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Updated 15 February 2013

Varicose veins

Varicose and spider veins can occur in men and women at any age, but most frequently affect women during their childbearing years and later lives.

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Description

A vein is a blood vessel that carries blood low in oxygen content from the body to the lungs and heart. It is a normal part of the circulatory system. Thousands of people every year consider getting treatment for varicose veins and spider veins.

Advertisements for treating venous disease often tout "unique," "permanent," "painless," or "absolutely safe" methods – making it difficult to decide on the best treatment. If you are considering this procedure, the following information may help. Remember, though, "spider veins" also can appear on the skin surface. These may look like short, fine lines, "starburst" clusters, or a web-like maze. Spider veins are most common on the thighs, ankles, and feet. They may also appear on the face.

Cause

The causes of varicose and spider veins are not entirely understood. In some instances, the absence or weakness of valves in the veins, which prevent the backward flow of blood away from the heart, may cause the poor circulation. In other cases, weaknesses in the vein walls may cause the pooling of the blood.

Less commonly, varicose veins are caused by such diseases as phlebitis (inflammation of the veins) or congenital abnormalities of the veins. Venous disease is generally progressive and cannot be prevented entirely. However, in some cases, wearing support hosiery and maintaining normal weight and regular exercise may be beneficial.

Prevalence

Varicose and spider veins can occur in men and women at any age, but most frequently affect women during their childbearing years and later lives. A family history of the problem and ageing increase the tendency to develop these vascular abnormalities.

Treatment

Varicose and spider veins may be primarily a cosmetic problem. Severe cases of varicose veins, especially those involving ulcers, typically require treatment. Consult your doctor if you are uncertain.

Varicose veins are frequently treated by eliminating the "bad" veins. This forces the blood to flow through the remaining healthy veins. Several methods can be used to eliminate the affected veins, including, most commonly, surgery or sclerotherapy.

Less commonly, laser or electrocautery has been used to treat small spider veins, especially on the face.

Surgical removal of varicose veins, commonly referred to as "stripping," is usually done under local or partial anaesthesia, such as an "epidural." Here, the affected veins are "stripped" out by passing a flexible device through the veins and removing them through an incision near the groin. Smaller tributaries of these veins also are stripped with this device or removed through a series of small incisions. Those veins that connect to the deeper veins are then tied off. This stripping method has been used since the 1950's. Use of the Trivex system has greatly improved removal of varicose veins.

Spider veins cannot be removed through surgery. Sometimes, they disappear when the larger varicose veins are removed, which feed the spider veins. Remaining spider veins also can be treated with "sclerotherapy." For sclerotherapy, a fine needle is used to inject a solution (sclerosant) directly into the vein. This solution irritates the lining (intima) of the vein, which causes total obliteration of the venous lumen following compression with a tight bandage. To achieve this, the vein is injected while it is as empty of blood as possible (for example by elevating the leg).

The substances most commonly used today are hypertonic saline or sodium tetradecyl sulphate.

During sclerotherapy, after the solution is injected, the surrounding tissue is generally wrapped in compression bandages for several days, causing the vein walls to stick together. The vein later turns into scar tissue that fades from view. Patients whose legs have been treated are put on walking regimens, which forces the blood to flow into other veins and prevents formation of blood clots. This method and variations of it have been used since the 1920's. Some doctors treat both varicose and spider veins with sclerotherapy. In most cases, more than one treatment session will be required.

For all of these procedures, the amount of pain sensation will vary, depending on the person's general tolerance for pain, how extensive the treatments are, which parts of the body are treated, whether complications arise, and other factors. Because surgery is performed under anaesthesia, no pain is felt during the procedure. After the anaesthesia wears off, the patient will likely experience pain near the incisions.

For sclerotherapy, the degree of pain will also depend on the size of the needle used and which solution is injected. Most people find hypertonic saline to be the most painful solution and experience a burning and cramping sensation for several minutes when it is injected. Some doctors mix a mild local anaesthetic with the saline solution to minimise the pain.

Carefully question doctors about the safety and side-effects for each type of treatment. Thoroughly review any "informed consent" forms your doctor gives you explaining the risks of a procedure.

For surgical removal of veins, the side-effects are those for any surgery performed under anaesthesia, including nausea, vomiting, and the risk of wound infection. Surgery also results in scarring where small incisions are made and may occasionally cause blood clots.

For sclerotherapy, the side-effects can depend on the substance used for the injection. People with allergies may want to be cautious. Some substances may cause allergic reactions, occasionally severe. Hypertonic saline solution is unlikely to cause allergic reactions. Any sclerosing substance may burn the skin (if the needle is not properly inserted) or permanently mark or "stain" the skin. (These brownish marks are caused by the scattering of blood cells throughout the tissue after the vein has been injected and may fade over time).

Occasionally, sclerotherapy can lead to blood clot formation. Laser and electrocautery treatments can cause scarring and changes in the colour of the skin.

Many factors will affect the rate at which treated veins recur. These include the underlying tissue and vascular weakness, the method used and its suitability for treating a particular condition, and the skill of the medical practitioner.

Sometimes the body forms a new vein in the same place of the one removed by the doctor or an injected vein that was not completely destroyed by sclerotherapy may reopen. Many studies have found that varicose veins are more likely to recur following sclerotherapy than after surgery. However, no treatment method has been scientifically established as free from recurrences. For all types of procedures, recurrence rates increase with time. Also, because venous disease is typically progressive, no treatment can prevent the appearance of new varicose or spider veins in the future.

The method you select for treating venous disease should be based on your doctor’s, the size of the veins to be treated, your previous treatment history, your age, your history of allergies, and your ability to tolerate surgery and anaesthesia, among other factors. As noted above, small spider veins cannot be surgically removed and can only be treated with sclerotherapy. On the other hand, larger varicose veins may, according to many studies, be more likely to recur if treated with sclerotherapy.

Be wary of claims touting "major breakthroughs," "permanent results," "unique treatments," "brand- new," "painless," or "absolutely safe" methods. Always ask for specific documentation for claims made about particular recurrence rates or fewer health risks or cosmetic side-effects.

Reviewed by Prof Don du Toit (M.B.Ch.B) (D.Phil.) (Ph.D) (FCS) (FRCS).

 
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