Sunday, 24 July 2011

Treating Varicose Veins

Published in City Times

Understanding and Treating Varicose Veins

The term Varicose Veins is a descriptive one: it refers to tortuous, enlarged, painful veins on the superficial layers under the skin. The incidence is greater in females than males, being in the ratio 7:3, reveals Dr.Walid Achi, Specialist General and Laparoscopic Surgeon, Belhoul European Hospital, Dubai.

What is the problem and why do varicose veins appear?
Varicose veins are the result of a weakness in the vein wall that is in some cases familial.
The problem is due to hyper pressure or high pressure in the superficial venous system. This high pressure disrupts the structures inside the vein which bring back blood to the heart. This weakness causes distension of the vein and secondary incompetence of the unidirectional valve systems attached to the walls of the vein. As a result, there will be a reverse flow of blood induced by gravitation. With passage of time, this will further distend the veins, thus worsening the situation. There is a big associated functional problem which is the late or slow evacuation of the consumed blood which is rich in carbon dioxide and not in oxygen. The disruption of the system creates a vicious cycle that increases the problem by making the veins more tortuous, becoming more dysfunctional, making them even more painful until complications emerge.

Unlike the arterial system, in the venous system, there is no pumping mechanism to ensure the return flow of blood from the extremities, back to the heart. However, multi-factors are involved in doing this task. Respiration creates a negative, aspiratory pressure which helps blood in the venous vessels to go back to the heart. Secondly, the unidirectional valves in the veins enable blood flow to the heart, by creating a low pressure which is unidirectional. Therefore blood does not flow backward from these valves. Thirdly, muscle tone and muscle contraction brought about by movement of the lower limbs, particularly, during walking, running, etc., apply pressure on these veins creating an influx of blood which will go back to the heart. Varicose veins occur when there is disruption of these mechanisms.

Why is it that some people get varicose veins and not others?
It is true that females are more prone than males. There is also a heredity factor associated with the condition. Some families do develop varicose veins much more than others. Gravity is a very important factor in varicose veins. The incidence of the problem is higher in people who are inactive, are immobile for long periods of time, are standing for long hours because their jobs demand it because these features make the return of blood from the lower limbs to the heart, more difficult. With time, this will lead to dilatation of the veins, making them inefficient because of the valves that are not keeping the flow of blood, unidirectional.

How are varicose veins different from spider veins?
By definition, spider veins present an aesthetic problem and sometimes it is very, very bad. But it has no functional problem. One can have only spider veins, only varicose veins or have both, simultaneously. They are very small veins immediately below the skin surface and are very, very superficial. They can happen in the leg, on the abdominal wall.

Do varicose veins appear only in the legs and not elsewhere in the body?
By definition, yes, varicose veins appear only in the lower limbs. If somebody has a very large vein in the upper limb, in the hand or the forearm, we have to suspect a fistula between an artery and a vein. In this case, it is called an arterio-venous fistula and has a completely different pathology. But these are not classified as varicose veins.

What are the symptoms of varicose veins and how do they manifest in their earliest form?
They are painful and tortuous. But before this we have preliminary symptoms that will indicate to us that something is wrong with the venous system. First of all is heaviness after standing for an hour or two. You would feel as if your legs are heavier than the whole body. When you want to move, you feel a numbness; you feel your foot and leg have increased in volume. You feel your skin is tense and you feel if you lift your leg up, for say 10 minutes and if you breathe deeply, this heaviness is relieved. Taking the gravity as your saviour, you will notice that your symptoms improve. This is a positive indication that you do have a problem with your venous system.

There will be discolouration of the skin which indicates obstructed, tortuous vein due to pooling of carbon dioxide rich blood in the area. Ulceration is another symptom. Very often, people mistake these non-healing ulcers of wounds they do not know how they got. But the point is, ulcers associated with varicose veins do not need a cut or trauma to make them occur. The ulcers happen because that part of the skin is suffering from a lack of oxygen. Once we operate to remove the varicose veins, the ulcers will disappear without trace.

What is the relation between varicose veins and Deep Vein Thrombosis (DVT)?
We have two venous systems: the deep venous system and the superficial venous system which are interconnected by perforant veins. It is very, very important to note that these two systems are complementary and that, if the deep system is fine and patent, we can then remove the whole superficial system without any problem. On the other hand, if the deep system is occluded, the superficial system takes all the importance and therefore removing it, would become dangerous. This explains why, before going in for surgical removal of the varicose veins, we have to examine very carefully for DVT and be sure the deep vein system is patent.

