Sunday, 24 July 2011

Varicose Veins

Published in Panorama

Treating Varicose Veins

Simran abhorred the sight of those purple-blue squiggles that looked like roadmaps on her legs. She decided to do something about them. These squiggles are varicose veins – tortuous, distended, dilated veins, which usually affect the lower limbs, from the groin to the ankles and feet, though they can appear elsewhere in the body.

Veins in our body carry blood back to the heart. They have a number of valves in them to ensure that this function is carried out efficiently and that blood flows uni-directionally. The tiny door-like valves, when they are competent, will not allow the backflow of blood. As for the veins themselves, there are superficial veins just below the skin and deep veins within the muscles, close to the bones, both of which take blood back to the heart. Also, between the superficial and deep veins, there are communicating or perforator veins. Valves exist within all these veins and also between these three system of veins. Varicose veins occur when the superficial valves, perforator valves or the valves between the superficial and deep veins become incompetent. When this happens, there is a backward flow of blood and consequent rise in pressure within the veins, causing them to swell and look knotty, externally, explains Dr.J.C.Mathias, Specialist General Surgeon & Head of the Department, General Surgery, Welcare Hospital, Dubai.

What are spider veins and how are they different from varicose veins? Dr.Mathias explains, “Spider veins or thread veins are just red or blue blemishes on the skin which can appear anywhere on the body, but again, are more common on the legs. They are dilated, very superficial capillaries under the skin which don’t look good, especially in fair-skinned people. And as you get older, you tend to get more of them. We tend to treat them for cosmetic reasons more than for anything else.”

What are the factors that contribute to incompetent valves and consequent varicose veins?
1. We tend to get varicose veins when we stand for prolonged periods of time, without much movement.
2. There may be a familial tendency for this to happen. For instance, if your mother or grandmother has had it, then you are likely to get it.
3. Professions that require you to stand for long periods of time, increase the probability of your getting varicose veins.
4. General tendency for people resident in warm climates to have varicose veins than those dwelling in cold climates.

Is there a gender bias to the condition? Women appear to be slightly more prone to the condition than men, though the reason for this is not known. And hormones do play a role in spider veins though not in varicose veins per se, says Dr.Mathias. Besides, the tendency for varicose veins is predominant during pregnancy when the enlarged uterus may restrict blood flow in the abdominal veins.

How far is varicose veins an age-related problem? As we grow older, the proneness to the problem is slightly increased, though in actual fact, we are less likely to be bothered by them at that age, opines Dr.Mathias.

What are the earliest manifest symptoms of varicose veins? The earliest manifestations probably, of most veins, is just the unsightliness, says Dr.Mathias. “In actual fact, varicose veins per se, do not give rise to any severe symptoms and therefore they can be neglected or overlooked for a long period of time, if the sight of them doesn’t bother you! However, in people who are standing up for long periods of time, they can get symptoms from the veins, which are unique to varicose veins: they can have a dull, aching, tired feeling in the legs, especially towards the evening, after the day’s task is over. This is relieved by keeping the legs in a raised position while sitting or lying down. So if someone complains of similar pain after waking up in the morning, then I believe it is not due to varicose veins.”

One can get other signs and symptoms if the veins get inflamed or infected, reveals the surgeon. “This is a condition called thrombophlebitis when the superficial veins get inflamed. You can get this when needles are put into your hands to give you intravenous fluids, particularly when potassium is an ingredient of this fluid. You can also get the condition in the lower limb after you hurt yourself or if you have bumped against something – your veins can get inflamed and you have reddened, painful, superficial veins. The pain worsens while walking and resting or putting the feet up, helps.

Can symptoms of varicose veins mimic symptoms of other problems? While varicose veins by themselves tend to cause no symptoms except that they look bad, when there is pain in the legs alongside the visible veins, it is important to rule out other reasons for the pain, cautions Dr.Mathias. “You can get pain in your legs because of poor footwear, from arthritis in the knee, hip and ankle joints, due to poor arterial circulation in your legs as in the case of smokers and diabetics, due to nerve problems like sciatica or a trapped nerve in the spine which can give a pain in the lower limbs. It is important not to attribute the pain in the legs to the visible varicose veins in your legs, because you might have the veins surgically removed but the pains wont go away since they are not the reason for that pain! You have to exclude all these conditions before you confirm that veins may be the cause of your symptoms.”

What is the relation between varicose veins and Deep Vein Thrombosis (DVT) or the so-called Economy Class Syndrome? Dr. Mathias emphasizes, “It is important to know that DVT is not related to varicose veins and the significance of this is important when it comes to treatment of varicose veins. Because if surgery is required to remove the varicosed vein, you need to make sure that at least one system of veins is patent, for the survival of your leg! The deep veins which you cannot see, but which, if they thrombose or block off due to clots inside them, will preclude you from operating on the superficial veins. This is because blood circulating in the body, has to get back to the heart through the veins and when we operate on the varicose veins, we are removing them. So the deep veins serve as channels to carry back the blood in place of the superficial veins that have been removed. So in a patient who has a history of DVT, you should not or can not, remove the superficial veins.”

How is varicose veins diagnosed? Clinical examination, by making the person stand up is the mainstay in diagnosing the condition, for these veins are much more prominent when you stand up. The most important diagnostic modality is the Dopler Ultrasound Scan which shows you the direction of the flow of blood and also enables you to see the status of the deep veins – to see if they are patent or not, explains Dr.Mathias. A more invasive technique of diagnosis is a venogram which involves injecting a contrast medium into the vein and taking pictures to show the exact location of the affected veins.

How are varicose veins treated? The treatment of the condition is varied, says Dr.Mathias. “In a lot of people you may not need any treatment at all if they have no symptoms. You certainly need to treat people who get more complications from them. One such complication could be a bleed. The easiest way to treat varicose veins is to give the person support stockings which are elasticated and graduated. They are tighter at the ankle and as they go up your leg, they get less tight. This helps to send the blood back and thus prevent it from pooling in the veins. Depending on the specific location of the veins in your legs, these stockings are available in the pharmacies, measured for you and in varying lengths, to reach up to the thighs.”

Sclerotherapy is done in some cases. This involves injecting a “sclerosing” solution, directly into the vein with a very fine needle. Depending on the size of the affected veins, they may have to be injected more than once. This sclerosing solution tends to scar or fibrose or shrink these veins, explains Dr.Mathias. The improvement brought on by this treatment is gradual and could take up to 3 months to show up the benefits. The side effects of the treatment include the appearance of brown marks on the skin which may disappear in time. Few individuals may develop matting. That is the development of networks of fine red blood vessels near the sites of injection of larger vessels, particularly on the thighs. Most of these resolve spontaneously and some with treatment, while a few may persist. Very rarely, there may be the formation of small, painful ulcers at the treatment site within two weeks of injection. These may occur because the solution may have escaped into the surrounding skin. But these ulcers heal, though slowly and they may leave a small pale scar. In very rare situations, the patient may be allergic to the sclerosing solution, which again may be antidoted with appropriate treatment. Again, very rarely following sclerotherapy, the person may have DVT.

Laser treatment, though not yet popular, is another treatment modality besides conventional surgical removal of the affected veins, says Dr.Mathias.

Once treated, can Varicose Veins come back? Other than true treatment failure, no. However, some patients may require repeat treatment over the years for new varicosities, says Dr.Mathias.

Is it possible to prevent Varicose Veins? Since the condition has a genetic predisposition, prevention to that extent is not possible. But regular exercise, walking, wearing appropriate footwear, graduated stockings can help to slow down the progression of the condition.


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