Makindo Medical Notes

Introduction

Varicose veins are enlarged, tortuous, and dilated veins that primarily occur in the lower limbs due to venous insufficiency. They result from weakened vein walls and valves that cause blood to pool, leading to vein dilation. Although varicose veins are generally considered a cosmetic issue, they can lead to discomfort and complications if left untreated. Varicose veins develop due to increased pressure in the veins, often in combination with several risk factors

Causes and Risk Factors

• Age: The risk of developing varicose veins increases with age as vein walls weaken and lose elasticity.
• Gender: Women are more likely to develop varicose veins, particularly due to hormonal changes during pregnancy, menopause, or use of birth control pills.
• Pregnancy: The increased blood volume and pressure on the pelvic veins during pregnancy contribute to varicose vein development.
• Prolonged Standing or Sitting: Occupations that involve long periods of standing or sitting can increase the risk of varicose veins by impairing venous return.
• Obesity: Excess body weight puts additional pressure on the veins, increasing the risk of varicosities.
• Family History: A family history of varicose veins increases the likelihood of developing them.
• Previous Deep Vein Thrombosis (DVT): A history of DVT can damage vein valves, leading to venous insufficiency.

Pathophysiology

• Varicose veins occur when the valves in the superficial veins of the legs become incompetent, causing blood to flow backward (venous reflux).
• This leads to increased venous pressure and pooling of blood in the veins, which stretches and enlarges the vein walls. Over time, this causes the veins to become tortuous and visible under the skin.
• Varicosities are most commonly found in the great saphenous vein (GSV) and its tributaries. The deeper venous system typically remains functional, but in severe cases, both superficial and deep venous systems may be affected.

Clinical Features

• Visible Veins: Dilated, twisted, bluish veins are the most obvious sign of varicose veins.
• Leg Pain or Discomfort: Aching, heaviness, or a throbbing sensation in the legs, particularly after prolonged standing or walking.
• Swelling: Swelling of the ankles and lower legs, especially at the end of the day.
• Itching or Burning: Itching or a burning sensation around the varicose veins.
• Night Cramps: Cramps in the legs, especially at night.
• Skin Changes: Over time, skin over the varicose veins may become discolored (brownish or bluish), and ulcers may develop in severe cases.

Complications

• Superficial Thrombophlebitis: Inflammation of the vein due to clot formation, causing redness, pain, and tenderness along the affected vein.
• Venous Ulcers: Chronic venous insufficiency can lead to skin breakdown and ulcers, particularly near the ankles.
• Bleeding: Varicose veins close to the skin surface may rupture and cause significant bleeding.
• Chronic Venous Insufficiency: Persistent venous reflux can cause long-term damage to the skin and subcutaneous tissues, leading to lipodermatosclerosis and venous stasis ulcers.

Diagnosis

• Physical Examination: Inspection of the legs for visible varicosities, skin changes, and signs of chronic venous insufficiency. Palpation of the veins to assess for tenderness and thrombosis.
• Doppler Ultrasound: The gold standard for diagnosing venous insufficiency. Doppler ultrasound assesses the flow of blood in the veins and helps identify areas of venous reflux and obstruction.
• Plethysmography: A non-invasive test that measures changes in blood volume in the leg to assess venous function.

Conservative Management

• Compression Stockings: Graduated compression stockings are the first-line treatment for symptomatic varicose veins. They help improve venous return and reduce swelling, pain, and discomfort.
• Elevation of the Legs: Elevating the legs helps reduce venous pressure and swelling.
• Weight Loss: Losing excess weight can reduce pressure on the veins and improve symptoms.
• Exercise: Regular exercise, particularly walking, improves calf muscle pump function, promoting venous return.
• Avoid Prolonged Standing or Sitting: Frequent movement and leg exercises can prevent blood pooling in the legs.

Interventional Treatment

• Sclerotherapy: A minimally invasive procedure where a sclerosant solution is injected into the varicose veins, causing them to collapse and eventually disappear. It is effective for smaller varicose veins and spider veins.
• Endovenous Laser Ablation (EVLA): A catheter-guided laser is used to heat and seal the affected veins. This minimally invasive procedure is used for larger varicose veins and is done under local anesthesia.
• Radiofrequency Ablation (RFA): Similar to EVLA, RFA uses radiofrequency energy to heat and close the veins. It is effective in treating venous reflux in the great saphenous vein.
• Ambulatory Phlebectomy: A surgical procedure where small incisions are made to remove varicose veins. It is typically done for larger, bulging veins.
• Vein Stripping and Ligation: A more invasive surgical procedure where the affected vein is tied off and removed. This is generally reserved for severe cases or when less invasive treatments are not effective.

Prevention

• Although it is not always possible to prevent varicose veins, certain lifestyle measures can reduce the risk or delay progression: Maintain a healthy weight. Exercise regularly to improve circulation, particularly leg exercises that strengthen the calf muscles.
• Avoid prolonged periods of standing or sitting. If standing is required, shift weight frequently or perform calf raises.
• Wear compression stockings if at risk of venous insufficiency. Elevate the legs when resting to promote venous return.

Conclusion

• Varicose veins are a common condition that can cause cosmetic concerns, discomfort, and complications if left untreated. Early diagnosis and management can help alleviate symptoms and prevent complications.
• Treatment options range from conservative measures such as compression therapy to minimally invasive procedures like sclerotherapy and EVLA. For patients with significant venous insufficiency, interventional treatment may be necessary to achieve optimal results.