Definition of Varicose Veins
Varicose veins are a condition affecting both men and women. Essentially, they are veins that have become enlarged and twisted, traditionally occurring in the legs. However, any vein in the body can become varicose. The reason the legs are the most traditional place for varicose vein is because when standing and walking, the increased pressure on the veins in the lower body leads to a higher likelihood of the veins becoming enlarged. This is due to the force of the weight of the body along with the flow of blood to the lower body. For some people, varicose veins are only a cosmetic concern, as they are unsightly and sometimes disfiguring. Treatment may be sought out in order to improve the person’s appearance. For others, varicose veins can cause aching pain and discomfort. The condition can lead to more serious problems if not treated. Varicose veins may indicate a higher risk of other circulatory problems. The most severe case of varicose veins may include ulcers forming on the skin. Ulcers are caused by long-term fluid buildup in the tissues and may indicate poor blood circulation in the legs.
Prevalence and Risk Factors
Prevalence of a disease is the percentage of people in a population who have the disease at a specific time. An increase in prevalence means that the number of people with a disease has increased. According to the World Health Organisation, varicose veins affect one in every four people worldwide. One of the reasons why it is more common to be affected by varicose veins is because people are living longer. Varicose veins is an age-related condition, with prevalence indicating that it is more common as you get older. Cross-sectional data from the Edinburgh Vein Study and the Framingham Study show an increase in prevalence with age, to about 70% in the 7th and 8th decades of life. Women have a higher chance of getting varicose veins with a lifetime risk of 50%, whereas in men the lifetime risk is about 40%. This difference in risk between the genders has been demonstrated in populations from Europe and the USA, and is most evident in the older age groups. A risk factor is something that increases a person’s chance of getting a disease. According to the NICE guidelines, there are numerous risk factors for varicose veins. These include family history, age, gender, pregnancy, and obesity. The impact of these risk factors on the prevalence of varicose veins and whether they affect the disease’s severity is poorly understood. An epidemiological analysis of the Edinburgh Vein Study suggested that obesity is an important risk factor for varicose veins, with a population attributable risk of 30.3%. The analysis also showed that severe varicose veins were more common in obese people and that obesity was not just an important risk factor but also a disease severity factor. This was in keeping with data from the VEIN-NORD RCT which showed that obese patients had a more marked improvement in health-related quality of life after varicose vein treatment. This is all very recent work and more research is required, particularly on the potential reversibility of obesity as a risk factor and its effect on vein disease severity.
Importance of Research and Advances
There have been a lot of recent advances in research on varicose veins, and this has helped identify the mechanisms underlying the disease. This information has been important to help understand why the disease occurs and what treatments would be effective. One of the most significant recent advances is the understanding that the underlying cause of varicose veins is due to a condition known as chronic venous insufficiency. This condition causes damage to the valves in the veins and the vein wall. This damage leads to reflux, which is the backward flow of blood in the veins. The reflux in the veins causes the back of the vein to become congested with blood, and this leads to the enlargement and twisted nature of varicose veins. Understanding this mechanism has meant that the treatment of varicose veins is now much more effective, as it is possible to seal off the faulty veins that are causing the problem.
Varicose veins are a common condition, affecting approximately 25-40% of women and 10-25% of men. They are superficial veins that have become enlarged and twisted and usually occur on the legs. These veins can cause a lot of pain to individuals and in severe cases can cause skin ulcers. However, what is the importance of research and advances on this condition?
Causes and Symptoms
There are many different theories on the cause of varicose veins, but most likely there are a number of factors that contribute to the condition. In addition to heredity, women are at an increased risk for developing varicose veins when hormonal changes occur such as during pregnancy, or with the use of birth control pills. Some studies suggest that as many as 40% of women may develop varicose veins during their lifetime. Hormones could also be the reason that varicose veins are more common in women, since hormonal changes relax the vein walls. It is also thought that the added weight of the womb on the veins in the pelvis can lead to varicose veins. This is a debatable point, but it does make sense, since the veins in the legs have to carry the increased volume of blood from the lower extremities back up to the heart. The exact cause of varicose veins is not entirely known, but damage to the valves in the veins is a likely place to start. If the valves do not function properly, the blood will flow backward and pool in the vein. This high pressure of the stagnant blood will then dilate the vein and cause the familiar twisted and bulging of varicose veins. This is why some people who have varicose veins report feelings of achiness or tiredness in their legs. These symptoms usually worsen with prolonged sitting or standing.
