Veins are blood vessels that return oxygen-poor blood from the outer parts of the body back to the heart and lungs. When veins become abnormally thick, full of twists and turns, or enlarged, they are called varicose veins. Generally, it is the veins in the legs and thighs that have a tendency to become varicosed.
- The thickened, twisting or dilated parts of the vein are called varicosities.
- Varicose veins can form anywhere in the body, but they are most often located in the legs.
- Varicose veins tend to be inherited and become more prominent as the person ages.
Veins in the leg are either superficial or deep
- The superficial veins and their branches are close to the skin. These are the veins that typically become varicosed. Also included in this category are the perforating veins, or communicating veins, which connect the superficial veins with the deep veins.
- The deep veins are encased by muscle and connective tissue, which help to pump the blood in the veins back to the heart. The veins have one-way valves to prevent them from developing varicosities.
- Generally, blood travels from the superficial veins to the deep veins. From there the blood travels through a network of larger veins back to the heart.
Normally one associates varicose veins with the legs only, but varicose veins can also be seen on the chest and face.
Pressure and pump
When you are resting in the supine position, the pressure is 12 to 15 mm of mercury (mmHg) at the venous end of the capillary bed in your lower extremities and falls steadily as the blood flows toward the right atrium of the heart where the atrial pressures are 4 to 7 mmHg.
What causes varicose veins?
Many theories exist for why varicosities occur in veins, but the consensus is that defective or damaged valves within the veins are to blame.
Valves prevent backward flow of blood within the vein. They keep blood in the vein moving toward the heart. Why the valves stop working is the subject for much debate but a couple of theories are:
- Some experts think inherited problems cause some people to have too few valves or valves that do not function properly.
- Some people may be born with abnormalities of the vein wall. The resulting weakness may cause them to be more inclined to have the valves separate and become leaky.
Whatever the cause the result is that when a person with poorly functioning valves stands up, the blood flow actually reverses and flows down the superficial veins when it should be flowing up toward the heart. When the muscles surrounding the deep veins contract, emptying the deeper veins, a build-up of pressure occurs. This then causes even more blood to go the wrong way from the deep to the superficial veins through faulty valves in the perforating veins thus increasing pressure in the superficial veins and causing varicose veins (varicosities).
Many factors can aggravate the situation.
- Pregnancy is associated with an increase in blood volume. There is added pressure on the veins in the abdomen from the weight of the growing uterus. High estrogen levels increase venous capacitance. High progesterone levels weaken vein walls to affect smooth muscle causing the veins to dilate. Relaxin secreted by the corpus luteum early in pregnancy is a potent dilator. These all contribute to the development of varicose veins during pregnancy.
- Prolonged standing
- Obesity or a distended belly
- Straining or stress such as with chronic constipation, urinary retention from an enlarged prostate, chronic cough or any other conditions that cause you to strain for prolonged periods of time.
- Prior surgery or trauma to the leg that interrupts the normal channels through which blood flows.
- Age: Generally, most elderly individuals show some degree of varicose vein occurrence.
What are the symptoms of varicose veins?
Symptoms of varicose veins are often rather non-specific and it can be hard to correlate the severity of the symptoms with those of the venous disease and are not always a serious or uncomfortable condition. For some the small discolored vessels or minor swelling may be the only signs and usually are considered to be more cosmetic. However, for millions of sufferers they can cause symptoms severe enough to significantly impact the quality of life. The veins that tend to have the most symptoms are those veins that are:
- Bigger veins that are dark purple or blue in color
- Veins that appear twisted and bulging, often like cords on your legs
Varicose vein symptoms can be progressive and can worsen over time, and the more severe instances of varicose veins may lead to significant complications. Symptoms of varicose veins may include:
- An achy or heavy feeling in your legs often worse at night and after exercise.
- Burning, throbbing, muscle cramping and swelling in your lower legs.
- Worsened pain after sitting or standing for a long time.
- In some people the skin above the ankle may shrink (lipodermatosclerosis) because of arteries and veins in this area and the loss of fatty tissue.
