by Dr. Ashish Sam Enos, Specialist General Surgeon, Thumbay Hospital Day Care, Rolla, Sharjah

Varicose veins are tortuous, widened veins in the subcutaneous tissues of the legs and are often easily visible. Varicose veins are widely seen as a medically unimportant and deserving low priority for treatment. However, they are quite common, affecting nearly a third of the adults in Western societies. A few people with varicose veins are even seriously affected. Varicose veins cause concerns and distress on a large scale, most of which can be allayed with good explanation and reassurance, or through a variety of treatments.

Who gets varicose veins?

The recent study has shown age wise prevalence of 40% in men and 32% in women, although women more often present for treatment. The age of onset varies; some people develop varicose veins in their teens, but prevalence rises with age. Varicose veins often appear first in pregnancy, and further pregnancies can make them worse. Family history is common, but people should be reassured that having close relatives with severe symptoms from varicose veins or ulcers does not confer a greater likelihood that they will have similar problems.

What problems can varicose veins cause?

Cosmetic concerns: For the great majority of people, varicose veins cause no symptoms and never cause harm. However, their appearance is a cause of concern, particularly for women. Cosmetic concerns may increase the emphasis that patients place on other symptoms.

Fears about future harm: A questionnaire study found that many people are worried about the possible harm their varicose veins might cause, but these fears are usually misplaced particularly in relation to bleeding, ulcers, and deep vein thrombosis.

Discomfort: Varicose veins can cause a variety of symptoms of discomfort in the legs, but it is important to try to differentiate these from the many other reasons for leg pains. The Edinburgh Vein Study found that the symptoms significantly associated with varicose vein were itching, heaviness and aching, but the relation of these with varicose veins was inconsistent, particularly in men. Traditional pointers to symptoms being caused by varicose veins include worsening of symptoms after prolonged standing or walking and towards the end of the day, relieving symptoms by elevating the legs or wearing support hosiery, and tenderness over the veins.

Leg swelling: This is a common symptom of varicose veins. Unilateral swelling of a leg with big varicose veins is the most typical presentation.

Thrombophlebitis: Superficial thrombophlebitis (phlebitis) can complicate varicose veins. It is the inflammation of the superficial veins. Veins may sometimes remain permanently occluded.

Bleeding, skin changes, and ulcers: These are the complications of varicose veins that mandate consideration of treatment. They are all associated with high venous pressure in the upright position as a result of incompetent venous valves. Bleeding is common and usually occurs from a prominent vein on the leg or foot with thin, dark, unhealthy skin overlying it. ‘Skin changes’ range from eczema, through brown discoloration, to florid lipodermatosclerosis with induration of the subcutaneous tissues. Sometimes this can become painfully inflamed ‘inflammatory liposclerosis’ which is often misdiagnosed as phlebitis or infection. If neglected, lipodermatosclerosis can lead to ulceration, which can be chronic and troublesome.

What other conditions can varicose veins be confused with?

Many people have telangiectases on their legs often called thread, spider, or broken veins. Small dark blue reticular veins are also common. All of these are of cosmetic importance only. They are not the same as varicose veins, though they often occur in association with them.

Many people with varicose veins worry about deep vein thrombosis, but the superficial veins of the legs that become varicose are separate and distinct from the deep veins where deep vein thrombosis occurs. Varicose veins pose no proved risk of deep vein thrombosis during people’s normal daily lives. Varicose veins occurring as a result of a deep vein thrombosis are uncommon. However, varicose veins may coexist with deep vein incompetence, particularly in people with complications such as lipodermatosclerosis or ulcers, which makes treatment more difficult.

How should varicose veins be assessed?

Sites of venous incompetence are best diagnosed by duplex ultrasound scanning, which is done during an initial specialist assessment. Duplex scanning shows both venous anatomy and blood flow and is essential for assessing more complex cases. Use of a handheld Doppler machine provides a quick screening test for selecting those who need duplex scanning.

Is there a non- medical management for varicose veins?

Patients for whom discomfort is the main problem should be advised that wearing support hosiery can provide good relief. Elevation of the legs may relieve symptoms. Advice about regular exercise sounds sensible but is not supported by any evidence. For people who are obese, weight loss may reduce symptoms and would make any intervention easier and safer (but losing a lot of weight may make varicose veins more visible).

What are the treatment options for varicose veins?

For patients with symptomatic veins and substantial venous incompetence, surgery has been the optimal treatment for many years.

1. Conventional surgery: This usually means saphenofemoral ligation, stripping of the veins and ligation of incompetent perforators.

2. Radiofrequency and laser ablation: These are alternatives to the stripping of the long saphenous vein. Radiofrequency and laser ablation each involve passing a probe up the long saphenous vein from knee level to the groin under ultrasound guidance and then ablating the vein in sections. This avoids a groin incision and may lead to less bruising and quicker recovery. Some surgeons use these techniques under local anesthetic infiltration rather than general anesthesia.

3. Sclerotherapy: This involves an injection of a sclerosant—commonly sodium tetradecyl (STD) or polidocanol into varicosities, followed by a period of compression bandaging and/or compression hosiery. Traditional sclerotherapy works well for smaller veins below the knee: foam sclerotherapy can be used to treat larger veins. The main risk of sclerotherapy is injection outside the vein, which can result in local tissue necrosis and scarring.