As Published in M.D. News …
Treating Varicose Veins
– It’s not what it used to be
by Bruce R. Hoyle, M.D.Board Certified in Phlebology
When I reflect back to medical school training, I remember having only one lecture on varicose veins. All I remember from that lecture was to use compression hose and, when that didn’t work, to send the patient to a surgeon for stripping. While compression hose remains a cornerstone of treatment, a lot has changed in our understanding and management of varicose veins and spiders (telangiectasias).
A Brief Review
Varicose veins are increasingly common with age and by age 70, the prevalence is about 70 percent, with women being affected almost twice as often as men. In addition, it should be noted that heredity plays an important role. The baseline risk of developing varicose veins in one's lifetime is about 20 percent. However the percentage rises to 47 percent if one parent is affected and 89 percent if both parents have the disease. Pregnancy is another important risk factor with a direct relationship to parity. Occupations involving prolonged standing are also a contributing factor.
The pathophysiology starts at the cellular level, where smooth muscle cells degrade to a less contractile type along with other degenerative changes in the vessel wall. The genetic nature of this disease is evidenced by the fact that these changes continue even when the smooth muscle cells are removed from the body and placed in tissue culture. These changes ultimately affect the valves (remember them?) and lead to reflux or the bidirectional flow of blood. In larger veins, the increased hydrostatic pressure from the reflux ultimately causes dilation and subsequent bulging varicosities.
It is important to stop here and mention the other common cause of varicose veins: the post-phlebotic syndrome. After a deep or superficial phlebitis, there is direct destruction of the valves which potentially leads to chronic venous insufficiency. The importance of the valves cannot be overstated. They are present in both the deep and superficial veins in the lower leg as well as the perforating veins connecting the two systems and are seen in veins as small as 1 mm. Contractions of the calf muscle (pump) during walking are primarily what propels the blood from the legs back to the heart.
New Developments – Diagnostic Ultrasound
Of the new developments in the management of varicose veins, the most significant is the use of diagnostic ultrasound. Diagnostic ultrasound to evaluate arterial circulation and diagnose DVT’s has been around for over 20 years, but has only recently been applied to the superficial veins to determine reflux. In fact, even ultrasound technicians are just beginning to receive training for the use of ultrasound in this matter. If you want to evaluate a patient’s varicose veins and send them to the hospital for a venous u-sound of the lower legs, you are likely to get a report that only addresses the presence or absence of a DVT.
As a result, many doctors treating varicose veins have ultrasound units in their offices so that they can do the exam themselves, as this helps determine treatment options. Ultrasound has become the “gold standard” in evaluating varicose veins and should always precede any surgical intervention.
There are several new therapies which I will touch on briefly now and explore in more detail in the next issue. Endovenous laser treatment (EVLT) involves inserting a laser fiber in the vein and, under ultrasound guidance, threading it into position, such as 1–2 cm below the sapheno-femoral junction. The laser is then turned on. As the fiber is pulled back, the laser causes a thermal injury to the intima or lining of the vein, resulting in thrombosis or closure of the vessel.
There is another device that works on similar principle but uses radiofrequency energy instead of laser energy to destroy the intima. These procedures are an alternative to stripping. In veins that are not accessible to these devices, there are other new interventions. While Sclerotherapy has been around for decades, there are newer solutions and new ways of delivering these solutions. To treat deeper refluxing veins in the subcutaneous tissues, a needle can be placed under ultrasound guidance into the vein and a sclerosant injected. This is known as ultrasound guided sclerotherapy (USGS).
More visible bulging veins have been traditionally stripped or avulsed through segmental incisions that are ¼ to ½ inch (6-12 mm) long. Ambulatory phlebectomy or micro phlebectomy removes veins through incisions as small as 1-2 mm and can be done under local anesthetic in an office surgery room. These incisions require no sutures.
Finally, a few words on spider veins: while they are considered cosmetic, spider veins are not exclusively so. Yes, there are many patients (especially women) who come for treatment just because they “don’t like to see them on their legs.” Not infrequently, they will complain of symptoms such as burning pain which will be resolved with treatment. Spiders are treated with either lasers (several wavelengths) or sclerotherapy. There are some medical treatments for the symptoms of varicose veins and spiders.
Horse chestnut extract is available OTC and has been shown to increase venous wall tone and can help with edema. Trental (pentoxyfilline), can reduce inflammation, and retard the progression to ulceration.