- Restless leg syndrome appears to be an overlapping symptom in patients with varicose veins and other chronic venous insufficiency.
- Whitened, irregular scar-like patches may appear at the ankles (atrophie blanche).
- Itching around one or more of your veins.
Serious complications of varicose veins although rare can include:
- Blood clots. Occasionally, veins deep within the legs become enlarged. In such cases, the affected leg may swell considerably. While a blood clot in a superficial vein is usually not life threatening and should not be confused with deep vein thrombophlebitis (DVT), any sudden leg swelling warrants immediate medical attention.
- Ulcers. Extremely painful ulcers may form on the skin near varicose veins, particularly near the ankles. Ulcers are caused by long-term fluid buildup in these tissues caused by increased pressure of blood within affected veins. A discolored spot on the skin usually begins before an ulcer forms. See your doctor immediately if you suspect you may be developing an ulcer.
- Bleeding. Thin-walled varicose veins protrude just under the skin and bumping or scratching a large varicose vein may cause severe bleeding. Varicose veins bleed more than healthy veins because of abnormally high pressure within the damaged veins.
Bleeding happens only rarely; but if a varicose vein does bleed, it can be quite serious and the bleeding can be profuse. You need to stop the bleeding quickly and do the following:
- Elevate the leg. Proper elevation is critical. Lie down flat and raise the leg high so that it is well above the level of your heart. For example, put your foot up a wall, rest it on a chair or, if you are not alone, someone can hold your leg higher than your heart. As we talk about in our discussion on what is proper elevation, this turns over your water tower.
- Apply pressure. Put a clean cloth or dressing on the bleeding area and put firm pressure on it until the bleeding stops.
- Call an ambulance. If the bleeding is heavy or does not stop quickly call an ambulance. If you are alone and not near a phone, DO NOT STAND UP but scoot or crawl to the phone so the pressure does not return to the vein in the leg.
- See a doctor immediately. You may need treatment (most usually sclerotherapy) to prevent the bleeding from happening again.
When should I see my doctor?
Besides those things discussed above as complications requiring you see a doctor, if you have varicose veins and any of the following occur, you should see your doctor as soon as possible:
- Inflammation, discoloration, or ulceration of the skin or swelling of the calf or leg is more typical of problems related to the deeper veins, especially a blood clot.
- Unexplained pain or swelling in a leg particularly suggests a blood clot. Varicose veins by themselves do not usually cause a leg to swell.
Varicose veins alone are relatively harmless, but every now and then they can cause significant problems.
- If the skin overlying the vein is thin or irritated, minor trauma from a bump or even shaving can tear the vein and cause bleeding. In this case, elevating the leg higher than your heart and applying pressure for several minutes should be enough to stop the bleeding. If it does not, contact your doctor immediately or go to the emergency room.
- If at any time you feel chest pain or have trouble breathing, this may indicate the presence of a blood clot in the blood vessels of the heart or lungs. You should go to a hospital emergency room immediately.
Having varicose veins does not necessarily mean you will eventually have a blood clot or that a blood clot somehow caused them. In rare instances, however, a clot increases pressure in the veins by blocking blood flow. This elevated pressure will cause backward flow of blood through weakened valves creating varicose veins. For this reason, you should see your doctor if your leg is swollen or if you experience worsening pain in the leg or if you should suddenly develop varicose veins and you do not have any of the common risk factors.
How are varicose veins diagnosed?
Your doctor will perform a physical exam in which your legs will be checked while you are standing looking for swelling or other signs of varicose veins. Your doctor will also ask you to describe any pain and aching in your legs. You most likely will be referred to a vascular specialist for ultrasound and recommendations for treatment.
You may also need an ultrasound test (venous duplex Doppler) to see if the valves in your veins are functioning normally or if there is any evidence of a blood clot. This is a noninvasive test done right in the office of the vascular specialist. You will lie on an examination table and a small amount of warm gel applied to your skin. The purpose of the gel is to help eliminate the formation of air pockets between the scanning head (transducer) and your body.
