Introduction to Varicose Veins

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• What is the normal venous anatomy in the legs?

  Veins carry blood from the legs back to the heart. The venous system in the lower limb is made up of a network of veins consisting of:

  
  

  Superficial veins: Are veins located close to the surface of the skin. They drain the blood supply of the skin and superficial tissues to the deep veins. There are two main trunks called the long saphenous vein and the short saphenous vein as demonstrated in the illustrations. Similar to a tree trunk or a river they have many branches (also called tributaries) which form a network of inter-connecting veins that drain a wide area into the main trunks. When talking about varicose veins these are ones which are affected.

  
  

  Deep veins: Are larger veins located deep in the legs between the muscles and the bones of the legs. They usually follow the course of the arteries and have similar names to their arterial counterparts eg.; deepfemoral vein or popliteal vein. These deep veins are the main vessels that return the blood (brought into the legs by arteries) up from the legs to the heart. When talking about deep vein thrombosis (economy class syndrome) these the ones which are affected.

  
  

  Perforator (communicating)veins: Connect the superficial veins to deep veins. They are many in number along the length of the leg but some are more constant in position (such as the Cockett’s group, Boyd’s and Dodd’s perforator). The most important perforators however, are the sapheno-femoral junction and the sapheno-popliteal junctions at the top of the leg and behind the knee respectively. In the normal physiological setting the direction of flow is from deep to superificial in these veins.

  
  

  Thread veins/Spider veins/Reticular veins: These are not a constant finding. They become more frequent with age, and are a more common in women especially of the reproductive age and beyond. They are completely confined to the skin and are not part of the system of veins described above. Reticular veins tend to be more pronounced than the other two; but none of them represent varicose veins.

  
  

  The return of venous blood to the heart from the lower limbs requires a pump equipped with one way valves. The pumping action is provided by the tone and contraction of the muscles which squeeze or milk the blood towards the heart during walking or periods of muscular contraction. The valves prevent the blood coming down the leg again.

• How do Varicose Veins develop?

  
  

  Venous Reflux disease develops when the valves (within the veins that help blood flowing up the legs and back to the heart) become diseased or "incompetent". As a consequence, the blood being returned to the heart by the pumping action of the muscles simply returns down the leg. Venous reflux is the beginning of the varicose vein process; with increasing reflux the vein becomes increasingly distended, tortuous, and therefore more visible. This process also makes reflux worse because as the vein increases in diameter the valves are no longer able to meet in the middle and therefore develop functional "incompetence".

  
  

  • How does venous reflux lead to varicose vein formation?

    
    

    Varicose vein is usually a term used to describe dilated tortuous superficial veins in the leg. It is thought that the main causes of varicose veins is the constant pressure from venous reflux which leads to elongated, twisted and enlarged veins on the lower limbs. The reason for this is that the blood being pumped up the leg in the deep veins by the muscle pump action tends to return down the leg through the incompetent valves and at the junctions of the deep and superficial veins. The most important of these are at the top of the leg (sapheno-femoral junction) and behind the knee (sapheno-popliteal junction).

    
    

    The perforators also play an important role in varicose vein process. Generally speaking, the direction of flow is from deep to superficial veins. This means that during resting or lying down positions, the flow from is from the skin to the deeper tissues. This is permitted because the pressure within the “calf pump” (see below) is low. The valves in the perforator veins are also uni-directional, that is to say they allow the flow of blood only in one direction; i.e.; from deep to superficial. During walking or exercise the pressure in the deeper veins increases and blood flow through these perforators ceases. The contracting muscles squeeze the veins and help "pump" the blood up the leg. These perforator veins and their valves can also become affected by the varicose vein process and develop reflux and "incompetence". In these situations, the valves lose their uni-directional action and blood moves in both directions from superficial to deep and vice versa. This tends to make the varicose process worse.

    
    

  • What are the causes of venous reflux/varicose veins?

    
    

    • It is thought that varicose veins are part of the penalty we pay for the adoption of the erect posture because as far as we know, other animals do not suffer from varicose veins.
    
    
    • Age, gender, family history of varicose veins, multiple pregnancies, obesity and having a profession which requires a long period of standing all play a part in varicose veins causation.
    
    
    • It is thought that a congenital scarcity of the valves in isolation or with muscle weakness and wasting or defect in the deep fascia stretching might play part in the impairment of the pump.
    
    
    • It has been estimated that on standing, the whole weight of the column of the blood from the leg to the heart is exerted on the valves (up to pressure of 90mmHg, 12kpa) particularly on those guarding the communications between the superficial and deep venous systems of the leg (perforator veins) as the blood normally flows from the superficial system into the deep veins.
    
    
    • The main valves affected are the sapheno- femoral junction lying at the junction of the long saphenous and common femoral veins. This can lead to dilatation of the long saphenous vein system down the whole length of the vein with each subsequent valve in this long vein becoming in turn “incompetent” under the pressure of the column of blood above. The same process might also lead to sapheno-popliteal junction “incompetence” with dilatation and torturous appearance of the short saphenous vein behind the leg.
    
    
    • Varicose veins may also start at the site of any incompetent perforating vein in the deep fascia.
    
    
    • When the valve is incompetent, there is a high intermittent pressure leakage of blood into the superficial system leading to reversal of blood flow from deep veins to the superficial veins.
    
    
    • It is also thought that hormonal factors such as progesterone in women might pre-dispose to varicose vein formation.
    
    
    • Varicose vein might also be caused by obstruction to venous return in conditions such as pregnancy, tumours and thrombosis of deep vein.
    
    
    • Varicose veins in young people might suggest underlying congenital abnormalities.
    
    
    • There are many cases where no cause could be found.

    
    

  • What other places can varicose veins occur?

    Varicose veins can also occur in other parts of the body, for example:

    • Varicose veins of veins at the lower part of gullet and stomach area (esophageal varices and gastric varices).
    
    
    • Varicose veins of the lower large bowel area (haemorrhoids/piles).
    
    
    • Varicose veins of the genital area for example, varicose veins of veins inside scrotum called varicocoele.
    
    

• What are the symptoms of varicose veins?

  • Most cases of varicose veins are asymptomatic.
  
  
  • The most common symptoms of varicose veins are aching sensation or tiredness in legs. Symptoms are especially in the calf towards the end of the day.
  
  
  • Sharp and localized pain at the site of the varices might be noticeable if the varicose veins are grossly dilated.
  
  
  • The ankles may swell towards the evening and the skin of the leg may itch or gradually discolour over a period of time.
  
  
  • Some patients may suffer cramps in the calf shortly after retiring to bed.
  
  
  • Other symptoms such as heaviness and fatigue and swollen limbs might occur as a consequence of varicose veins.
  
  
  • Symptoms of varicose veins can worsen over time if left untreated.

• What are the complications of varicose veins?

  • Bleeding may occur from the varicose veins following relatively minor trauma.
  
  
  • Thrombophlebitis of the superficial varicose veins. This refers to thrombosis (blocked vein) associated with surrounding inflammatory reaction causing redness and tenderness of the tissues around the varicose veins. It is not an infection – merely the body’s reaction to blood clot within a vein.
  
  
  • Eczema or chronic dermatitis (inflammation of skin)with allergic manifestation itching and redness.
  
  
  • Varicose vein ulcers might occur around the ankle area which might prove difficult to treat.
  
  
  • There are other rare complications of varicose veins.
  
  

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