|
|
|
Overview |
|
|
Definition |
|
Varicose veins are large, dilated, tortuous, elongated superficial veins
exhibiting reflux or retrograde flow as a result of valvular incompetence,
weakness of the venous walls, or increased intraluminal pressure. They occur in
10% to 20% of the population, most commonly in the greater and lesser saphenous
veins and their tributaries in the legs. Varicose veins may appear at any age,
but the peak incidence is between 50 and 60 years of age. Varicose veins must be
distinguished from spider veins or telangiectases, which are tiny, dilated,
superficial veins visible on the skin surface. |
|
|
Etiology |
|
Primary varicose veins result from intrinsic weakness in the walls of the
veins coupled with incompetent, perforating veins; 50% of these cases are
familial (genetic). Secondary varicose veins are most often caused by
post-thrombotic deep venous insufficiency and the resulting diversion of flow
into superficial collateral vessels. They may also arise from superficial
thrombosis. Less often, they are caused by arteriovenous
fistulas. |
|
|
Risk Factors |
|
- Primary varicose veins
- Family history of varicose veins (50%)
- Female gender (three times more common in women)
- Pregnancy
- Occupations requiring prolonged standing
- Obesity
- Secondary varicose veins
- Proximal obstructing lesions (e.g., tumor)
- Conditions predisposing to deep venous thrombosis, such as surgery or
immobilization, hereditary thrombophilia (e.g., protein C or S deficiency,
factor V Leiden), acquired thrombophilia (e.g., malignancy), trauma, and
arteriovenous fistulas
|
|
|
Signs and Symptoms |
|
Primary varicose veins are often asymptomatic, causing only cosmetic
concerns. Secondary varicose veins are more likely than primary varicose veins
to be accompanied by the following.
- Chronic pain or heaviness or aching in the legs, relieved by
elevation
- Ankle edema
- Skin ulcerations
- Superficial thrombosis
- Rupture with bleeding after minor trauma
(rare)
|
|
|
Differential
Diagnosis |
|
Differentiating between primary and secondary varicose veins is critical
before invasive therapy is attempted. Chronic venous insufficiency may develop
if varicose veins are ablated when the deep venous system is obstructed. Chronic
leg pain may not be due to the varicose veins themselves but to superficial or
deep venous thrombosis. Additional causes of leg pain that must be considered
include the following.
- Sciatica
- Peripheral neuropathy
- Arthritis of hip or knee
- Baker's cyst
|
|
|
Diagnosis |
|
|
Physical Examination |
|
The physician must conduct the examination while the patient is standing
position so that the veins distend and are therefore easily seen and palpated.
The following three tests may be helpful to distinguish primary and secondary
varicosities.
- Brodie-Trendelenberg test—to determine
valvular incompetence in the saphenofemoral system
- Percussion test—to determine valvular
competence in the great saphenous vein
- Perthes test—to determine valvular competence
in the deep femoral vein
|
|
|
Imaging |
|
- Doppler ultrasound—to determine the
relationship of varicosities to the saphenous system; to assess competence of
the greater and lesser saphenous systems; to rule out deep venous obstruction
and arterial occlusive disease
- Duplex ultrasound scanning with color-flow
imaging—used for the same purpose as Doppler ultrasound
but may also permit more complete and accurate diagnosis, especially in obese
patients.
- Venography—to visualize veins filled with a
contrast medium; most commonly used to detect thrombophlebitis
- Photoplethysmography—to quantitatively
measure venous function; to assess the severity of chronic venous insufficiency
|
|
|
Treatment Options |
|
|
Treatment Strategy |
|
Conservative (noninvasive) therapy is the initial treatment of choice for all
patients and may be the only treatment ever needed for all but the most severe
cases. These measures include the following.
- Avoidance of prolonged sitting, standing, or walking
- Regular exercise since action of the calf and other leg muscles
increases venous return
- Periodic elevation of the legs
- Graduated compression stockings
- Ablative (invasive) procedures, including sclerotherapy and surgery,
are indicated for superficial varicose veins accompanied by chronic pain;
chronic venous insufficiency with edema, ulceration or other skin changes; and
recurrent superficial vein thrombosis.