During a venous duplex Doppler, the doctor or technician trained in ultrasound imaging (sonographer) presses a small hand-held device called a transducer about the size of a bar of soap against your skin. Simply put, a transducer is anything that converts energy from one source into another that can be heard or read much like a microphone or a thermometer and is certainly nothing to be dreaded. The sonographer will move the transducer over the area of your body being examined moving from one area to another as necessary. The transducer transmits images of the veins in your legs to a monitor so a technician and your doctor can see them.
Diagnosis of varicose veins is done both supine and standing to properly document the size of these veins, the length of reflux in milliseconds and seconds and the location of this reflux. Reflux can only be properly evaluated on a standing duplex Doppler.
In addition to checking your veins, the artery at the ankle should always be checked at the same time to be certain there is not an arterial component and that you can tolerate support stockings.
Again, this is all done right in the office of the vascular specialist.
What about treatment and what are my options?
The goal of all treatment is to reduce symptoms and reduce the risk of complications.
When is treatment necessary?
Varicose veins may require medical treatment if they make walking or standing painful. You should always ask your doctor for advice and most especially if a sore develops on or near a varicose vein or if your feet or ankles swell.
In some cases, varicose veins can become serious and harmful to your health when they are associated with these conditions:
- Venous stasis ulcers that result when the enlarged vein does not provide enough drainage of fluid from the skin. As a result, an ulcer (open sore) may form.
- Fungal and bacterial infections may occur as the result of skin problems caused by fluid buildup (edema) in the leg. These infections also increase the risk of tissue infection (cellulitis).
- Thrombophlebitis which is an inflammation of the vein due to blood clot formation.
- Venous hemorrhage, or bleeding in the vein.
- Permanent to dark brown staining of the skin of the lower 40 percent of your lower leg
What Is conservative treatment?
Conservative treatment many times is sufficient to control symptoms. Those things that you can begin to do at home or your doctor will recommend if a diagnosis is found early include the following:
Begin a weight loss program if you are overweight. Being overweight puts additional pressure on your leg veins thus increasing the force of gravity and making the task of carrying blood from the legs back up to the heart.
Begin a regular exercise program. The most important part of a non-medical treatment for varicose veins is exercise. In fact, it is a vital part of maintaining a healthy and balanced body for everyone. Any program of regular exercise stimulates circulation, improves muscle tone and helps prevent varicose veins. Walking is great exercise for the lower leg whether it is done out in the open or on a treadmill, especially when on an incline.
High impact exercise such as jogging may increase blood pressure in the legs and only emphasize varicose veins.
At rest you flow 300 to 400 cc per minute of blood into your legs. With high-impact workout this may increase to at least 900 to 1200 cc. per minute. if you have a chronic venous blockage (from an old thrombophlebitis), what goes into your leg may have trouble getting back out causing the calf to become tight and painful until you have rested a few minutes and given it time to empty out the blood. The person with this chronic blockage needs to slowly build up an exercise program to allow collateral veins (veins around the blockage) time to develop which can take three months to one year. You should wear compression stockings while these collateral veins are developing and probably wear them for life.
Avoid prolonged standing or sitting. When you need to stand for long periods, take frequent breaks by sitting down and properly elevating your feet. When you have to sit for long periods of time, pump your feet up and down 20 times every 30 minutes to keep the venous muscle pump in your calf working to move the blood and keep it from pooling in your lower legs.
Elevate your legs properly. Proper elevation means getting your legs above the level of your heart. Water and blood both flow downhill and it is important that you turn over your water tower by getting your heart at the bottom of the hill.
Compression therapy, also called compression stockings, is the most conservative approach for treating varicose veins, especially when the veins are symptomatic. Support stockings can be purchased at some pharmacies and most medical supply stores and come in various styles including below-the-knee, above- the-knee and pantyhose. They also come in different compressions and your vascular specialist will recommend the compression that is right for you and most likely this will be based on the findings of how good is the quality of your arterial flow.
What if conservative treatment does not work?