How can this be ensured?
We diagnose this by Doppler ultrasound of the lower limb where we can identify any problem in the deep vein system.

What is the correlation between pregnancy and varicose veins?
Pregnancy can also cause varicose veins, as a temporary phenomenon. Anything that increases the pressure in the superficial venous system will help create distension of the veins, leading to varicose veins by disrupting these very fine structures of the valves. So, pregnancy creates high pressure and sometimes the gravity will push the uterus on the inferior vena cava which is the tube carrying blood, up, to the heart. If there is structural disruption of the superficial veins, even after delivery, the woman will still have the problem of varicose veins. If this does not go to physical disruption, the varicose veins will disappear after delivery, which is what usually happens. Also, these days women are taking care to protect their legs by wearing suitable stockings when they find there is oedema in the legs on account of pregnancy, at least till delivery.

How is varicose veins diagnosed?
Diagnosis of varicose veins is usually clinical, with history taking and physical examination of the affected region. In some cases, it is better to go for a complementary investigation with the Echo Doppler. This examination, if done properly, will give us the exact situation with respect to the pressure inside the veins and the arteries.

How are varicose veins treated?
The severity of the condition is graded from 1 to 6. Grade 1 and 2 are very common and don’t require surgery or any special treatment. They are often accompanied with spider veins. Grades 3 and 4 are as common. These definitely need surgical treatment or long term medical treatment. It is a must to perform surgery on Grades 5 and 6, at the earliest possible. We give the patients medication which help the contraction of the veins and thus push the blood up. The other thing is to prohibit people from wearing tight clothes on the lower abdomen, particularly, tight belt and jeans, that might affect the pouring of blood from the superficial system to the deep one. Using elastic socks if you have varicose veins and also after surgery for the condition.

When should surgery be undertaken:
Ideally, before complications set in, in grades 3 and 4. This doesn’t include the symptoms of heaviness, numbness and oedema. But surgery should be performed before the skin manifestations. Surgery is simple and may be done under local or general anesthesia.

What are the complications from surgery?
• Infection and bleeding as with any surgical procedure.
• Complications may arise if the surgeon did not ensure a patent deep venous system.
• Not all of the affected veins may be removed by surgery. This is a possibility when we are dealing with a very late varicose veins case where you have these veins everywhere, covering large areas of the leg. These will need more than one surgical session. But in the hands of a good surgeon, we can ligate all the affected veins and help the patient recover normally.
• People may have large blue spots in the areas of surgery. But these will usually disappear in about 10 days and this is not a complication at all.
There is a big associated functional problem which is the late or slow evacuation of the consumed blood which is rich in carbon dioxide and not in oxygen.

What are the post operative precautions that need to be taken?
Wearing bands or sock is a must, following surgery, to prevent recurrence of varicose veins. This will help establish a good flow of the deep venous system, preventing any accidents and any coagulation in the blood stream. This is very much part of the treatment. Walking is encouraged after surgery. Regular physical exercise, even a small one, is a must.

How can varicose veins be prevented?
• Walking from time to time for people who require long standing hours as per their job requirements.
• It is important to have good physical activity, keeping a good tone of muscles so they can compress by isostatic contractions, the flow of the venous system.
• By taking care of your breathing, controlling it and having a deep breath from time to time.
• If needed, wearing socks
• For people traveling long distances by air, they have to take adequate care by rehydrating themselves, by walking at least for 10 minutes every two hours while in the aircraft,
• by wearing special socks that compresses the superficial system, increasing the flow in the deep one, thereby not allowing deep vein thrombus.
• For people who have had DVT before, take the necessary anti-coagulation medication to prevent the clot formation.

Many diseases can mimic the symptoms of varicose veins and sometimes, they are together. Arteriopathy, for instance, is one such condition. This is a disease of the artery, especially in diabetics. So sometimes, you have varicose veins co-existing with arteriopathy, particularly in diabetics. Varicose veins may also be due to a pelvic tumour. There is compression of the inferior vena cava in this condition, thus leading to varicose veins. So the presence of varicose veins should draw attention to the possibility of such other underlying conditions.


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