Varicose veins

Patients with varicose veins present with symptoms ranging from asymptomatic to significant symptoms, which include:

• Discomfort
• Itching (eczema)
• Swelling
• Aching pain that may worsen after prolonged sitting or standing
• Blood clots in the deep veins of the legs
• Twisted, swollen, and lumpy veins
• Veins that appear blue or dark purple
• Throbbing or cramping sensations
• Itchy or irritated rash
• Darkening of the skin and loss of its soft texture
• Longer than normal bleeding from minor injuries to the affected area
• Tender areas around the veins
• Hardening of fat under the skin just above the ankle, leading to skin shrinkage
• Irregular whitish patches resembling scars at the ankles
• Irresistible urge to move the legs, typically in the evenings

Varicose veins can lead to painful ulcerations on the legs if not managed properly. Learn how to effectively manage varicose veins.

Varicose veins may be caused by weakened valves within the veins that result in the pooling of blood in the veins instead of traveling to the heart. The causes of varicose veins can include:

• Primary varicose veins: These may have a hereditary factor, such as weakness in the wall of the vein, and can occur in some members of the same family.
• Secondary varicose veins: These develop due to secondary causes such as trauma or deep vein thrombosis (blood clots in the deeper veins).
• Familial and congenital varicose veins: These are due to vascular malformations in the limb that are present at birth.

The most important risk factors leading to the development of varicose veins are:

• Age: This is due to the loss of elasticity of the tissues as a person gets older, causing the valve system to fail.
• Gender: Women have a higher incidence of varicose vein disease due to high levels of female hormones (estrogen) and their effect on the vein walls.
• Family history: Studies show that screening of parents and family members revealed that if parents and grandparents had the problem, it increases the risk of varicose veins irrespective of gender.
• Obesity: Being overweight can put extra pressure on veins. Studies demonstrate that the risk increases especially in overweight women.
• Alcohol and smoking: Studies concluded that alcohol is likely to increase the risk of varicose veins in women, and smokers had a higher incidence of varicose veins compared with non-smokers in both genders.
• Hormonal changes: These occur during different stages of life and include puberty, pregnancy, menopause, post-menopause, hormone replacement, and other medicines containing estrogen and progesterone that may contribute to the development of varicose veins.
• Prolonged standing: Occupations that involve prolonged standing increase the volume and pressure of blood in the lower legs due to the effects of gravity, leading to the development of varicose veins.
• Immobility: Lack of mobility, such as sitting for a long time especially when legs are bent or crossed, may force veins to work harder to pump blood to the heart, increasing the risk of varicose vein formation.
• Physical trauma: Trauma or damage to the underlying blood vessels is an important risk factor leading to the formation of varicose veins.
• Deep vein thrombosis (DVT): A DVT occurs when a blood clot forms in one or more of the deep veins in the body, especially in the legs. DVT significantly increases the risk of incidents of varicose veins.
• Tall height: In both sexes, increasing height shows a significant relationship with varicose veins.

Diagnosing varicose veins requires a thorough history, physical examination, and a series of tests. These include:

• Complete medical history: This should include previous interventions or surgery on the affected leg, pregnancy, ulcerations, trauma, any history of uterine fibroids and cancer, previous DVT (deep vein thrombosis), past hospital stays, cardiovascular disease, and previous lower limb fractures.

• Clinical examination: The clinical evaluation of varicose veins is performed in the standing position and inspected for redness, tenderness, swelling, hyperpigmentation, and ulcerations. Classification of venous reflux is used to assess the clinical severity of symptoms, which includes:

• C0: No visible or palpable signs of venous disease
• C1: Reticular veins (purple-blue veins)
• C2: Varicose veins
• C3: Edema (swelling)
• C4a: Pigmentation and itching
• C4b: Changes in the skin of the lower legs and white scar as a result of healed ulcer
• C5: Healed leg ulcer
• C6: Active ulcer on the leg

To determine the exact cause, the following tests are included:

• Trendelenberg test: Also known as the Brodie–Trendelenburg test, it determines the competency of the valves in the superficial and deep veins of the legs in patients with varicose veins. It is performed by elevating the leg to 45º, and a tourniquet is applied to the mid-thigh after the veins have completely drained.

• Perthes test: This is conducted in a standing position with a tourniquet applied to the mid-thigh. If the varicose veins collapse after a 5-minute walk or if the varicose veins become more prominent and painful with walking, then the deep veins are obstructed.

