Veins work to carry blood from the body back to the heart. It functions like pipes but instead of carrying water, it transports blood. From the body, veins carry blood that needs to be supplied with oxygen again.
The veins of the lower extremities are divided into superficial and deep veins. They are connected through the perforator veins. Veins in the lower extremities also contain valves that aid to pump back the blood towards the heart. In cases where the valves become weak or dysfunctional, venous insufficiency and varicose veins start to form.
Varicose veins are tortuous or widened veins caused by poorly functioning valves or vein walls that have lost their elasticity. (1) With poor elasticity, the veins could no longer effectively pump blood causing reflux or pooling of blood on the dependent parts of the body.
Approximately twenty percent of the global adult population will get varicose veins in their lifetime. (1) Women are more affected by varicose veins than men. In ages between 40 and 80 years old, 22 million women are affected while 11 million are men. (2)
Common Risk Factors for Varicose Veins
Risk factors for varicose veins are classified as hormonal, lifestyle, acquired, or inherited. (2)
Hormonal Risk factors
The risk of developing varicose veins is increased in females as estrogen levels are elevated. High levels of estrogen increase venous relaxation promoting venous dilatation, especially in menopausal women. (3) Women who are undergoing hormonal therapy are also at increased risk of developing varicose veins.
Lifestyle Risk Factors
Lifestyle risk factors are modifiable habits we acquire as we age. These are our ways of life that could affect our health and overall well-being.
We put ourselves at risk of developing varicose veins when we smoke. Smoking induces venous endothelial damage. (1) (2) The endothelium is the lining of the wall of our veins. Smoking simply causes injury to the vein walls. Another way by which smoking increases the risk of developing varicose veins is by causing vasoconstriction. During vasoconstriction or narrowing of the veins, there is increased pressure. Blood flow is impeded causing difficulty in the pumping of blood back to the heart.
Another lifestyle risk factor is prolonged standing or sitting. (1) (2) Work that involves prolonged standing or sitting puts you at risk of developing varicose veins. Prolonged sitting or standing allows blood to pool in the veins causing an increase in the pressure making it difficult to pump the blood back up to the heart. Both the valves and veins are damaged in prolonged sitting and standing. (4)
Obesity is also a risk factor for varicose veins. (1) Like prolonged sitting/standing, obesity also causes venous hypertension. (2) The increased weight carried by our lower limbs makes it difficult for the veins to pump blood back up. This damages the vein walls and valves as well. Venous disease is more advanced in those who are obese than in non-obese patients. (5)
Acquired Risk Factors
Age is an acquired non-modifiable risk factor for varicose veins. (1) (2) As we age, our veins and valves also undergo wear and tear. This causes venous valvular incompetence or dysfunction of valves.
Pregnancy is also an acquired risk factor but it can also be classified as a hormonal risk factor. The risk of developing varicose veins increases with pregnancy as it is a state wherein there is a high estrogen level. High estrogen levels as said earlier in this article cause vasodilation. Pregnant women undergo several physiologic changes and one of these is the increasing weight. The additional weight carried during pregnancy also increases the pressure in the veins of the lower limbs causing damage and predisposing pregnant women to develop varicose veins.
The last acquired risk factor for varicose veins is deep vein thrombosis. Deep vein thrombosis is a disease state wherein a clot is formed in the veins of the lower limbs. (6) Deep vein thrombosis is often caused by damage to the vessel wall, blood flow turbulence, and hypercoagulability. (6) Having a history of DVT puts you at a higher risk of developing varicose veins because it causes a deep venous obstruction and venous valvular incompetence. (2)
Inherited Risk Factors
Having a family history of varicose veins increases your risk of developing it. Positive family history of varicose veins is seen in first-degree relatives of patients. (2) The mechanism by which varicose veins develop is through dysfunctional valves in the veins. There is a strong association of varicose veins with a positive family history. (8)
Another inherited risk factor is being tall. A study was conducted by Stanford University School of Medicine stated that you are at more risk of developing varicose veins when you are taller. (7) This could be attributed to your genes. In taller individuals, there may be venous hypertension, increasing the chances of you developing varicose veins. (2)
The last inherited factor that could increase your risk of developing varicose veins is congenital syndromes. Syndromes such as Klippel-Trenaunay syndrome, Ehlers-Danlos syndrome, and the gene mutation are thrombomodulin increase the risk of varicose veins. (8) The mechanism by which each syndrome or mutation increases risk could be through venous hypertension, venous valvular incompetence, or deep venous obstruction. (2)
How do varicose veins develop?
