Varicose Veins: an Overview

Copyright 2001 Craig F. Feied, MD, FACEP, FAAEM

Indications for Evaluation

Subjective Symptoms

Many patients with superficial varicosities complain of cramping, aching, burning, itching, soreness, or tired legs. Studies have found that more than 90 percent of true varicosities are symptomatic, and that the vast majority of patients experience relief of their symptoms after treatment for the varicosities.

Edema

Swelling of the ankles and feet may be due to retrograde flow though varicosed superficial veins or it may be completely unrelated. Plethysmographic studies can quantify the amount of retrograde flow and the associated calf volume changes in order to decide whether or not ankle edema is likely to respond to obliteration of the retrograde superficial system.

Phlebitis

Prolonged stasis in superficial varicosities and telangiectasias frequently does lead to recurrent superficial thrombophlebitis. Although active phlebitis is a contraindication to treatment for superficial varicosities, a history of phlebitis is a strong indication that the amount of reflux and of stasis is enough to warrant treatment.

Stasis Dermatitis

If the fraction of blood involved in a local-flow circuit through the superficial varicosities is large, stasis dermatitis may be seen. Part of the discoloration, skin thickening, and tendency toward ulcer formation will be reversible and part will be irreversible. At the very least, interruption of the retrograde flow pathways will prevent the progression of disease caused by that retrograde flow.

Bleeding Varicosities

It is not at all uncommon for patients to present to an emergency room with spontaneous rupture and massive bleeding from bulging superficial varicosities. There are recent case reports of patients actually exsanguinating and dying from spontaneous rupture of a superficial varicosity during sleep. Ruptured varicosities are most often located on the posterior thigh and on the anterior leg overlying the tibia. Several weeks before a varicosity ruptures, it very often becomes more prominent, darker in color, and develops a bulging and inflamed appearance.

Cosmetically Disfiguring Vessels

Regardless of the medical indications for treatment of diseased superficial vessels, the most common reason for patient concern is the cosmetic appearance of varicosities or telangiectasias. Even a single small starburst on the posterior calf may be of great concern to a young patient who must endure the comments of friends and the glances of strangers. Surgical treatment of varicosities is very successful at addressing the medical problems caused by retrograde flow through a dilated superficial venous system, but patients know it as a relatively poor solution from a cosmetic point of view. Vein stripping can cause significant scarring, particularly in a patient with compromised local tissue perfusion due to chronic stasis. Stripping of varicosities also fails to address associated telangiectasias which, from a patient's point of view, may be even more disfiguring.

Evaluation Modalities

Trendelenburg's Test

Careful physical examination permits the identification of the level of reflux in most patients with peripheral varicosities. The leg is raised to drain the venous system, and a venous compression tourniquet is placed at the level to be tested. When the leg is lowered, the deep veins fill quickly. If there are incompetent perforators below the level of the tourniquet, the superficial varicosities below that level will also fill quickly. If there is reflux from above the level being tested, release of the tourniquet will cause immediate visible distention of the superficial varicosities below.

Pulse Wave Test

The pulse wave test allows the examiner to decide whether or not a given pair of vessels communicate without intervening patent valves. A palpating finger is placed over one vessel while the other hand is used to percuss a varicosity. If an unbroken column of blood connects the two, a sharp pulse wave will be felt with the palpating finger.

Bidirectional Doppler

Doppler studies at 8 MHZ and 5 MHZ permit the evaluation of flow through both the superficial and the deep peripheral venous systems. Bidirectional doppler is capable of detecting the direction of flow as well as its magnitude, and permits the demonstration of retrograde flow in superficial varicosities. If the deep venous system is intact, deep retrograde flow should not be observed. Treatment of superficial varicosities is rarely indicated when the deep venous system is incompetent.

Plethysmography

Both air plethysmography and photoplethysmography are necessary in the complete evaluation of the peripheral venous system. The measurement of changes in calf venous pulsation and venous volume permits the detection of superficial and deep venous incompetence, deep venous thrombosis and other peripheral venous pathology. Under normal conditions, calf volume is rapidly reduced with 'pumping' of the calf muscles, and returns slowly to baseline as arterial inflow refills the venous system. Calf volume drops much more slowly when an obstruction to venous outflow (such as deep vein thrombosis) is present, and rises much more quickly when deep or superficial venous incompetence and retrograde flow are present. Quantitative measurements permit the repeatable comparative assessment of the severity of venous disease. If retrograde flow is detected, repetition of the examination with an occlusive thigh tourniquet in place may permit localization of the site of incompetent valves.

Contrast Varicography

The injection of radiopaque contrast material into a proximal varicosity permits x-ray evaluation of the entire incompetent retrograde venous system. Contrast varicography was once the mainstay of the diagnostic workup, but is uncommonly used today. Under special circumstances varicography may be useful to define the extent of disease and to locate all identifiable reflux points preoperatively.

Contrast Venography

Radiopaque contrast material is injected into a distal foot vein, and tourniquets are placed so as to occlude the superficial venous system and force contrast into the deep venous system, permitting x-ray evaluation of the entire deep venous system. Contrast venography was once the mainstay of the diagnostic workup for deep venous disease, but is now being replaced by duplex ultrasound imaging, which is of equal or greater sensitivity in the symptomatic patient. Contrast venography continues to offer a higher sensitivity when used as a screening exam in a high-risk population, such as in patients with pulmonary embolism but with no leg symptoms.