Underlying Causes of Varicose Veins
As they are now known to be caused by a range of factors, the best way to classify the accurate underlying cause for each individual’s varicose veins is to seek the advice of a doctor. A large number of patients discover that their varicose veins have been caused by increased pressure inside the abdomen, known as intra-abdominal pressure. This can be caused by a number of conditions such as a tumor, constipation, heavily restrictive clothing, or shoes, and most often pregnancy. This pressure places added force on the internal veins, potentially forcing blood to flow in the wrong direction and worsen the varicose veins. High force and duration of these pressures greatly increase the likelihood of varicose veins developing.
All veins contain one-way valves to ensure that blood only moves in one direction, against gravity, and back to the heart. If these valves fail, blood will flow backwards, enlarging the vein. When this occurs near the surface of the skin, a varicose vein is formed. This explains why varicose veins are most often found in the legs. The cause of this valve failure has not been identified, but a hereditary link has proven to increase the likelihood of developing varicose veins. Hormonal factors have also been identified as a cause. This is clearly shown in the increased likelihood of women developing the condition while they are pregnant, pre-menstrual, or upon taking oral contraception.
Common Symptoms and Complications
Some people with varicose veins also suffer from restless legs. This is an urge to move the legs with an uncomfortable feeling. It is often worse at night and can disturb sleep. In most cases, it is difficult to settle on a cause for restless legs, and it is often idiopathic. However, there is no doubt that it can be associated with vein problems, and an improvement often occurs after treatment.
Symptoms that are often attributed to other conditions, such as tiredness, heaviness, aching, itching, and cramp, tend to be more severe in the evening. A common misconception is that varicose veins are caused by crossing the legs. This is not true, although it can make the leg symptoms worse. In some respects, the severity of the leg symptoms is a better indicator of the requirement for treatment than the extent of the visible varicose veins.
Leg symptoms occur because of the damage to the valves in the veins. It is not uncommon to have secondary symptoms of leg swelling, and in severe cases, with skin changes or even venous ulcers. Usually, the leg symptoms and swelling are worse after standing for long periods. Some women notice that the symptoms are worse during the latter part of the menstrual cycle.
Current Treatment Options
Patients with advanced chronic venous insufficiency may require minimally invasive or surgical intervention to alleviate symptoms and improve the cosmetic appearance of varicose veins. Minimally invasive procedures function to block off refluxing veins using less invasive techniques than traditional vein stripping surgery. This is often achieved by the thermal ablation of veins, commonly utilizing radiofrequency or laser energy to collapse and seal off the affected veins. Newer techniques are said to cause less pain and bruising than traditional surgery; however, there is still debate regarding the long-term efficacy and ideal methods of patient selection for these procedures. Other invasive methods involve the injection of sclerosant into veins (sclerotherapy) or the use of surgical vein ligation to prevent the recurrence of venous ulcers.
Conservative management of CVI is considered the first-line treatment. This typically involves a combination of lifestyle modifications and compression therapy. Several regular periods of leg elevation throughout the day are thought to reduce ambulatory venous pressure by using the calf muscle pump. The most preferred method of compression therapy is the use of compression stockings. It is believed that the external pressure accredited by stockings helps to correct venous reflux and improve the efficacy of the calf muscle pump by reducing the diameter of the distended veins. Additionally, the use of compression bandaging for venous ulcers has shown to significantly improve the rate of healing. With combined efforts of compression and bandaging, lifestyle modifications aim to prevent the occurrence of venous ulcers by immobilizing the ulcerated area and reducing edema. High-quality clinical trials validating the effectiveness of conservative management techniques are scarce and often do not provide significant evidence in support of their use.
Conservative Management Techniques
The superficial venous system of the lower extremity in humans is a highly complex network with abundant anastomoses between veins. It is composed of the great and small saphenous veins and their tributaries. Varicosities can affect any of these veins, and it is essential to evaluate the pattern and extent of venous reflux before determining the appropriate management strategy. There is some evidence that physical activity might reduce the risk of acquiring varicose veins; however, for people who are already affected, exercise may exacerbate symptoms, and it is uncertain whether it has any effect on the progression of the disease.
