Varicose veins are one of the most common diseases, as nearly 75% of people will be affected to varying degrees during their life and 25% require medical attention.
Varicose disease affects mainly but not exclusively women:In France it is estimated that 40% of women have or will experience symptoms in their relationship with venous insufficiency,20% of men.
A varicose vein is a superficial dilated enlarged and twisted tortuous vein,in which the blood circulates to counterflow,resulting a pathological movement.
What are varicose veins?
Varicose veins are veins located beneath the skin which are enlarged and twisted as a result of damaged valves within them.Varicose vein doesn't exist on deep veins.
THE DIFFERENT VARICOSE VEINS
They are different varicose veins
Any vein may become varicose, but the veins most commonly affected are those in your legs and feet. That's because standing and walking upright increases the pressure in the veins of your lower body.
Varicose veins are distinguished from reticular veins (blue veins) and telangiectasias (spider veins), which also involve valvular insufficiency, by the size and location of the veins.
Large varicose veins can be visible, bulging, palpable (can be felt by touching), long, and dilated (greater than 4 millimeters in diameter).
They grow on the trunk of the saphenous vein:Long saphenous vein(or anterior) and short saphenous vein(or posterior)and their tributaries to first and second order.
Small "spider veins" also can appear on the skin's surface. These may look like short, fine lines, "starburst" clusters, or a web-like maze. They are typically not palpable. Spider veins are most common in the thighs, ankles, and feet. They may also appear on the face. The medical term for them spider veins is telangiectasias.
Neglected for many years both by patients and doctors, varicose veins are now better explored through the development of additional noninvasive tests.
Outside cosmetic consequences, varicose veins untreated can cause thromboembolic complications (phlebitis) and skin conditions like dermatitis ocher, white atrophy, hypodermitis or leg ulcers. These complications usually have a significant social and professional repercussions.
Because of best information, prevention and early treatment, these complications have become less frequent.
Here are some information to better understand what are varicose veins, and what are their causes
In humans,Circulation is like a large network of "pipes" including arteries, veins and lymphatic
• the arteries bring oxygenated blood from the heart to various cells and organs. • veins return blood venous (non-oxygenated) to the heart and lungs • the lymphatic carry interstitial fluid or lymph.
There is Two system:
Veins have different sizes depending their location and their function. The largest veins are in the center of the body; these collect the blood from all the other smaller veins and channel it into the heart. The branches of these large veins get smaller and smaller as they move away from the center of the body. The veins closer to the skin surface are called superficial veins. The veins that are deeper and closer to the center of the body are called deep veins. There are also other veins that connect the superficial veins to the deep ones which are called the perforating veins.
- The Superficial veins:
They drain only 5 to 10% of venous blood. They have only the skin above them. Therefore they tend to dilate and become varicose.
- The Deep veins:
The" highway" which drains 90% to 95% of venous blood. It is the most important. The deep veins of the leg to the thigh are located within the muscles. These are large-caliber veins. The smallest muscle contraction then pushes the blood in these veins towards the groin.
There are also other veins that connect the superficial veins to the deep ones which are called the perforating veins.
The vein normally pumps the blood upwards against gravity, as far as the groin where it links with a deep vein. If the valves of this vein no longer close, we get backflow of blood. This leads to congestion of the other small veins draining via this larger vein. A similar vein running from the calf to the pit of the knee can cause the same problem, but this is a less common occurrence.
The Superficial veins
For each leg there are two main superficial veins:The Great saphenous vein (or anterior) and the Short saphenous vein (or posterior)
The great saphenous vein (GSV),
also greater saphenous vein, is the large (subcutaneous) superficial vein of the leg and thigh.It extends from the ankle to the groin, and receives numerous tributaries (branches) at the saphenofemoral junction.
It joins with the femoral vein in the region of the femoral triangle at the saphenofemoral junction.
The Small saphenous vein (SSV)
From its origin, it courses around the lateral aspect of the foot (inferior and posterior to the lateral malleolus) and runs along the posterior aspect of the leg (with the sural nerve), passes between the heads of the gastrocnemius muscle, and drains into the popliteal vein, approximately at or above the level of the knee joint.
Anatomical variations are common compared to the great saphenous vein.
Symptoms of varicose veins are the appearance of bluish, soft, and sometimes tender lumps and bulging veins under the surface of the skin. These can be painful at times, but not always. Heaviness, pain or venous phlébalgies, nocturnal cramps ,cause the patient to consult. These disorders appear to standing during the day, and resolve in the supine position, and walking. Paresthesia, impatience are also common edema, increased heat, disappears completely in the supine position. Very tiny veins of the legs can also dilate. These are called spider veins because of the spider web pattern they form. They are actually not related to real varicose veins at all.