If conservative therapy does not give you the desired results, other treatments are available and include:
- Laser and pulsed-light therapy
- Endovenous laser
- Radiofrequency ablation
- Stripping of the veins (rarely)
These treatments are discussed in detail separately but will be briefly discussed here. All can be performed in the doctor’s office.
Sclerotherapy involves the injection of a solution directly into the varicose veins causing them to collapse and disappear. This is a simple procedure and can be performed in the doctor’s office.
Laser and pulsed-light therapy are used to heat the blood vessel causing it to shrink. Laser therapy is most effective for the treatment of small varicose veins and spider veins. Laser therapy may also be used as an additional treatment following sclerotherapy, endovenous procedures, or surgery of larger veins.
Endovenous laser in the last 10 to 15 years is becoming the gold standard for treatment. In endovenous laser treatment, a thin fiber is inserted into the damaged vein through a very small entry point in the skin. A laser light is emitted through the fiber and the fiber is pulled back through the vein delivering just the right amount of energy. This treatment closes off the problem veins but leaves them in place and the blood is naturally routed to other healthy veins.
Microphlebectomy (or micro-incision) is done by the physician making a tiny incision and using a small surgical instrument to remove the problem vein through the opening. The vein is removed a tiny piece at a time.
Ligation and Stripping may be the best treatment when varicose veins are extremely large and too large to be treated with endovenous laser or radiofrequency ablation.
Blood returns to your heart by three means:
- Pressure goes to the arteries through the capillary beds pushing the blood along in the veins.
- The calf and thigh muscle pumps, of which the calf muscle pump is the primary pump. If you stand and rise up on your tiptoes ten times rapidly, you empty 65 percent of the venous blood out of the sinuses in your calf muscles. If you flex your thigh, you only empty 15 percent. This calf pump pumps blood up above the normal one-way valves which do not let the blood fall all the way back down your leg.
- When you elevate your legs higher than your heart. Water and blood still run downhill.
Proper elevation of legs
Leg elevation is ineffective if it is not higher than your heart. Simply putting your feet on a footstool still leaves your heart higher than your feet. Stretching out in a recliner is better because you are nearly horizontal, but you will need to put pillows under your feet. When you lie in bed at night, at least you have turned over your water tower. If the town water tower turns over, not much water will run out of your faucet at home.
Proper elevation of your legs is extremely effective if it is done for an hour two or three times a day.
Support (compression) stockings
Compression stockings help relieve symptoms and slow the progress of varicose veins. They improve circulation and are a mainstay of treatment for symptomatic varicose veins. You should put these on first thing in the morning before getting out of bed before your legs and/or ankles have a chance to start swelling and wear the stockings throughout the day.
Avoid elastic bandages for varicose veins unless your doctor specifically suggests them and instructs you on how to wrap them. Wrapped improperly they can cut off blood flow and may make varicose veins worse.
For more serious symptoms, you may need to purchase special support stockings from a medical supply store and for these you will need a doctor's prescription. These stockings are graduated where they are tighter at the ankles and get looser as they go up the leg. Prescription support stockings are more costly and usually need to be replaced after 4 to 6 months of regular use. Numbers, such as 15 to 20 mm of mercury, 20 to 30 mm of mercury are not just a range. They specifically mean that the higher pressure is at the ankle and the lower pressure is at the top.
If you have serious varicose vein symptoms and are considering support stockings, be sure not to buy stockings that are too tight or are uncomfortable and too difficult to get on because you may not wear them.
Detailed information on compression and what it means, why it is important and special tips can be read by clicking here.
Note: If there is any question whatsoever about the quality of blood flow in the arteries to your feet and legs, you should see a vascular specialist for consultation and possible arterial diagnostic testing before wearing strong gradient support stockings.
Avoid sitting or standing for long periods of time
Sitting or standing still for long periods of time puts added stress on the veins in your legs. You should make every effort to do the following if your work situation requires this of you. The British studied British factory workers with varicose veins (2854) and found that those who just stood had the most problems (65.5%). Those who just sat were slightly better (29.2%). Those who had the least problems walked all the time (6.3%).
Grandmother's treadle sewing machine was not all bad! It kept her blood moving.