Chronic venous insufficiency (CVI) is a widely prevalent condition that affects millions of people and is the root cause of most varicose veins. While there are a number of ways to treat varicose veins, one important point to recognize is that there is no cure for the condition. Even after completing a treatment, whether it be a surgical or a minimally invasive procedure, it is quite possible that new veins will become affected. For these reasons, it is essential to understand and explore the most conservative methods of managing CVI and varicose veins.
Minimally Invasive Procedures
Clarivein – an exciting new technique that mechanically abrades the vein from the inside while delivering a dose of sclerosant drug. This method is painless and is associated with good evidence from early uses.
Foam Sclerotherapy – An improved version of traditional sclerotherapy where a medication is injected to irritate the vein and cause it to seal shut. Foam sclerotherapy has been proven to be a highly effective method of treating smaller varicose veins, often with good cosmetic results. It can also be used to treat recurrent varicose veins when used in conjunction with other methods as described in the REVIVE trial.
Endovenous Thermal Ablation methods – The use of laser energy or radiofrequency energy to seal the main leaking vein. A thin catheter is inserted directly into the vein, and energy is applied to seal the vein. These procedures are associated with excellent recovery times and good success rates for truncal vein reflux.
In recent years, a number of new procedures that use minimally invasive techniques have been developed, causing less discomfort and quicker recovery than conventional surgery. These treatments are usually performed using local anesthetic, sometimes supplemented by mild sedation. All are provided on a day-case basis with no overnight stay.
Surgical Interventions
Recent developments in technology and procedures have meant that more surgical options are available. Vein stripping surgery is now largely considered to be outdated, painful and has a long recovery time. There are now many endovenous procedures that have much better results and fewer complications. These procedures are done by inserting a catheter into the abnormal vein and using heat or other methods to seal the vein shut. The catheter is guided through the vein using ultrasound. This means the procedure is minimally invasive and doesn’t require a general anaesthetic. Echosclerotherapy is a method that enhances ultrasound-guided sclerotherapy by allowing the doctor to see the needle entering the vein in real time. This is a more efficient and accurate way of treating varicose veins with sclerotherapy. Sclerotherapy is the injection of a solution into the abnormal vein which causes the vein to collapse and fade away. This can also be done to smaller varicose veins and spider veins.
The definitive treatment for varicose veins is surgery. Traditional surgery involves tying and removing the affected vein. This is usually done under a general anaesthetic. Phlebectomies are the removal of the large lumps of veins that have come to the surface and these are also often done at the same time as the vein ligation. Vein stripping and high ligation is a surgery that allows for the removal of large varicose veins. This is done under general anaesthesia and requires an incision at the top and bottom of the vein, where the top incision is where the problem vein is tied and then removed through the bottom incision. Ambulatory Phlebectomy is a minimally invasive procedure that is used for the resection of large surface varicosities. The procedure requires a needle stick or a small incision and it is performed while the patient is awake and standing. It is done in an office setting whereas vein stripping is done in a hospital.
Latest Research and Advances
High ligation and stripping have declined as foam-based techniques have risen, so new classification systems for chronic venous diseases and chronic venous insufficiency have been created to guide appropriate management. This involves C1 and C2 diseases being treated by endovenous thermal or chemical ablation, C3 with a combination of ablation and foam sclerotherapy, and surgical methods for C4-6; the latter indicating the most severe forms of venous insufficiency.
Foams and gases have been used to deliver sclerosants, using either air or carbon dioxide. The gas may remain in the vein for 24 hours and provide greater contact time between the sclerosant and the vein wall, increasing its effectiveness. Any adverse effects can be alleviated by aspiration of the gas from the vein.
Nevertheless, strong evidence supports ultrasound-guided foam sclerotherapy with 5-year closure rates similar to more invasive surgery and less divergence from it than traditional sclerotherapy. Sclerotherapy costs also fall below that of surgery, so it is still popular in use today.
Endovenous microwave ablation, for example, is not widely used due to a lack of evidence and it being a newly developed technology. A meta-analysis showed that this technology is associated with minor post-operative pain but some recurrent varicose veins.