- Such treatment may also be indicated purely for
cosmesis.
|
|
|
Surgical Procedures |
|
Sclerotherapy involves injection of a sclerosing solution (e.g., sodium
tetradecyl sulfate) into a varicosity, followed by application of a compression
dressing. This produces inflammation in the vessel wall, which leads to fibrosis
with obliteration of the vessel lumen. It is used most often for spider veins
(telangiectases) and smaller, nonsaphenous varicose veins. Use of sclerotherapy
alone and in combination with surgery to treat larger, more extensive
varicosities of the greater and lesser saphenous veins is controversial in the
U.S.
Phototherapy employs laser or high-intensity pulsed light to destroy
telangiectases. It is not used to treat varicose veins per se. Radiofrequency
ablation uses a catheter threaded into the varicose vein to heat the vein wall
either to obliterate the lumen or shrink it enough to restore valve competence.
It is suitable for treating large varicosities in the saphenous system, yet it
is a relatively new technique where long-term results are unknown.
Surgical therapy involves removal of varicose veins by various techniques
including classic stripping and ligation and the more recently developed
stab-avulsion technique, which uses smaller incisions. |
|
|
Complementary and Alternative
Therapies |
|
Nutritional supplements and herbs may be beneficial in enhancing the
integrity of the vasculature, stimulating circulation, and relieving discomfort.
|
|
|
Nutrition |
|
- Include dietary fiber in the form of complex carbohydrates (e.g.,
whole grains) to avoid constipation, which may contribute to venous congestion.
Include foods rich in bioflavonoids, such as dark berries, dark leafy greens,
garlic, and onions, which strengthen collagen tissues. Drinking fluids and
getting regular exercise also help prevent constipation.
- Vitamin C (500 to 1,000 mg tid), vitamin E (200 to 600 IU/day), and
zinc (15 to 30 mg/day) are essential for vascular health.
|
|
|
Herbs |
|
Herbs may be used as dried extracts (pills, capsules, or tablets), teas, or
tinctures (alcohol extraction, unless otherwise noted). Dose is 1 heaping tsp.
herb/cup water steeped for 10 minutes (roots need 20 minutes). Commercial
preparations often contain a combination of the following herbs. They may also
be taken individually, as noted.
- Horse chestnut (Aesculus hippocastanum) 500 mg tid or
standardized Aescin 10 mg tid
- Butcher's broom (Ruscus aculeatus) standardized extract (9% to
11% ruscogenin) 100 mg tid
- Gotu kola (Centella asiatica) 1,000 mg bid to qid or
standardized extract (asiaticoside 40%, Asiatic acid 30%, madecassoside 1% to
2%) 60 mg once to twice daily
- Bilberry (Vaccinium myrtillus) standardized extract (25%
anthocyanoside) 80 to 160 mg tid
Combine the following in equal parts to support the vasculature and tone the
circulatory system: yarrow (Achillea millefolium), hawthorn (Crataegus
monogyna), ginkgo (Ginkgo biloba), marigold (Calendula
officinalis), horse chestnut (Aesculus hippocastanum), and ginger
(Zingiber officinalis). Take 30 to 60 drops tincture bid to tid or drink
three to four cups of tea daily. |
|
|
Homeopathy |
|
An experienced homeopath would consider the individual's constitution. Some
of the most common acute remedies are listed below. Acute dose is three to five
pellets of 12X to 30C every one to four hours until symptoms
resolve.
- Aesculus for generalized venous congestion, especially with
hemorrhoids and constipation
- Fluoricum acidum for painful varicose veins and sensation of
heat
- Hamamelis for weak veins and easy bruising or bleeding;
varicose veins with stinging pains
- Secale for varicosities with burning, constricting pains that
are worse with exertion
|
|
|
Physical Medicine |
|
Cold compresses of witch hazel (Hamamelis virginiana) and yarrow
(Achillea millefolium) tea may provide temporary relief.
|
|
|
Acupuncture |
|
May be helpful in improving the overall circulatory system and reducing
venous congestion. |
|
|
Massage |
|
May be beneficial in alleviating venous congestion and mechanically
stimulating circulation. |
|
|
Patient Monitoring |
|
Varicose veins, while treatable, will eventually recur and progress
regardless of the treatment chosen. Recurrences may develop in residual varicose
veins not completely removed by surgery or obliterated by sclerotherapy or in
veins not previously affected. This may be assessed by periodic
monitoring. |
|
|
Other
Considerations |
|
|
Prevention |
|
Regular exercise increases venous return. Both weight loss and exercise
decrease the likelihood of thrombosis. |
|
|
Complications/Sequelae |
|
Both primary and secondary varicose veins develop progressively. Once a vein
segment dilates, valvular incompetence develops and blood refluxes distally.
