Varicose Veins - Causes and Treatment

Varicose veins are enlarged and tortuous veins that occur at such vessel disease, which can be seen through the skin.

This paper will describe the varicose veins in legs (varicose veins of the lower limbs), emphasizing their causes, symptoms, prevention and treatment.

Varicose  veins
Varicose veins
 

Contrary to what one might think, the varicose veins of the legs are not just an aesthetic problem. The presence of a varicose vein indicates that a patient suffers from chronic venous insufficiency.

In order to understand what causes varicose veins and what their potential complications, one must understand how veins work.


What are varicose veins?

Our blood is transported by two types of vessels: arteries and veins. The artery is the vessel that carries oxygen-rich blood away from the heart toward the rest of the body, nourishing organs and tissues. The vein is the vessel that brings blood back to the heart and lungs so it can receive oxygen again.

The blood comes through the arteries to the legs and goes back to the heart through the veins. As you may have thought, the leg veins work against gravity. We can say that varicose veins are a "side effect" of our evolutionary process that allowed us to walk upright on two legs. When we became bipedal, our heart started to get away from our legs, which greatly hindered the return of blood to it. But how does this blood rises then?

Only pumping of blood by the heart is not enough to overcome gravity. In fact, the veins have a mechanism that facilitates their work: the valves.

The valves are security mechanisms that function as locks, preventing the blood from flowing back. Thus, blood flows always in one direction.

Now imagine if these valves become incompetent. The blood which should only rise begins to return down and builds up the new blood that is rising. It is not hard to see why the veins dilate. This is the basic mechanism of varicose veins, patients become dilated and tortuous by inability to drain the blood toward the heart.

Because the peripheral veins of the legs are very close to the skin, any tortuosity dilation becomes readily apparent. In addition to the valves, our legs have two more "aces in the hole":
  • Plantar pump: each time we step, the impact of the foot with the ground causes a mechanical pumping of blood accumulated in the feet.
  • Pump calf: beyond a plantar pump, when we step, we use the calf musculature, popularly known as calf. Similarly, the contraction of muscles stimulates venous blood upwardly.

To summarize, there are three mechanisms that facilitate the return of blood to the heart: the presence of valves in the veins, plantar pump and calf pump, the latter two driven when we walk.


Risk factors

About 25% of women and 15% of men have varicose veins in legs. As have been already explained, the varicose veins arise when there is an impoundment of the blood in the veins, usually due to incompetence of the venous valves.

The main risk factors are:
  • Females: the presence of some hormones, such as progesterone, which causes dilation of the veins and favours valvular incompetence.
  • Age: varicose veins emerge from 30 years and become more common with aging. Veins are getting older and due to being subjected for decades of work against gravity are more likely to get sick.
  • Family history: the presence of varicose veins is usually a familial tendency. There is a genetic component facilitating the appearance thereof in some people.
  • Obesity: the heavier we are, the more pressure there is on the veins.
  • Smoking: Cigarette smoking harms the vessel walls, making them sick.
  • Pregnancy: the increase in hormones associated with an increased circulating blood volume and compression of intra-abdominal veins by a growing uterus, favoring the appearance of varicose veins.
  • Sedentary way of life: As have been already explained, the act of walking facilitates venous return, reducing the damming of the blood inside the veins.
  • Leg traumas: any injury that causes trauma in the veins can make them weaker and more susceptible to dilations.
  • Standing still for long periods: one person standing without walking for several hours is impairing venous return and facilitating the appearance of varicose veins.
  • Staying several hours sitting with your legs bent: Sitting down and crossing your legs is normal for us. But imagine your vessels are like hoses. If you stay with your legs bent for several hours, the blood still needs to overcome gravity to climb, only adding a more tortuous path.
  • Birth control pills: one more time, hormonal variation is a factor responsible for varicose veins.


Symptoms

Varicose veins are dilated and tortuous veins and they usually do not cause major symptoms other than the aesthetic nuisance. They always come in the most superficial veins, that is why they are so apparent.

When large, varicose veins can clinch after suffering trauma or form small thrombi, a condition called thrombophlebitis.

Varicose veins, when multiple, may be a manifestation of so-called chronic venous insufficiency. When multiple veins become varicose and insufficient, the blood begins to be trapped in the lower limbs, causing discomfort, heaviness, local pain, swelling, darkening of the skin and, in advanced cases, appearances of ulcers and skin infections.

Indeed, one must face the varicose as an intermediate stage of venous insufficiency, which can be divided into the following stages:

Spider veins
Spider veins
 

1. Telangiectasia or spider veins


The purplish telangiectasia is a condition characterized by dilation of the capillaries arising at the initial stage of venous insufficiency. It is a sign of disease of very small superficial veins that lie just below the skin. They are a species of spider veins.