Imaging techniques: If the cause of varicose veins is not clear from the clinical examination or if an intervention is being considered, imaging tests are performed. These include:

• Venography: This procedure involves an x-ray of the veins after a special dye is injected into the bone marrow or veins. It is used to find blood clots and identify a vein for assessment of varicose veins before surgery.
• Venous Doppler test: This ultrasound scan checks the direction of blood flow in the veins and looks for any blood clots.
• Color duplex ultrasound scan: This technique uses high-frequency sound waves to evaluate the speed of blood flow and the structure of the veins in the legs.
• Computed tomography (CT): CT can help identify deep, hidden varicose veins and the underlying cause of symptoms. Studies show that CT venography can provide an excellent roadmap for varicose veins surgery.
• Magnetic resonance imaging (MRI): MRI can be used as an alternative tool that effectively assesses varicose veins of the lower extremities and deep veins of the pelvis and abdomen.
• CT Angiogram: This test can help confirm the presence of varicose veins or any other issues. A dye is injected that outlines your veins on x-ray images.

Ambulatory venous pressure measurements: This method detects the decline in pressure from a higher value in the leg veins. Ambulatory venous pressure (AMVP) measurement is considered the gold standard in evaluating calf pump function in chronic venous disease.

Book your tests from the comfort of your home.

As the saying goes, "he who has a healthy body has everything," and the prevention of varicose veins mainly consists of making lifestyle changes to maintain overall health. The following recommendations can help:

• Be active and exercise regularly: Regular exercise promotes good blood circulation and increases vein and muscle strength. Strenuous exercises should be avoided if you already have varicose veins.
• Maintain a healthy weight: As obesity is a known factor for the emergence of varicose veins, weight control helps avoid pressure on leg circulation.
• Avoid prolonged sitting or standing: If you must stand for long periods, shift your weight from one leg to the other every few minutes. While sitting, take short walks every 30 minutes. Avoid high heels for extended periods, as they can lead to decreased vein efficiency and pooling of venous blood in the legs. Consider using heel supporters for added comfort.
• Wear loose clothing: Tight clothing can reduce blood circulation. Opt for loose-fitting, comfortable clothing to promote good circulation.
• Keep your legs elevated: To improve blood circulation, take several short breaks throughout the day to elevate your legs above heart level.
• Use compression stockings: Wearing compression stockings or socks improves blood flow by applying pressure to the legs, relieving swelling and lowering the risk of blood clot formation.
• Eat the right diet: Excess salt can cause swelling in the legs. A low-sodium diet rich in high-fiber foods can help prevent varicose veins.
• Control your blood pressure: High blood pressure strains blood vessels, making them more susceptible to becoming varicose veins.
• Limit sun exposure: Sun exposure can worsen the appearance of varicose veins, and excessive exposure can cause spider veins (small dilated red or purple veins) on the cheeks or nose in fair-skinned individuals. Protect yourself from the sun's harsh rays.

Varicose veins treatment requires a correct understanding of the severity of symptoms. The treatment consists of the following:

Conservative Management

For individuals with milder symptoms who do not want to undergo surgery, long-term graduated compression stockings, leg elevation, and oral pain medications can help relieve symptoms. Stockings should be worn daily to see results and avoid surgery.

Surgical Management

For patients with symptomatic veins and substantial venous incompetence, surgery has been the optimal treatment for many years. Traditional surgical treatment consists of the following:

• Conventional Surgery: A small incision is made in the groin crease, and the top of the main incompetent vein is dissected and tied off. A fine plastic wire is passed through the vein and retrieved through the inside of the leg at the knee level.
• Vein Stripping: This procedure is used to remove or tie off a large vein in the leg that helps treat varicose veins.
• Radiofrequency and Laser Ablation: These involve passing a probe up the long vein from knee level to the groin under ultrasound guidance and then ablating the vein in sections. This avoids a groin incision and may lead to less bruising and quicker recovery.
• Sclerotherapy: This involves the injection of an agent called sclerosant into varicosities, followed by a period of compression bandaging and/or compression hosiery. The main risk of sclerotherapy is injection outside the vein, which can result in local tissue necrosis and scarring.
• Foam Sclerotherapy: This involves mixing sclerosant with a small quantity of air to produce a foam that spreads rapidly and widely through the veins, pushing the blood aside and causing the veins to go into spasm.

Minimally Invasive Procedures

• Endovascular Laser Ablation (EVLA): This is a preferable treatment usually for larger varicose veins in which a thin catheter is inserted into an enlarged vein, heating the tip of the catheter using radiofrequency energy. As the catheter is pulled out, the heat destroys the vein by causing it to collapse and shut.
• Micropuncture or Micro-incision or Stab Phlebectomy: In this procedure, a physician makes a tiny incision and uses a surgical instrument or a large needle to hook the problem vein through the opening. The vein is then removed a tiny piece at a time.
• Transilluminated Powered Phlebectomy: The procedure involves inserting a light under the skin while simultaneously injecting a mixture of saline and a local anesthetic that guides the surgeon to cut the vein into smaller pieces and suction the pieces from the space.