Several mechanisms have been attributed to the development of varicose veins. As discussed earlier, varicose veins could be developed through venous hypertension, venous valvular incompetence, and deep venous obstruction. Venous hypertension and venous valvular incompetence are two of the major mechanisms by which varicose veins develop. (2)
Venous hypertension results from obstruction to venous flow, dysfunction of venous valves, and failure of the venous pump. (9) Chronic venous hypertension and dilatation causes change in the vein walls. Changes in the shear stress coupled with the inflammatory processes increase the permeability of the vein walls. (10) Decreased oxygen supply, cell death, and extracellular matrix changes occur because of the decreased blood flow in the veins. (10) This contributes to the progression of the varicose veins. Red blood cells also seep out of the damaged vessel wall causing an influx of inflammatory cells. This further damages the vein walls. All of these would later contribute to the remodeling and thickening of the vein walls. (10)
Increased blood pressure in the lower extremities makes it difficult for the veins to pump up the blood towards the heart. Blood will pool on the lower extremities causing increased pressure. This damages the veins causing it to dilate and subsequently damaging the valves.
Venous valvular incompetence can be primarily present at birth in those who have primary chronic venous insufficiency. Venous valves function by forcing the blood upwards towards the heart and prevent the reflux of blood in the lower limbs. The dysfunction of the valves results in the pooling of blood and thus, again, the formation of varicose veins.
Why are varicose veins dangerous?
In the early stages of venous disease, some may feel symptoms without varicose veins while others would present with varicose veins without symptoms. (10)
Initially, varicose veins are considered a cosmetic concern. Generally, it does not present with pain and would only appear displeasing to some. (11) Varicose veins would also present as discomfort on the lower limbs. Other symptoms would be itching, heaviness, and aching of the legs. Like chronic venous insufficiency, symptoms would also worsen after prolonged standing or walking. For more advanced varicose veins, skin changes, and ulceration may be seen. (10)
Varicose veins may appear non-threatening but when left to progress, it becomes more dangerous. Varicose veins are life-threatening as it could lead to a debilitating disease. It is the early symptoms of chronic venous insufficiency. This is a disease involving the veins where leg swelling, pain, and varicose veins are present. (12) The pathology of chronic venous insufficiency and varicose veins are similar both involving vein wall weakening and valvular dysfunction. Chronic venous insufficiency if left untreated would later progress into venous ulcers and non-healing sores. This could further complicate into deep vein thrombosis or even worse pulmonary embolism.
Complications of varicose veins
Varicose veins may complicate into painful ulcers that are often found near the ankles. Venous ulcers are defined as open lesions found between the ankle and knee joints associated with venous disease. (13) It usually starts as skin discoloration and later would gradually become venous ulcers. These venous ulcers represent the most advanced form of chronic venous disorders. (13)
Superficial varicose veins usually tend to bleed. Although rare, this is a complication of varicose veins. (11) Bleeding varicose veins are most often caused by a harmless bump or cuts to the superficial vein. Bleeding is usually hard to stop. Steps into stopping the bleed involve elevation of the legs while adding pressure on the site of bleeding.
Superficial thrombophlebitis or blood clots are complications of varicose veins. (14) This often starts with a formation of microscopic blood clots in the veins. When the blood flow is impeded, inflammation occurs and there is a state of abnormal coagulation. These microscopic blood clots would then progress into a macroscopic blood clot. (14) Superficial thrombophlebitis is diagnosed clinically and is often prevalent in older women with a body mass index of more than 25kg/m2 and those with varicose veins.
