Introduction to venous disease: varicose veins and telangiectasia
Venous disease is a widespread problem that affects 40% to 55% of the population. Varicose veins, reticular veins and spider veins (telangiectasia) are the most common vascular disorder of the lower extremities and their incidence increases with age. For some they might be just an aesthetic problem, but varicosities can be associated with dull pain or discomfort, swelling, skin changes, burning sensation and can lead to ulcerations, thrombophlebitis, deep vein thrombosis and inflammatory dermatitis among the many.
Varicose veins are caused by venous insufficiency, a vascular problem due to the failing of venous valves which are supposed to prevent the blood from flowing backwards. When this happens, the veins get congested, suffer an higher pressure on their walls and overtime they develop the typical dilated and tortuous appearance.
Phlebology is the medical specialty dedicated to diagnosing and treating venous problems. It dates back to 400 BC when Hippocrates, the father of medicine, already described treatments such as vein stripping to treat varicose veins.
During the 20th century, the treatment approaches have been mainly the classical stripping and sclerotherapy. Since the 1980s, new techniques have been developed that increase efficacy of treatment and improve aesthetic results, while decreasing post-operative disabilities and complications shifting the approach from surgical to non-surgical.
Diagnosis of varicose veins
The diagnosis is generally done by a vascular surgeon after visual examination of the leg, palpation of the veins and after performing some simple tests without the need of technologically advanced equipment. Color Doppler Duplex Ultrasonography is the standard imaging technique that should be executed for diagnosis, treatment planning and mapping of the veins prior to treatment. In particular cases a magnetic resonance venography (MRV) or a direct contrast venography might be prescribed to clear doubts or better understand the issue.
Due to the gradual onset of symptoms, many patients do not report them, having accepted them as normal discomfort due to other reasons, or might feel them as less severe having become accustomed to the discomfort. After treatment, these patients are surprised by the amount of discomfort, now gone, they previously accepted as normal.
What are the risk factors?
- Heredity: studies show a genetic predisposition to the development of varicose veins.
- Age: incidence increases with age.
- Sex: women are more likely to be affected than men, probably due to the hormonal changes that occur during pregnancy and menopause.
- Pregnancy: due to hormonal factors varicose veins are generally seen in the first trimester of pregnancy. The increased blood volume and decreased flow in the lower limbs, designed to better support the growing fetus, contributes to the problem.
- Obesity: being overweight puts additional pressure on your veins
- Standing or sitting for long periods of times, often due to the patient’s occupation, and sedentariness play a big role in the development of venous disease
Treatment of varicose veins
Currently, there are different types of treatment for varicose veins and telangiectasia including:
- Lifestyle changes (exercising, weight loss, avoiding standing or sitting for long time without changing position, avoiding high heels, …)
- Compression stockings, which help the veins moving the blood from the extremities towards the heart, by steadily squeezing the legs (the leg muscles help in the same way while we stand: by contracting they squeeze the veins and help the blood-flow).
- Foam Sclerotherapy
- Laser surgery
- Catheter-assisted radiofrequency or laser treatment
- Endoscopic Vein Surgery
Sclerotherapy is performed by injecting a chemical agent into the target vein, causing its walls damage and inducing a series of events(thrombosis and fibrosis) that in the end cause the vein to be occluded. Several agents have been used and are available for the scope and the choice depends upon many factors, such as the vein diameter, location and depth, pain tolerance of the patient, reflux considerations.
The area to be treated is wiped clean with alcohol (it helps better visualize the vessels) or other antiseptic agents. Anesthesia is usually not required, although it might be administered topically after consultation with the patient; anti-anxiety drugs might be administered too before the procedure when required.
The sclerosant agent is diluted and loaded into a syringe. Different injection techniques might be used at this point, based on the doctor’s expertise.
The procedure may be done in multiple treatments and usually 4-8 weeks between treatments helps reducing the number of necessary sessions.
A visual aid, such as direct duplex ultrasound, might or might not be used.
After the procedure, compression is applied to the area treated: it improves the effectiveness of the treatment by collapsing and decreasing the blood flow to the treated vein allowing maximal effect on the vessel walls and it helps in removing and diluting any sclerosing solution that might have entered the venous system beyond the treated area. Compression stockings (15-30 mmHg) are recommended for at least 2 weeks.
An alternative to traditional liquid sclerosant therapy is the use of a foamed sclerosant agent. The advantages over the liquid therapy are:
- It provides better and prolonged contact of the agent with the vessel wall
- It maintains its concentration better than liquid sclerosant, which is diluted by blood itself.
- It travels farther along the vessel.
- A smaller volume of sclerosant is needed
- Foam is better visualized on duplex imaging (when used).
Side Effects and Complications of Sclerotherapy
- Hyperpigmentation: usually occurs 6-12 weeks after treatment and slowly regresses, with a 1% incidence of persisting pigmentation after 1 year
- Telangiectatic Matting: it is defined as the appearance of a fine web of telangiectatic veins. It usually resolves over a 3-12 months period.
- Cutaneous Necrosis: it is the result of the sclerosing agent when in contact with tissue outside the vein.
- Thrombophlebitis: although compression greatly reduces the occurrence of this complication, thrombophlebitis may appear after 1-4 weeks following treatment.
- Arterial injection:
- Allergic reaction
- Pain, swelling, urticaria
- Nerve damage
- Pulmonary embolism
Laser Vein Treatment
Laser is the treatment of choice for the smaller vessels of the lower limbs and for facial talangiectasia. It works by selectively destroying (photothermolysis) the targeted vessel by applying heat. It is a good option for vessels resistant to sclerotherapy or for patients who do not tolerate needles or traditional sclerotherapy. To improve the comfort of the patient, some form of cooling is applied to the treated area.
Warnings and Advices
Sclerotherapy and laser vein treatment continue to evolve with new and improved techniques and with the development of new technologies. The lack of anesthesia, no downtime and the fact that it is an outpatient procedure make these the gold standard for varicose veins and spider veins treatment. Although being considered a safe procedure, as always, we recommend choosing an experienced and knowledgeable doctor as there are many variables to consider that will influence the results.
- Varicose veins that develop during pregnancy generally improve without medical treatment within three to 12 months after delivery
- Do not shave, wax or apply any cream on the area to be treated. Your treating physician will remind this to you during the consultation.
- Those who are more likely to develop varicosities or telangiectasia may avoid or delay the progression of this problem with simple precautions: losing weight if overweight, avoid standing for long periods of time, wear loose clothing, raise the legs when sitting and when sleeping raise them 10cm above the heart, avoid high heels.