Varicose veins can lead to venous thrombosis, which is the medical term for a blood clot. When this occurs,circulation becomes poor. They may lead to swollen ankles, feet and legs, scaly, itchy skin, darkening of the skin, changes in temperature in the legs and feet and may even cause sores and ulcers on the skin to develop. These are called venous stasis ulcers. Blood clots in the legs can be dangerous. Symptoms of venous thrombosis, or blood clots in the legs include, but are not limited to swelling, redness and tenderness along a vein.
Many patients consult for cosmetic reasons. The presence of varicose veins, spider veins or telangiectasia in the thighs and legs, although well tolerated, motivates them very often. On this occasion a more complete clinical examination will highlight established venous insufficiency.
What causes varicose veins?
Anyone can develop varicose veins and telangiectasias. But there are predisposing factors:
• Age • sex • Heredity • Obesity • Positions prolonged standing or sitting • a sedentary lifestyle • pregnancy • Hormonal changes • oral contraception. • Sources of heat causing dilated superficial veins • The role of diet and including vitamin E.
Epidemiological studies are currently underway to demonstrate the protective role of polyphenols present in certain foods, mainly fruits and vegetables
Physical exercise and especially walking is very important. Long standing must be avoided. Some sports are favorable to venous return: swimming, cycling, gymnastics, dance, golf.
Other sports, must be practiced with moderation : tennis, volleyball, handball, basketball, squash. Sports not recommended are : riding, weightlifting, All heat sources are not recommended: prolonged solar exposures, hot waxing , saunas ,hammams .
Self-Care at Home
•Elevate your legs as much as possible. If you can take half-hour breaks during the day to rest, do it. It is important to raise your legs up above the level of your heart to get the maximum effect, and to do this for about a half-hour each time.
•Wear compression stockings (such as Ted Hose or Jobst stockings). The key is to put them on in the morning before you start walking around and before your veins become more swollen. If you try them and experience worsening pain, especially after you have been walking, remove them and see your health care provider. You may have problems with the blood supply to your legs (the arterial supply, which provides oxygen).
•If you are overweight, try to lose weight. A healthy diet high in fiber and low in fat and salt can help.
•Avoid alcohol, which can cause the veins in your legs to dilate.
•See your health care provider if you have problems such as chronic constipation, urinary retention, or chronic cough. Relieving conditions that are causing you to strain may help with the varicose veins.
•Avoid wearing tight clothing such as girdles or belts.
•Do not cross your legs when sitting.
•Walking is good exercise. It can help the muscles force the blood out of the deeper vein system.
•If you are driving on a trip or working at a desk all day, try to get up and walk around every hour or so to allow the muscles to pump the blood out of the veins.
Curative treatment: Surgery
There are different procedures of operation. The most classic and most practiced is the removing of the great saphenous vein( or the small saphenous vein) : this is called "stripping "
« The Stripping »
The other techniques are:
The endovenous laser therapy or EVLT
The RadioFrequency ablation or Closure *
This is the traditional operation for the removal of large varicose veins, for which we have the longest follow up and that we know best the short and long term. The surgery usually need three steps: ligation, stripping itself (stripping) and the elimination of small residual varices(avulsion) by microphlébectomy.
Most of the surgical procedures are performed on an outpatient basis.
Legs are shaved or depilated the day before surgery. With the patient standing, varicose veins are marked with a pen by the surgeon in the operating room to properly identify varicose branches (while lying down, varicose veins diminish in size). In most cases, the marking of varicose veins has been done under duplex scan by the angiologists the day before surgery
Some patients prefer to stay awake during the operation, others absolutely not. Anesthesia can be either: General anesthesia (the patient is asleep) or epidural anesthesia (only the lower body is made insensitive). Sometimes local anesthesia is performed injecting anesthetic around the vein ("tumescent anesthesia") or block (nerve block) in the groin: an anesthetic is injected around the nerves transmitting pain.
3) LIGATION or CROSSECTOMY
This usually involves an incision at the groin. The incision measures about 2-4 cm, and the saphenous vein is identified where it enters the femoral vein. It is tied just at the entrance. The procedure can be performed under local anesthesia.
When the varicosities occur behind the lower leg, the incision is made behind the knee joint to access the small saphenous vein
After ligation, follow the operation itself, the stripping .
Internal Saphenous vein extends from the ankle to the groin. A micro incision near the ankle is performed: • The traditional method is to introduce a flexible guide or "stripper" in the vein, starting at the ankle, until it comes out the other end into the groin. It sets an "olive" with a diameter greater than that of the vein. The stripper is removed from the leg and the saphenous vein is dragged or pulled out from the leg. The incisions are then sutured.
• Stripping classic is however dethroned by stripping "by intussusception.
