Varicose Veins and Spider Veins (Telangiectasias)

Varicose Veins

Varicose veins.

Varicose veins are enlarged superficial veins that afflict millions of Americans, primarily women. Pregnancy, weight gain, long periods of standing, and a family history of varicose veins are all risk factors for this disease. Varicosities become distended and bulging in the sitting or standing position, and often have a twisting, coiled appearance. Varicose vein symptoms may worsen over time. Varicose veins can cause aching, ankle swelling, night cramps or feelings of leg fatigue or heaviness after prolonged periods of standing. If left untreated, they can progress and cause skin damage including brown pigment deposits under the skin or skin ulcers.

You have three kinds of veins in your legs:

• the superficial veins, which lie closest to your skin, and which give rise to varicose veins and spider veins,
• the deep veins, which lie in groups of muscles, and lead directly to the vena cava (the largest vein in the body) and thus to the heart,
• and the perforating veins, which connect the superficial veins to the deep veins.

What are the Symptoms of Varicose Veins?

If you have varicose veins, your legs may feel heavy, tired, restless, or achy. Standing or sitting for too long may worsen your symptoms. You may also experience night cramps. You may notice clusters of veins in a winding pattern protruding above the surface of the skin on your leg, or soft, slightly tender knots of veins. Sometimes, the skin on your legs may change color, become irritated, or even form sores.

Occasionally, the stagnant blood in these large surface varicose veins can clot, called superficial phlebitis. If you have varicose veins, you also have a slightly increased chance of developing deep vein thrombosis (DVT). DVT may cause sudden, severe leg swelling. DVT is a serious condition that requires immediate medical attention.

Spider veins.

Spider Veins

Spider veins are tiny varicose veins. They look like a nest of fine red or blue lines just under your skin. Spider veins are not a serious medical problem, but they can be a cosmetic concern, and they can cause symptoms of aching or burning pain, or itching.

Venous Valve Function, Reflux, and Varicose Vein Formation

The function of the leg veins is to return the bluish, oxygen-poor blood to the heart. When you are in the upright position, the blood in your leg veins must work against gravity to return to your heart. To accomplish this, your leg muscles squeeze the deep veins of your legs and feet. One-way flaps, called valves, in your veins keep blood flowing in the right direction. When your leg muscles contract, the valves inside your veins open. When your legs relax, the valves close. This prevents blood from flowing in reverse, back down the legs.

When you walk and your leg muscles squeeze, the venous pump mechanism works well. But when you sit or stand, especially for a long time, the blood in your leg veins can pool and the pressure in your veins can increase. Deep veins and perforating veins are usually able to withstand short periods of increased pressures. However, if you are a susceptible individual, your veins can stretch if you repeatedly sit or stand for a long time. This stretching can sometimes weaken the walls of your veins and damage your vein valves. Damaged valves allow venous blood to cascade back down towards the foot, a process known as venous reflux. Venous reflux causes high blood pressure inside your superficial leg veins, and contributes to varicose vein formation.

Other factors that can increase your risk for varicose veins include having a family history of varicose veins, pregnancy, being overweigt or a prior clot in the deep veins (called a "DVT"). Women are more likely than men to develop varicose veins. Varicose veins usually affect people between the ages of 30 and 70. Pregnancy often results in the first noticeable appearance of varicose veins, which sometimes improve after childbirth. Women have an increased risk of developing varicose veins compared to men.

What Tests Will I Need?

First your surgeon will ask you questions about your general health, medical history, and symptoms. In addition, your physician will conduct a physical exam. Together these are known as a patient history and exam. Your physician will examine the texture and color of any prominent veins. To confirm a diagnosis of varicose veins, your physician may order a duplex ultrasound test. The test can take approximately 20 minutes for each leg.

Venous duplex ultrasound uses painless, high-frequency sound waves. Your surgeon uses duplex ultrasound to see the structure of your leg veins, and look for the presence of clotted segments of vein. Venous reflux testing uses specialized methods to check for “wrong-way” venous blood flow through damaged or incompetent valves.

How are Varicose Veins and Spider Veins Treated?

