be done and it is a painless test that does not require any prior training, which uses no contrast and a high diagnostic reliability. The combination of ultrasound with the Doppler effect allows us to see veins in all their way and check not only valve insufficiency but if there are existing thrombi, venous flow abnormalities and map all the anatomy and extent of disease vein. These studies will be much more accurate as the quality of equipment used and the explorer’s experience.
Are there other diagnostic tests in addition to the echo-Doppler?
Other tests such as phlebography (Rx after injection of contrast into the veins) Angioecho Magnetic AngioTAC, isotopic phlebography ... are tests that can be used for specific cases as a complement to studies on eco-Doppler.
What varicose veins should be treated?
Varicose veins are, in their different ways, a progressive degenerative disease that is usually not serious but they are uncomfortable and unaesthetic. In many cases their treatment is palliative, others can be cured permanently. Therefore they should be treated: developed varices, which have produced changes in the skin or subcutaneous fat and those that want to avoid future complications (risk of thrombophlebitis, ulcers or bleeding). For purely aesthetic reasons reticulate varices or spider veins can be treated.
What treatments are available for varicose veins?
There are four treatment groups that can or should be used together:
Physical-hygienic measures: consist in the correction of the predisposing factors. Patients with varicose veins should avoid obesity, constipation remedy, correct orthopedic abnormalities and exercise to promote venous return through the development of gemellary muscle. Careful hygiene is essential and moisturizing the skin of the legs. In most cases it is recommended to use normal compression stockings.
Drugs: There are numerous venous tonics acting on the vein wall or improving reabsorption of transudate. They are only useful only complementary measures to those described previously.
Sclerotherapy: is the introduction of liquids within the vein or foams that produce inflammation and blockage of the vein with the subsequent disappearance of the venous network. The type and concentration of the sclerosant is related to the size and location of the vein. Not all varicose veins can be treated with this method and there is a recurrence rate although its use has spread since the introduction of micro foam. It is also used as an adjunct to surgery.
Surgery: The traditional method involved the removal of internal or external saphenous vein by pulling a "cable" associated with ligation or closure of their union with femoral or popliteal veins. Its collateral branches were extracted by following the Muller micro incisions technique. After 10 years, there is a 25% local recurrence.
Recently less invasive endovascular techniques have been introduced such as radiofrequency or Endolaser. They are surgical procedures that prevent "tearing off” the saphenous replacing it with the elimination of saphenous with a powerful beam of light (laser) or radio waves (radio frequency) to "burn" the vein from inside. Associated with the Muller's technique to simultaneously remove the collateral saphenous varicose. They have similar results to conventional surgery but are less aggressive and the post-surgery is better. Another technique used for some years is the method CHIVA or hemodynamics venous surgery. The theoretical underpinnings of this technique are discussed at international level and although some authors report good results they are associated with many subsequent re-surgeries. In selected cases they can be effective.
What are risks of these treatments?
No medical or surgical treatment is exempt of risk in any area of medicine. Sclerotherapy may be associated with chemical burns of the skin, brownish tattoos along the way where the varicose vein was, deep vein thrombophlebitis and pulmonary embolism (especially in cases treated with foam). They are rare but can be long to resolve. The surgery also has a low rate of bleeding complications but are described, organized hematoma, surgical wound infections, deep vein thrombosis of sensory disturbances in the course of the saphenous nerve ... etc.
If I do not remove the varicose veins, what complications may occur over time?
The four most common complications that can occur throughout the evolution of some untreated varicose veins include:
- Varicorragia or bleeding from ruptured varicose vein eroding the skin. Like any bleeding its appearance is very shocking but does not usually lead to anything serious. They have to be treated with limb elevation and compression bandaging.
- Varicophlebitis, which is the formation of a clot inside a varicose vein. It is relatively common in large varices and is presented as a hard cord, painful and erythematous (red). If the thrombus does not extend to the area near the junction of the saphenous femoral or popliteal no great danger is assumed. There are different forms of treatment, since surgical removal of the thrombus to the use of subcutaneous heparin or anti-inflammatories at the discretion of the physician regarding the status and severity of thrombus.
- Varicose ulcers. They are painful and slow to heal. They are treated by local cleaning, elevation, and very compressive bandages. There are also numerous ointments, patches and other products that help the healing of the ulcer.
- Dermatitis. They are inflammations of the skin, reddened and itchy and uneasiness. They are treated with steroid ointment, elastic stockings and by eliminating the underlying varicosity that has occurred.
escrito por Dr. G. España, August 24, 2009