Here, the vein is back on itself like a glove, while withdrawing the guide leg. This method is safer and less traumatic for the patient.
5) PHLEBECTOMY (Treatment of small residual varicose collaterals)
To improve cosmetic results after stripping, we can at the same time extract the small residual varicose collaterals. This requires many tiny incisions and removal of the varicose veins that have been outlined on the skin• The surgeon makes tiny incisions and residual varicosities are removed with a hook. This technique is called phlebectomy (or Muller intervention). We can also remove very small varicosities( transillumination phlebectomy ) The removal of incompetent perforating vein is done with small incision. The incisions are closed with simple small adhesive bandages (Steri-strips *) and leave no scar. .
They are simple , not painful, requiring only minor analgesics, possibly an anti-inflammatory for a few days. Mobilization is immediate, intervention being performed on an outpatient basis, walking is allowed on the same day. Normal daily activity (walking, driving car) is possible from the next day.
Almost all skin incisions are closed with resorbable sutures or closed with Steri-strips *. Occasionally, non-resorbable sutures are used and, in this case, removal of stitches is on the 10 postoperative day.
Stockings or tights are worn between 2 and 3 weeks during convalescence from morning until sunset and retired to sleep.
Prevention of deep vein thrombosis
Heparin prophylaxis (subcutaneous 1 time a day for 6 days) is necessary in patients at risk for thromboembolic events.
Work stoppage is very short only one or two days, depending on the extent of surgery performed and the occupational activity.
Patient has to consult 3 weeks after surgery. A control is provided 6 months to a year later.
Stripping is the treatment of choice for large varicose veins . Other treatments exist, but nothing has proven superiority to traditional vein stripping: Foam sclerotherapy, endovenous laser, Radiofrequency ...
• Sclerotherapy consist in injecting a liquid that causes the obliteration of the vein. Sclerotherapy is suitable for small varicose veins or as an adjunct treatment after stripping. A variant is foam sclerotherapy, some argue that now also for larger varicose veins. Under ultrasound guidance, foam sclerosant is injected, which causes the vein occlusion. Because blood can not pass, the varicose veins disappear.
This treatment is to consider only when, a stripping is not possible.
Endovenous Laser therapyis a new technique that uses a laser to destroy the vein. The procedure is usually performed in a surgical room and takes about 30-45 minutes. The small laser is passed into the vein with guidance from the ultrasound machine. The laser is then fired up and the entire vein is fibrosed. The laser is fired at multiple locations and the entire procedure is performed with some local anesthesia.
Presented as "a perfect alternative" to stripping, endovenous laser has another advantage: no incision in the groin, as for a conventional stripping.Recovery is rapid and involves minimal pain.
Radiofrequency ablation or Closure* is a similar technique to endovascular laser, but it uses heat to destroy the vein. The probe is placed in the vein under ultrasound and once in position, the vein is heated along the entire length. The procedure is performed under local anesthesia and takes about 30 minutes. It is a relatively new procedure and short-term results are excellent.
Procedure VNUS Closure ®
The Closure is performed as an outpatient. Under ultrasound, the catheter is positioned in the Closure patient vein through a small puncture in the skin. The thin catheter radiofrequency energy supplied transmits heat to the vein wall. The thermal energy delivered causes a retraction of the vein wall and occlusion. After the procedure, a simple bandage is applied to the insertion point and a compression bandage or stocking is placed. Walking is permitted on the same day and in general, patients who undergo the procedure Closure resume normal activities the next day
Ambulatory phlebectomywas invented by R. Muller.Varicose veins are remove under local anesthesia without hospitalization.
Ambulatory phlebectomy is performed under local anesthesia (Xylocaine ®) with or without potentiation (mild sedative). It allows the extraction of superficial varicose veins of preference, of any size, with a special hook (Mullerhook ). The scars are tiny (1 to 2 mm). The aesthetic superiority of this method, as well as long-term results give it a real advantage over the sclerosis of varicose veins.
The technique has several stages:
1 - Identification: the patient in standing position, the varicose branches are marked with a dermographic pen.
2-The patient lying: disinfection of the leg with an antiseptic (Betadine *,Biseptine )
3 - Local anesthesia: With 1% Xylocaine.
4 - Micro-incisions: Using the tip of a knife or a single needle, a micro-incision is made at the points originally marked.One Muller hook is inserted through the micro-incision and just enter the varix is thus "harpooned" and gently pulled through the micro-incision and removed.
The whole is thus removed varicose segments, smooth and totally devastated.
5 - The incisions are closed with simple small adhesive bandages (Steri-strips *) and leave no scar.
6 - The compressive dressing: It allows the patient to get up and walk immediately after its establishment, and the resumption of activities. Elastic stockings may be indicated at times for a few days.