Management of Spider Veins

Many patients will have visible superficial veins referred to as "spider veins." These may not be a cause for concern just for cosmetic reasons but can also be painful. Its management includes:

• Liquid Sclerotherapy: It involves the injection of a liquid sclerosant into the superficial veins.
• Phlebectomy: It involves removing larger superficial varicose veins through small 2 mm to 3 mm incisions.
• Laser Therapy: Laser light can destroy the vein without damaging the skin. Laser therapy is only used to treat spider veins and is not useful for varicose veins.

Lifestyle modification is crucial to ensure a complete and durable treatment response for varicose veins. All management modalities to treat varicose veins are considered safe and can be long-term or short-term. However, surgery is not always necessary; there are certain home remedies that can be beneficial, including:

• Apple cider vinegar: It helps cleanse the body and enhances blood circulation through the veins. A study suggested that the external application of apple cider vinegar on patients with varicosity increased the positive effects of conservative treatment.
• Red chili (Laalmirch): Also known as cayenne pepper, it is rich in vitamin C and antioxidants that treat allergies and viruses. The compounds in the pepper prevent blood clotting, helping to prevent varicose veins.
• Garlic (Lahsun): It contains flavonoids that help strengthen the veins and blood vessels, protecting them from damage and reducing varicose veins.
• Lemon (Nimbu): A powerhouse of nutrients, minerals, and vitamin C, it can prevent varicose veins, regulate fluctuating blood pressures, and keep the skin glowing.

Note: Extract the juice from 2 to 3 lemons and add 4 teaspoons of olive oil. Mix it with garlic paste and leave it overnight. Massage the affected area of varicose veins with this mixture twice a day for two months to see results. Read more about the health benefits of lemons.

Varicose veins complications might be rare, but they include:

• Venous ulcers: These are leg ulcers caused by problems with blood flow in your leg veins.
• Pain: An achy or heavy feeling in the legs along with burning, throbbing, muscle cramping, and swelling in the lower legs.
• Poor cosmesis: Cosmesis usually refers to the surgical correction of disfiguring defects, which becomes difficult with the presence of varicose veins.
• Thrombophlebitis: Swelling of the veins in your leg.
• Deep vein thrombosis (DVT): It can cause pain and swelling in the leg and may lead to serious complications like pulmonary embolism.
• Bleeding: Uncontrolled bleeding near the surface of your skin can result from varicose veins.

Alternative or complementary therapies have proven to alleviate the symptoms of varicose veins and, when incorporated into the treatment plan, have shown promising results. Some of these therapies include:

• Hydrotherapy: Studies show that hydrotherapy is effective in treating primary varicose veins along with compression therapy and other conservative treatments. The warm sitz bath hydrotherapy is an effective non-invasive therapy for uncomplicated varicose veins and requires a high degree of patient compliance.
• Leech Therapy: A study suggested that medicinal leeches suck venous blood and aid in ulcer healing, serving as an effective adjunct in the management of complicated varicose veins. However, this requires further evaluation through controlled trials.
• Ayurveda: Ayurveda can be helpful in treating painful venous ulcers, a complication of varicose veins. Studies suggest that therapeutic procedures, such as sodhana (purification therapy), act on non-healing ulcers and help them heal.

Varicose veins cannot always be avoided completely; they may cause serious issues if not taken care of. Some advice that can help prevent the progression of the disease includes:

• Make the right dietary choices: Potassium-rich foods, such as almonds and pistachio nuts, reduce water retention and can help in reducing varicose veins. Cutting down on salty foods can also minimize water retention.
• Add flavonoids to your plate: Flavonoids improve blood circulation, reduce blood pressure in the arteries, and can relax blood vessels, all of which can reduce varicose veins. Foods that contain flavonoids include:
  • Onions
  • Bell pepper
  • Spinach
  • Broccoli
  • Grapes
  • Cherries
  • Apples
  • Blueberries
  • Cocoa
  • Garlic
• Massage religiously: Gently massaging the affected areas can improve blood circulation through the veins. Use massage oils or moisturizers for optimal effects and avoid pressing directly onto the veins, as it can damage fragile tissues.
• Make sure to keep moving: Avoid sitting for long periods and aim to get up and move around or change position frequently to keep the blood flowing smoothly. Avoid sitting with crossed legs, as it restricts blood flow to the legs and feet, which may contribute to circulation problems.
• Take a cold shower: Cold water improves blood circulation. You can also massage with a jet of water from the feet to the thighs. Ensure the skin of the affected area is clean and well-hydrated.
• Say “No” to alcohol and tobacco: These are risk factors for varicose veins and can worsen symptoms if you already have them. Avoiding them will not only help with symptoms but also promote a healthier lifestyle.
• Be aware of tourist class syndrome: Also known as traveler's thrombosis, this condition occurs when you sit in the same position for a long time. To avoid this, perform foot exercises, keep sipping water, wear loose comfortable clothing, and make sure to move every 2 hours during long flights.
• Take post-procedure follow-ups seriously: After endovenous ablation treatment, most physicians recommend a duplex ultrasound examination of the treated leg within the first week to evaluate for deep vein thrombosis.