Non-operative Therapy
Your surgeon will review the non-operative methods of treatment that may relieve your symptoms. If you have mild to moderate varicose veins, elevating your legs can help reduce leg swelling and relieve other symptoms. Your physician may instruct you to prop your feet up above the level of your heart 3 or 4 times a day. When you need to stand for a long period of time, you can flex your legs occasionally to allow the venous pump to keep blood moving toward your heart.

For more severe varicose veins, your physician may prescribe compression stockings. Compression stockings are elastic stockings that squeeze your veins and stop excess blood from flowing backward. In this way, compression stockings also can help relieve your symptoms of leg discomfort or even heal skin sores and prevent them from returning. You may be required to wear compression stockings daily for the rest of your life. For many patients, compression stockings effectively treat varicose veins and may be all that are needed to relieve pain and swelling and prevent future problems. However, although compression stockings can relieve the symptoms associated with varicose veins and venous reflux, they do not eliminate the underlying problem. To actually “cure” varicose veins, the damaged superficial veins must be destroyed or removed.

Therefore, when leg elevation or compression therapy alone does not relieve your varicose veins, you may require a surgical or minimally invasive treatment, depending upon the extent and severity of the varicose veins. These treatments include radiofrequency ablation, vein stripping, micro-incision venectomy, and sclerotherapy.

Ablation of the Saphenous Vein

The saphenous vein is the largest superficial vein of the lower extremity. If venous reflux testing demonstrates reflux in the saphenous vein, then your surgeon may recommend treatment of the reflux. Physicians today use either laser or radiofrequency energy for ablation (obliteration) of your vein. Radiofrequency ablation (RFA) uses a thin, flexible tube called a radiofrequency catheter to obliterate the saphenous vein that has demonstrated reflux. As it is withdrawn, the tip of the catheter heats the walls of your varicose vein and destroys the vein tissue. The treated segment of vein is then no longer able to carry blood, and it is eventually absorbed by your body. Eliminating the “wrong-way” blood flow in the saphenous vein will relieve the heaviness and discomfort caused by reflux, and limits the formation of new varicose veins.

The RFA procedure is performed in the outpatient or office setting, and generally takes less than an hour to complete. You will receive a sedative for comfort, as well as local anesthetic to the area of the treated vein. No incision is required, other than a small puncture or nick in the skin for the catheter entry. Postprocedural discomfort is usually mild, and return to work is normally quick. You will receive follow-up venous ultrasound exams in the weeks after the procedure.

Sclerotherapy

During sclerotherapy, your surgeon uses tiny needles to inject a chemical into your spider veins and small varicose veins. The chemical irritates the veins from the inside out so your abnormal veins can then no longer fill with blood. Blood that would normally return to the heart through these veins returns to the heart through other veins. Your body will eventually absorb the veins that received the injection. To hasten the time until the clotted vein is no longer visible, your physician may have you return to the office a few weeks after the initial sclerotherapy procedure to remove clot from these timy vessels, and to re-treat remaining spider veins. Typically sclerotherapy will be performed 2-4 times before a final cosmetic appearance is obtained.

The procedure is done in the office setting, and does not require any anesthetic or sedation. After the procedure, your leg will be wrapped snugly for 24-48 hours, and you may be asked to wear compression hose while the sclerotherapy sites heal.

Micro-incision Venectomy and Vein Stripping Surgery

A different procedure, called micro-incision venectomy, or ambulatory phlebectomy, can be done at the time of initial treatment of the saphenous vein reflux, or more commonly as a separate procedure. Tiny incisions with removal of varicose branches allows your physician to remove individual varicose vein clusters from your leg. This is typically done as an outpatient procedure while the veins are surrounded by local anesthetic, and recovery time is minimal.

Once a common procedure for treatment of saphenous vein reflux, vein stripping has now been almost completely replaced by the less invasive ablation procedures. To perform vein stripping, your physician first makes a small incision in the groin area and usually another incision in your calf below the knee. Then your physician disconnects and ties off all major varicose vein branches associated with the saphenous vein. Your physician then removes the saphenous vein from your leg.

Although these procedures sound painful, they cause relatively little pain and are generally well tolerated. Your vascular surgeon will advise you regarding which procedure is the best for your particular situation.

Please call 314.362.LEGS to schedule your leg vein evaluation with a Washington University vascular surgeon.

Information adapted from, and illustrations used with permission of, the Society for Vascular Surgery.