At this stage there are generally no other signs and symptoms, except the appearance of telangiectasia.

2. Varicose veins


The appearance of varicose veins indicates that the difficulty in returning the blood has reached larger veins. The patient may have a single varix or in advanced stages of the disease presenting various varices.

Edema
Edema
 

3. Edemas


The more varicose veins there are, the more obvious is venous insufficiency. The blood cannot return to the rest of the body while it is dammed in the legs, which causes the appearance of edema (swelling).

In the early stages the swelling is in the ankles and usually appears only at the end of the day, when the patient has already spent several hours standing. As the disease progresses, the swelling can become persistent and can affect the entire leg.

When there is already a swelling, there may be other symptoms such as heaviness in the legs, night cramps, burning sensation, itching and pain in the varicose veins.

Skin changes
Skin changes
 

4. Skin changes


Besides edema, retention of blood in the lower limbs can cause color change of the skin, becoming more dark and purplish. The damaged capillaries and small veins of the legs allow the extravasation of red blood cells (RBCs) that suffer the destruction, release their red pigments which eventually deposit on the skin.

At this stage the skin may change in its texture, being dry and ignited, which is called stasis dermatitis. This dermatitis is characterized by a thickening of the skin associated with scaling, erosion and loss of liquids through the pores.

At this stage the skin becomes vulnerable, facilitating invasion by bacteria and the development of infections such as cellulitis and erysipelas.
Ankle ulcers
Ankle ulcers
 


5. Ulcers


The last stage of venous insufficiency is the appearance of skin ulcers. They may be single or multiple and are located preferably near the ankle, the major stasis.

The ulcers generally appear after minor trauma and are formed due to the fragility of the skin and blood vessels. If left untreated, ulcers continue to grow circumferentially, becoming giant lesions and frequent points susceptible to infections.


How to prevent varicose veins?

It is understandable that the appearance of varicose veins and telangiectasia is an early stage that can evolve to chronic venous insufficiency. It is important that patients realize that these changes in veins of the lower limbs begin to show signs of failure.

In the early stages some changes in lifestyle are important. You should stop smoking and avoid long periods sitting or standing still, should be exercising frequently, especially hiking to encourage plantar pumps and calf. If you are overweight, lose weight.

Exercises like weight training, if done correctly, will not cause varicose veins. Shaving your legs also has no influence. Stair climbing does not matter, however, the impact of the feet on the steps favors the venous return. In patients with a strong genetic predisposition, the ideal is to seek other contraceptive methods than birth control pills.


Treatment

If there are varices already, the tips outlined above are essential, but alone may not be enough.

If there are already signs of varicose veins, or telangiectasia, the use of compression stockings helps. The socks should be worn throughout the day, especially at times of long standing. The socks should be not too tight. The ideal is to seek guidance from an angiologist or vascular surgeon in choosing the most appropriate socks.

Lying with the legs raised above the heart level for 30 minutes, three or four times per day, is also important.

Some medications, when used together with the above measures, help to control varicose veins. The most commonly used are pentoxifylline (Trental) and Daflon. Diuretics should be avoided. When used, they must be taken for a short time, as they may worsen edema.

Often, however, surgical treatment of varicose veins is necessary. The main types are:
  • Sclerotherapy: it is a procedure used for varicose veins of small size, when the doctor injects substances that cause sclerosis (destruction and scarring) of the selected vein. As this vein stops receiving blood, it becomes useless, and over time the body eliminates it. It is a technique that requires repetition, but dispenses anesthetic and can be performed in the office. However, to be effective it must be done by trained physicians.
  • Laser surgery: it is also used for small varicose veins and telangiectasia. It is the destruction of small vessels by applying laser. It is a procedure that does not require needles or incisions. Laser surgery is not as good as sclerotherapy as not all skin types can receive the laser pulses. Works best for telangiectasia.
  • Catheter ablation: It is for varicose veins with the highest diameter. A small tube (catheter) is inserted into the varix, which can be destroyed by heat (laser intravenous) or by radio frequency.
  • Surgery: it is a surgical removal of varicose vein. Currently this type of surgery is performed with minimal incisions and hospitalization lasts no more than a day. When varicose veins are very small, the procedure can be done to outpatients.

Regardless of the technique, destruction or removal of varicose vein, it brings no further problems to the legs, since the treated vein was not working right thereof. Blood flow is automatically diverted to other collateral veins.

Treated varicose veins do not return. What can happen is the emergence of new varicose veins. It is important to understand that the treatments described above only eliminate existing varicose veins, but do not interfere with the process that causes them.

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