Varicose veins -- visibly enlarged blood vessels that bulge in the legs -- are one of the most common conditions affecting the U.S. population, affecting 10-20% of all adults. The condition itself results from insufficient blood flow from the leg veins up to the heart when weakened valves don't close properly and allow blood to flow backward. In particular, this reflux in the great saphenous vein in the upper thigh is a common cause of varicose veins in the lower leg.

Approximately 25 million people in the United States suffer from this condition that may cause aching pain, easily tired legs, leg heaviness, darkening of the skin, and difficult-to-treat wounds. Unsightly and uncomfortable, varicose leg veins can promote swelling in the ankles and feet and itching of the skin. They may occur in almost any part of the body but are most often seen in the back of the calf or on the inside of the leg between the groin and the ankle.  Left untreated, patient symptoms are likely to worsen with some possibly leading to venous ulceration.

What Causes Varicose Veins?
The normal function of leg veins - both the deep veins in the leg and the superficial veins which feed them - is to carry blood back to the heart. During walking, for instance, the calf muscle acts as a pump, contracting veins and forcing blood back to the heart.  To prevent blood from flowing in the wrong direction, veins have numerous valves.  If the valves fail (a cause of venous reflux), blood flows back into superficial veins and back down the leg. This results in veins enlarging and becoming varicose.  The process is like blowing air into a balloon without letting the air flow out again-  the balloon swells.

To succeed, treatment must stop this reverse flow at the highest site or sites of valve failure.  In the legs, veins close to the surface of the skin drain into larger veins, such as the saphenous vein, which run up to the groin.  Damaged valves in the saphenous vein are often the cause of reversed blood flow back down into the surface veins.

Why Do Varicose Veins Occur More in the Legs?
Gravity is the culprit.  The distance from the feet to the heart is the furthest blood has to travel in the body. Consequently, those vessels experience a great deal of pressure. If vein valves can't handle it, the backflow of blood can cause the surface veins to become swollen and distorted.

Who is at risk for developing varicose veins?
Conditions contributing to varicose veins include genetics, obesity, pregnancy, hormonal changes at menopause, work or hobbies requiring extended standing, and past vein diseases such as thrombophlebitis (i.e. inflammation of a vein as a blood clot forms.)  Women suffer from varicose veins more than men, and the incidence increases to 50% of people over age 50.

Risk Factors
There are many factors which lead to the development of varicose veins including:

• Age
• Family history
• Gender
• Pregnancy, especially multiple pregnancies
• Obesity
• Occupations which require long periods of standing

Symptoms
Symptoms caused by venous insufficiency and varicose veins include:

• Aching pain
• Easily tired legs
• Leg heaviness
• Swollen limbs
• Skin changes and skin ulcers

People who have venous insufficiency can have symptoms even without visible varicose veins. The symptoms are caused by pressure on nerves by dilated veins.

Diagnosis
Using ultrasound to scan the leg(s), your physician will determine if superficial venous reflux is present and whether you are a candidate for the Closure procedure.

Treatments
Traditionally, patients diagnosed with venous reflux would undergo vein stripping surgery to correct this condition. Now, patients whose varicose veins are causing symptoms can be treated with the Closure procedure - a minimally invasive alternative to painful vein stripping surgery. This treatment is an outpatient procedure performed using imaging guidance. An interventional radiologist guides a probe through a tiny tube into the vein and then transmits radio frequency energy to close off the vein. By closing the great saphenous vein, the twisted and varicosed branch veins, which are close to the skin, shrink and improve in appearance. Once the vein is closed, other healthy veins take over to carry blood from the leg and re-establish normal flow.

With the Closure procedure, there is no incision, no real scarring, and most patients report an improvement in symptoms within one to two weeks following the procedure. Published data suggest that patients remain varicose-vein free after two years about 90 percent of the time.

What are venous leg ulcers?
Venous ulcers are areas of the lower leg where the skin has died and exposed the flesh beneath. Ulcers can range from the size of a penny to completely encircling the leg. They are painful, odorous open wounds which weep fluid and can last for months or even years. Most leg ulcers occur when vein disease is left untreated. They are most common among older people but can also affect individuals as young as 18.

What are some short-term treatments for varicose veins?
ESES (pronounced SS) is an easy way to remember the conservative approach.  It stands for Exercise Stockings Elevation and Still. Exercising, wearing compression hose, elevating and resting the legs will not make the veins go away or necessarily prevent them from worsening because the underlying disease (venous reflux) has not been addressed. However, it may provide some symptomatic relief.  Weight reduction is also helpful. If there are inflamed areas or an infection, topical antibiotics may be prescribed. If ulcers develop, medication and dressings should be changed regularly. There are also potentially longer-term treatment alternatives for visible varicose veins, such as sclerotherapy and phlebectomy.

What is sclerotherapy?
A chemical injection, such as a saline or detergent solution, is injected into a vein causing it to "spasm" or close up. Other veins then take over its work. This may bring only temporary success and varicose veins frequently recur.  It is most effective on smaller surface veins, less than 1-2mm in diameter.

What is ambulatory phlebectomy?
As with sclerotherapy, ambulatory phlebectomy is a surgical procedure for treating surface veins in which multiple small incisions are made along a varicose vein and it is "fished out" of the leg using surgical hooks or forceps.  The procedure is done under local or regional anesthesia, in an operating room or an office "procedure room."

What is Vein Stripping?
If the source of the reverse blood flow is due to damaged valves in the saphenous vein, the vein may be removed by a surgical procedure known as vein stripping.  Under general anesthesia, all or part of the vein is tied off and pulled out.  The legs are bandaged after the surgery but swelling and bruising may last for weeks.

What is the main difference between arteries and veins?
In simplest terms, arteries pump oxygen-rich blood FROM the heart; veins return oxygen-depleted blood TO the heart.

What are the three main categories of veins?
Deep leg veins return blood directly to the heart and are in the center of the leg, near the bones.

Superficial leg veins are just beneath the skin.  They have less support from surrounding muscles and bones than the deep veins and may thus develop an area of weakness in the wall.  When ballooning of the vein occurs, the vein becomes varicose.

Perforator veins serve as connections between the superficial system and the deep system of leg veins.

For more information or to schedule an appointment with a
Bryn Mawr Hospital interventional radiologist,
Call 1-866-CALL-MLH.