If your work requires that you stand in one place (such as with hairdressers), try to sit down for a few minutes regularly with your feet up. Some people use a small stool to prop up first one foot and then the other when standing at work.
If your work requires that you sit for long periods of time, such as at a computer, get up and walk around for a minute or two every hour to allow your venous muscle pump to pump blood back to your heart.
When traveling by automobile, stop for a brief walk every hour during long trips.
During a long plane trip, get up and briefly walk up and down the aisle every 30 to 45 minutes. If this is not possible, pump your feet up and down 20 times every 30 minutes. In fact, the reported instances of thrombophlebitis after long plane trips has resulted in flight attendants now instructing passengers to pump their feet.
The underlying thread through all of this is to perform an activity that will work your venous muscle pump and allow it to move the blood from the lower extremities and keep it moving back toward the heart.
If your ankle joints are frozen, see a physical therapist to help you improve the range of motion in your ankles so your calf muscles can go through a full contraction.
The American College of Phlebology now recommends that women never wear high-heel shoes because they do not develop a good calf muscle pump. Also, you do not go through a full range of motion at your ankles and thus your calf muscle does not completely empty.
Exercise and weight control
Exercise. Get your legs moving. Walking is a great way to encourage blood circulation in your legs. Your doctor can recommend an appropriate activity level for you. It also builds up your calf muscle to improve your calf muscle venous pump.
High-impact exercises such as running may be uncomfortable for people with varicose veins. The following exercises in addition to stimulating your venous muscle pump can help control weight and may help improve symptoms caused by your varicose veins.
- Walk to improve blood circulation in the legs. Try to walk every day and every two weeks add 10 to 20 yards to your walking distance. Ten yards every two weeks is 240 yards more by the end of the year.
- Bicycling and swimming are also recommended for varicose veins. Some doctors say swimming is ideal because, in addition to working your legs, it puts the legs at heart level and avoids the pooling of blood in the legs that comes with varicose veins.
- Exercise your legs. When you are sitting down, pump your feet up and down. Rotating them at the ankles in both directions making small circles helps some. Extend your legs and point and flex your feet. Bend your legs back and forth at the knees.
Watch your weight, and your diet. Being overweight can increase the swelling and discomfort of varicose veins. Shedding excess pounds takes unnecessary pressure off your veins. It is almost impossible to control edema or swelling of the ankles in an overweight person. Consider following a low-salt diet to prevent swelling caused from water retention.
During pregnancy: If you get pregnant, you should begin wearing support day one of your pregnancy because your body secretes hormones that relax your veins. This is compounded later in pregnancy because the size of the baby may decrease venous return to the heart as blood goes through your abdomen (inferior vena cava). You might even try sleeping on your left side so that the baby falls away from your inferior vena cava. Later in pregnancy you will need higher compression stockings.
One study of 405 women with varicose veins reported the following findings:
- 13% had 1 pregnancy
- 30% had 2 pregnancies
- 57% had 3 or more pregnancies
A study was done of 12 to 20-year-old women who had never been pregnant and, much to everyone's surprise, at age 12, 4% had reflux of their great saphenous vein . By age 14 to 16, 12.3% had reflux. By age 18 to 20, 19.8% had reflux. So when you get pregnant, you may already have been developing varicose veins before the pregnancy.
The largest organ of the body is the skin. The end organ of venous disease is the skin. The presence of skin findings should prompt evaluation of both the superficial and deep vein system with ultrasound examination. These skin changes may be chronic and not progressive or may precede development of leg ulcers. These skin changes are more distal over the leg and most often medially.
We hope the information on these pages is both informative and helpful, but it is intended for education only. Please do note that no web site, no matter how much information is shared, can replace a consultation with your doctor and a vascular specialist. Medical technology and treatment are continually improving and evolving so before making any decision on treatment, it is always advisable to see your doctor first for a comprehensive evaluation of your vascular disease and other medical conditions.
At the Vascular Center of Wichita Falls, we work closely with your other physicians. If you have concerns about your arteries or veins, contact us. A referral is not necessary to make an appointment.