Color-flow Duplex Ultrasound Imaging

Color-flow imaging has become the standard modality for the evaluation of patients with venous disease of any type. The addition of color-coded flow information overlying a standard gray-scale ultrasound image allows rapid and accurate mapping of both deep and superficial veins, with identification of any flow disturbance (such as DVT) and of all areas of valvular incompetence and venous reflux. Arterial evaluation is also facilitated by color-flow imaging, especially with newer machines which offer 'Triplex' imaging with simultaneous gray-scale, color-flow, and M-mode doppler sampling information all on the same screen.

Treatment modalities

Surgical Stripping

Vein stripping, or surgically pulling the vessels from the body through a series of incisions, is the traditional surgical means of managing significant varicosities. It is the most invasive approach, has the most complications, requires the longest recuperation time, and leaves the most scarring. It should be performed in a surgical suite, and sometimes requires general anaesthesia. It has the lowest recurrence rate of all treatment modalities, but recurrences may occur even when the procedure is performed perfectly. Stripping does not improve many telangiectasias even when they communicate with a stripped varicosity.

High Saphenous Ligation

Ligation of an incompetent saphenofemoral junction may be performed in the office under local anaesthesia, and is often used in combination with compression sclerotherapy to treat a large varicosity with significant retrograde flow originating at the level of the saphenofemoral junction. Ligation of the site of inflow greatly increases the success of injection sclerotherapy along the entire length of the vessel. Ligation without sclerotherapy is rarely effective, because most patients have, or will develop, additional incompetent perforating vessels below the level of the saphenofemoral junction.

Laser Ablation

Laser and photo-flash photocoagulation is effective for small superficial telangiectasias, but cannot be used to treat larger telangiectasias or varicosities. The light source is placed above the vessel to be treated, and the intense light must pass through the skin in order to damage the vessel below. Phototherapy can be painful enough to require local anesthesia, and can cause significant burning and scarring along the entire course of the treated vessel. Recent developments in flashlamp devices and tuneable dye lasers have shown promise in reducing the seriousness of burning and scarring complications. In the future this may become the preferred mode of therapy for all small telangiectasias, and even today it is appropriate for some patients.

Electrocautery

The use of high-frequency electrical energy to coagulate and 'burn' the vessel is effective only for small superficial telangiectasias with a readily identified 'feeder' vessel. Scarring is a common problem, and the treatment may fail completely if multiple inflow points are present. This technique is rarely used today.

Injection Sclerotherapy

The injection of a mild sclerosing agent is the initial treatment method of choice for most patients with peripheral venous varicosities and telangiectasias. Local tissue damage and discomfort are minimal because a #30 or #33 gauge needle is used. It may be used for varicosities and telangiectasias of any size, and is well-tolerated even where tiny facial vessels must be treated. A large varicosity that has failed treatment or has recurred after a course of injection/compression sclerotherapy may respond to a second course of sclerotherapy or it may require surgical ligation or even stripping.

Questions

Does removing, tying off, or injecting superficial branches of the saphenous vein prevent the patient from having bypass surgery in the future?

No. A diseased varicose vein is of no value for coronary artery bypass, and could not be used in any event. If the greater saphenous vein is healthy, it may still be used after more superficial veins have been treated.

Aren't these veins an important path for venous return?

No. Once retrograde flow and chronic venous stasis are established, the venous pathway is permanently pathologic. Venous blood is actually flowing backwards through the diseased surface system, preventing normal circulation in the extremity. Treatment of these diseased veins interrupts this reverse circulation of blood to improve peripheral oxygenation and venous return.

Is there a risk of deep vein thrombosis when injection sclerotherapy is performed?

No. Studies of many thousands of patients being treated with injection sclerotherapy have shown that the incidence of deep vein thrombosis is no higher than in the general population. The mild, FDA-approved sclerosing agents used today can only cause vessel wall irritation if they remain in contact with the wall in high concentrations for a fairly long time. Venous stasis in diseased vessels, along with good injection technique, help these conditions to be met, but as soon as the sclerosant leaks across into normal vessels, the normal velocity of blood flow dilutes it and carries it away from the vessel wall. This has been proven by clinical experience, by downstream blood sampling in vivo, and by histologic studies of vessel walls both in vivo and in vitro.

What are the complications of treatment?

Fortunately, neither laser therapy nor injection sclerotherapy are associated with any serious complications when properly performed. Anaphylactic reactions to modern sclerosing agents are so rare that many practitioners doubt their existence. Common minor complications include bruising at the site of an injection, itching along the course of a treated vessel, and mild inflammation. Patients may rarely develop a small local ulceration of a varicosity being treated, and superficial phlebitis is sometimes seen. Scarring or hyperpigmentation may occur with laser treatments. Treatment of a large number of vessels may lead to local edema. Healthy superficial microscopic vessels within an area of treatment may dilate slightly to become temporarily more visible to the patient.

Aren't most varicose veins asymptomatic?

Unfortunately, studies have shown that the vast majority of patients with varicosities do complain of aching, swelling, cramping, and other clinical symptoms. A survey reported in the Mayo Clinic Proceedings actually found symptoms in more than 97 percent of those with varicose veins.

What are the contraindications?

Patients should wait approximately 3 months after pregnancy or major surgery before starting therapy for varicosities or telangiectasias. Immunocompromised patients and others with poor expectations for healing should not be treated. Patients who cannot ambulate should not be treated. A past history of superficial phlebitis is a good indication that the patient has a medical need for treatment, but a history of deep vein thrombosis or deep venous incompetence is a relative, or in some cases an absolute contraindication to stripping or sclerotherapy.