Thermal methods such as EVLT are more effective than open surgery, with a 5% recurrence rate at 5 years compared to 15-20% with open surgery. Side effects include damage to underlying tissue, deep vein thrombosis, and pulmonary embolism. Energy sources for the thermal methods are supplied by radiofrequency or laser.
Open surgery and endovenous thermal ablation both cause bruising, which will usually last 1-2 weeks. This is an expected side-effect of the surgery and it can cause brown staining in the area, which is likely to be permanent.
Endovascular techniques have also been augmented, besides traditional surgically invasive procedures such as vein stripping, thermal methods including ablation are used. In addition, non-thermal, non-tumescent methods are also conducted, providing a certain level of efficacy and cosmetic results.
Novel Therapies and Treatment Approaches
Pharmacological methods of treatment will also be an area of interest for patients who prefer not to undergo any invasive procedures. Although drug treatment that is currently available appears more directed at treatment for symptoms of venous disease, studies are being conducted to find medication that has the potential to prevent progression of varicose veins or cause a reduction in their size. A randomized controlled study recently demonstrated that use of a flavonoids/endovenous compression sclerotherapy combination arrested disease progression and improved appearance better than sclerotherapy alone. This gives hope to the idea that future medication might act in conjunction with other treatments to promote better long-term outcomes for patients with varicose veins.
Although progression and consistency of reliable treatments are pivotal, it is likely that in the future more patients will consider the prospect of possible gene therapy and pharmacological approaches to treating varicose veins. In the quest to understand the genetic basis of varicose veins, gene therapy could be directed at turning off the genes responsible for vein wall weakness or inflammation and be a topic of debate in the coming decades. The selective targeting of the affected vein wall without causing damage to surrounding tissues, which might be achieved with gene therapy or identified enzymatic processes, is an attractive concept.
Despite the recent surge in studies examining the latest surgical and endovenous techniques, it appears that not all patients agree with the recommended treatment approaches for varicose veins. Patients often prefer minimally invasive techniques due to the decreased invasiveness and stress of surgery, causing less trauma and faster recovery. Such patients may be suited to methods such as ultrasound-guided foam sclerotherapy. ClariVein is an innovative technique involving a wire-directed mechanical ablation of the vein combined with simultaneous administration of liquid sclerosant. It is also possible that new techniques might encompass a more tailored approach to treating varicose veins. One study showed that with endovenous laser therapy, more rapid improvement and resolution of the presenting symptoms and signs of superficial venous disease were experienced in limbs treated to higher energy levels. This suggests the possibility of customizing energy dosages specific to patient symptoms and the size of the incompetent vein. Development in this area might also involve the improvement of pre-procedural duplex ultrasound for access to more detailed information regarding vein anatomy and specific areas of reflux, which could require individual attention.
Technological Innovations in Varicose Vein Treatment
Technological advances in the area of varicose vein treatment have been great indeed. The majority of these have been directed at minimizing the invasiveness of treatments, reducing downtime, and eliminating the need for general anesthesia. Sonography has been one of the key areas of advancement. This has enabled doctors to undertake more precise and less invasive procedures. Duplex or color sonography allows for a detailed visualization of the entire area affected by varicose veins. Sonography systems have been used to guide a number of minimally invasive treatments such as VNUS closure. Thermal ablation is another area in which technology has evolved. High-frequency closure uses a radiofrequency wave released from the tip of a catheter. This heat damages the vein wall, which is then treated using a catheter-based system that creates a controlled environment for the solid adhesive to become liquid. The liquid then seals the vein. The compression methods used parallel the same methods used around the world to prevent DVT, an area in which a lot of research has been done. Laser therapy, to a lesser extent, is now commonly used to close off small varicose veins and spider veins. The type of laser used, however, dictates the clinical results. Low-wavelength lasers are not powerful enough to heat the vein and thus have little effect. Very high-wavelength lasers instantly heat the blood in the vein, which can cause pain and inflammation to the surrounding tissue. A 940 nm diode laser has shown to be the most effective wavelength. It is quickly absorbed by blood, which heats the vein. The heat then causes the walls to shrink and collapse. This is clinically proven and can be done without the need for using a local anesthetic.