This increases hydrostatic pressure distally, causing further vein dilation and
elongation. Eventually this process may propagate throughout the length of the
vein and into peripheral branches and perforating veins. Varicose veins are not
thought to lead to venous ulceration unless accompanied by deep venous or
greater or lesser saphenous vein insufficiency. Thus, varicose veins may account
for only 20% to 30% of venous ulcers.
Complications of sclerotherapy include cutaneous hyperpigmentation; allergic
reactions to sclerosing agents; thrombus formation; edema; telangiectatic
matting; cutaneous necrosis; and ulceration. Arterial injection with sclerosing
agents may lead to limb amputation; pulmonary embolism; deep venous thrombosis;
and nerve damage. |
|
|
Prognosis |
|
Varicose vein disease is a chronic condition. New varicosities often occur
after treatment, such as residual varicosities from incomplete surgery or
sclerotherapy. |
|
|
Pregnancy |
|
The incidence of varicose veins during pregnancy varies from 8% to 20% and is
most common in multiparous women. These varicosities may be caused by
compression of the iliac veins by the uterus, which results in increased
pressure in the lower veins, or by the effects or estrogen and progesterone,
which make the walls of the veins more pliable. Elevation of legs may be
particularly effective. |
|
|
References |
|
Bergan JJ, Yao JST. Venous Disorders. Philadelphia, PA: Saunders;
1991: 201–215.
Blumenthal M, ed. The Complete German Commission E Monographs: Therapeutic
Guide to Herbal Medicines. Boston, Mass: Integrative Medicine
Communications; 1998:99, 149, 432.
Branch WT Jr. Office Practice of Medicine. 3rd ed.
Philadelphia, PA: Saunders; 1994: 144–146.
Fauci AS. Harrison's Principles of Internal Medicine. 14th
ed. New York, NY: McGraw-Hill; 1998: 1405.
Goldman MP, Weiss RA, Bergan JJ. Varicose Veins and Telangectasias:
Diagnosis and Treatment. 2nd ed. St. Louis, MO: Quality Medical;
1999: 3–41, 110–124,
164–174, 175–264,
414–424, 470–497.
Gruenwald J, Brendler T, et al, eds. PDR for Herbal Medicines.
Montvale, NJ: Medical Economics Company; 1998:729-730.
Hoffman D. The New Holistic Herbal. New York, NY: Barnes & Noble
Books;1995: 31.
Morrison, R. Desktop Guide to Keynotes and Confirmatory Symptoms.
Albany, Calif: Hahnemann Clinic Publishing; 1993.
Murray MT, Pizzorno JE. Encyclopedia of Natural Medicine. Rocklin,
Calif: Prima Publishing; 1998: 540.
Rosen P, et al. Emergency Medicine: Concepts and Clinical Practice.
4th ed. Vol 2. St. Louis, MO: Mosby; 1998:
1862–1863. |
|
Copyright © 2000 Integrative Medicine
Communications This publication contains
information relating to general principles
of medical care that should not in any event be construed as specific
instructions for individual patients. The publisher does not accept any
responsibility for the accuracy of the information or the consequences arising
from the application, use, or misuse of any of the information contained herein,
including any injury and/or damage to any person or property as a matter of
product liability, negligence, or otherwise. No warranty, expressed or implied,
is made in regard to the contents of this material. No claims or endorsements
are made for any drugs or compounds currently marketed or in investigative use.
The reader is advised to check product information (including package inserts)
for changes and new information regarding dosage, precautions, warnings,
interactions, and contraindications before administering any drug, herb, or
supplement discussed herein. | |