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Dealing with varicose veins

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Dr. Olugbenga Olusoji, Consultant cardiovascular and Thoracic surgeon at Lagos University Teaching Hospital (LUTH) explains varicose veins and how to deal with and prevent them.

Varicose veins           
Varicose veins are abnormal, distended and tortuous veins. They are usually generalised but more pronounced in certain parts of the body. The lower limbs are more commonly affected than other parts. Veins are the blood vessels that return blood, whose oxygen and nutrients have been depleted back to the heart. The veins do not have strong muscles in their walls, unlike the arteries. Those in the lower limbs also move blood against gravity, which is an uphill task; hence they depend on active contractions of the lower limb muscles, some of which have been termed “peripheral heart”, and competence of the valves in their wall, which permit only upward flow of blood.

So, prolonged sitting or standing will pool blood in the veins of the lower limbs, causing engorgement and tortuosity. There are two systems viz: the deep venous system (those veins within the muscles) and the superficial (those just beneath the skin). Varicose veins refer to the superficial veins. Along the limbs, the deep and superficial veins communicate via veins called perforators, which can also be involved in the abnormal dilation and tortuosity. Varicosity can be primary (causes not well known) or secondary (causes well established). The primary types are usually common in middle age, and can affect about 10 to 30 percent of the adult population. Women are four times more commonly affected than men.

Causes of varicose veins
The suggested causes of the primary type include, obesity, hormonal disturbance, advancing age, prolonged standing or sitting, tumours in the pelvic region, injuries/infections that damage valves of the legs, and presence of family members that had varicose veins. Certain female hormones like progesterone and oestrogen (the former more importantly) can cause relaxation of the veins, leading to engorgement and tortuosity of the veins. Apart from causing vein wall relaxation, their fluctuating levels have been suspected to cause damage to the valves within the veins, worsening their engorgement and tortuosity. This can be seen in pregnant women, those taking oral contraceptive pills, or those on hormone replacement therapy (HRT).

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Aside hormone issues, pregnancy also results in increased blood volume, and the pregnant uterus also compresses the veins coming from the lower limbs, further resulting in engorgement. And if it occurs repeatedly, it causes tortuosity.

Some occupations that involve prolonged standing or sitting also increase the likelihood of developing, by pooling blood in the veins. These include flight attendants, doctors/nurses, teachers and retail workers, among others. The secondary varicose veins can be due to arteriovenous fistula (AVF), which is an abnormal communication between arteries and veins, blockage of the pelvic veins (by blood clots in the veins), and genetic disorders that affect blood vessels, skin and muscles, and bones (Klippel Trenaunay syndrome).

Symptoms and signs of varicose veins
Most patients with varicose veins are asymptomatic. Presenting complaints when present could be cosmetic, pain, heaviness, itching, swelling, heavy bleeding following injuries, and ulcers in the legs.

Diagnosis
Diagnosis can usually be made by the doctor examinations at the clinics. Additional information can be obtained by the use of ultrasound (Doppler or Duplex), which can give details of the veins, site of valve incompetence, presence or absence of blood clots in the deep veins of the legs, which will affect the treatment choice. Other investigations could include abdominal/pelvic ultrasound scan or CT scan. CT venogram may also be requested.

Treatment options
Treatment options include surgery, minimally invasive, and non-operative therapy. Traditional surgical venous stripping procedure involves making a small cut over the lower and upper aspects of the vein under local or regional block. Then, a device is passed into the vein, tied around its upper part, and pulled out through the lower cut. Pressures are subsequently applied to minimise bleeding. This can be repeated for other vein tributaries.

Any abnormal perforator veins are tied off before the stripping. Patient can go home same day. Complications can include bleeding, infection, and injury to the nerves. Modifications have now been applied to the stripping operation and include use of endoscopes for perforator ligation and venous stripping and application of heat, among others. The success rate is quite high. Minimally invasive options include Radiofrequency ablation and Endovenous laser therapy. They can be done under general, regional or local anaesthesia.

For radiofrequency ablation, a slender catheter is passed into the lower aspect of the vein and manoeuvered up the thigh and heat is gently applied to occlude the whole length of the vein. Endovenous laser therapy is done under local anaesthesia, with a small laser probe passed up the vein under ultrasound guidance and the laser is deployed to cause apposition of the vein.

Non-operative options include Compression stockings and Sclerotherapy. Compression stockings gently squeeze the veins with improvement in the symptoms. However, this is limited to the period the stockings are worn. Compliance is also a challenge with prolonged use of the stockings. Sclerotherapy involves puncturing the vein with a fine needle and injecting some chemicals that can occlude the veins and cause fibrosis. The drawback is the high rate of recurrence, as the veins can open up again later.

Preventive measures for varicose veins
Prevention of varicose veins may not always be possible, depending on the predisposing factors. However, some measures can be helpful in preventing or relieving the symptoms. These include avoiding prolonged standing or sitting (if these cannot be avoided, consider elevating the legs); losing weight; gentle exercises that increase activities of the lower limb muscles, such as walking or swimming; limb elevation, which helps to empty the veins; avoiding high heel shoes often, as they are suspected to weaken the calf muscles; and avoid crossing the legs often while sitting. Avoid exercises that can worsen the varicosities, such as running, jogging, weightlifting, squats and sit-ups, among others.

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