Vein disease and varicose veins
Varicose veins are enlarged or bulging superficial veins that sometimes have snake-like appearance in the legs. The walls of these veins are weak and are wider and longer than normal. Varicose veins are a manifestation of chronic vein disease.
Veins are the blood vessels that return blood back to the heart. In the legs superficial veins located in the fatty layer just under the skin are connected through short veins to deep veins located inside the calf muscles.
Blood from superficial veins pass through the short veins to the deep veins in a one-way direction. Inside the veins are valves that allow blood to move unidirectionally. The valves open to allow blood to flow, then blood pushed downward by gravity causes the valve to close to keep blood from flowing back.
The calf muscles compress the deep veins and blood is propelled upward towards the heart. When the valves are damaged, blood leaks or flows back (venous valvular reflux) and pressure inside the vein increases (venous hypertension). When one stands, the veins with damaged valves easily fill with blood, causing further widening and elongation of the veins.
Varicose veins cause pain or aching, swelling, itching, and discomfort in the legs although in some cases varicose veins may not cause pain at all. Inflammation and rash in the overlying skin or of the vein (phlebitis) and bleeding can develop. Painful ulcers that hardly heal can also occur.
The cause of weak vein walls and progression to chronic vein disease is not exactly known. Risk factors are advancing age, leg injury, prolonged sitting or standing, inactivity, pregnancy, and weight gain.
In pregnancy, hormonal changes may weaken the walls of leg veins. Strong family history is also a risk factor – in a study by Cornu et al it was shown that the risk for varicose veins was 90 percent when both parents were affected, 25 percent for men and 62 percent for women when parent was affected, and 20 percent when no parent was affected.
Treatment is for the relief of symptoms, improvement of the appearance of the legs, and prevention of complications like lipodermatosclerosis a condition in which the skin becomes dry and darkened and skin ulcers develop.
Asymptomatic patients with small varicose veins(less than six cm. in diameter) may not require treatment unless there is a desire to improve cosmetic appearance. Sclerotherapy and surface laser therapy are options.
Measures that improve blood flow in the veins improve the transport of oxygen to the skin and the local tissue. These can decrease swelling, inflammation, and discomfort:
- Elevation of the legs to at least heart level for 30 minutes three to four times a day. This increases blood flow by 41 percent and can also help in the healing of skin ulcers. Raising the legs below the level of the heart has been to be ineffective in decreasing venous hypertension.
- Exercise –Daily walking and flexion of the ankles while seated can improve the efficiency of the leg muscles in pushing blood up towards the heart. A combination of heel lifts and physical activity like walking, treadmill exercises, or cycling has been shown to be very effective. Physical activity among patients with comorbid conditions like heart disease, diabetes mellitus, hypertension is carefully planned with the supervision of a physician.
- Compression therapy is a cornerstone in the treatment of chronic vein disease. This includes garments, hosiery, bandages and devices that provide static or dynamic mechanical compression. The choice of compression therapy is based on the nature and severity of the vein disease and other factors- the level of pain, presence of venous skin ulcer, one’s ability and willingness to comply especially when dressings are to be applied and changed, availability of resources, coexisting medical illness, and involvement of other vessels the arteries and lymphatic vessels.
Compression therapy is done under medical supervision because improper use may compromise blood flow in nearby arteries whose task is to deliver oxygenated blood to body parts. Ischemia due to arterial disease has to be ruled out because compression therapy can cause leg ischemia or gangrene in the limb.
There are medical conditions in which compression therapy may not be advised like peripheral arterial disease, superficial deep vein thrombosis, heart failure (the deep veins carry 90 percent of the blood from the legs to the heart and improper use of compression therapy may affect the heart’s pumping capacity and acute inflammation of the skin.
If compression therapy does not improve varicosities and the venous insufficiency, duplex examination of the legs confirms the diagnosis of venous insufficiency. Invasive procedures include superficial venous ablation and for more severe conditions surgery to remove venous outflow.
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