Treatment of varicose veins
Varicose vein treatment varies from a lifestyle change, conservative management, and surgical approach. These are all dependent on the preference of the patient.
The use of graduated compression stockings with the graduation of 20-30 mmHg or more for severe cases is the cornerstone of varicose vein treatment. (1)
It should reach the upper calf as a minimum requirement but it is best if thigh-high graduated compression stockings are used. Length of use differs depending on the severity of your varicose veins. Stockings should be worn daily if the patient is not inclined to have surgery.
For patients with severe varicose veins, surgery is the optimal treatment. (11) Different surgical treatments are used in varicose veins.
Vein ligation and stripping is the traditional approach in varicose vein surgery. (14) Incisions are made below the groin and behind the knee or ankle. The vein is then tied off and clamped. A wire is inserted into the vein up to the end. A cap is attached to the end of the wire. This vein is then stripped by pulling out the wire at the groin area. (15) This is what happens in vein ligation and stripping.
Endovenous thermoablation is another approach in the treatment of varicose veins. This is a minimally invasive surgical approach. A catheter is inserted into the vein to deliver thermal energy. The thermal energy will induce inflammation and subsequently close off the vein. (11) The advantage of endovenous thermoablation is that it can be performed as an outpatient procedure. Hospital admission is not needed and the patient could immediately work afterward.
Radiofrequency ablation is another endovenous treatment of varicose veins. It uses thermal energy like endovenous thermoablation but it has a lesser complication rate, reduced pain, and high vein occlusion rates. (11)
Other surgical approaches foam sclerotherapy and ambulatory phlebectomy. Foam sclerotherapy is performed by instilling a sclerosing agent into the vein using a duplex ultrasound. (11) It is also done in an outpatient clinic but the use of graduated compression stocking is advised after the procedure. Ambulatory phlebectomy removes the superficial veins by making small incisions. This is often done in patients with side branch varicose veins, and varicose veins of the foot, around the ankle, and the knee pit. (11)
Another supportive measure to lessen varicose veins is through lifestyle change. This could be done by stopping tobacco smoking, regular exercise, and a vein healthy diet. Exercises that promote the function of the calf muscles increase the blood flow in the lower extremities and reduce symptoms of venous insufficiency. (16)
Prognosis of varicose veins
Varicose veins have no definite cure and it often recurs after surgery. (1) Without treatment, varicose veins may progress into a more severe form of the disease. Advanced forms such as lower extremity edema and venous ulceration have higher morbidity. (2) This leads to poor quality of life and functional status.
Keeping our veins at an optimum level is very important and decreasing our risk in developing varicose veins can be lowered by eating healthy, exercising, and stop smoking. The dangers of varicose veins can always be minimized by getting yourselves checked early and getting the proper management.
In this article with discussed the following:
- Common Risk Factors for Varicose Veins
- How do varicose veins develop?
- Why are varicose veins dangerous?
- Complications of varicose veins
- Treatment of varicose veins
- Conservative Management
- Prognosis of varicose veins
If you suspect you have varicose veins and want to have them checked or book a free consult, you can contact us here!
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- Piazza, G. (2014). Varicose veins. Retrieved from https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.113.008331#:~:text=Approximately%2023%25%20of%20US%20adults%20have%20varicose%20veins.&text=If%20spider%20telangiectasias%20and%20reticular,men%20and%2085%25%20of%20women.&text=Generally%20more%20common%20in%20women,of%2040%20to%2080%20years.
- Ciardullo, A. V., Panico, S., Bellati, C., Rubba, P., Rinaldi, S., Iannuzzi, A., Cioffi, V., Iannuzzo, G., &Berrino, F. (2000). High endogenous estradiol is associated with increased venous distensibility and clinical evidence of varicose veins in menopausal women. Journal of vascular surgery, 32(3), 544–549. https://doi.org/10.1067/mva.2000.107768
- John Hopkins Medicine. (n.d.) Varicose veins. Retrieved from https://www.hopkinsmedicine.org/health/conditions-and-diseases/varicose-veins#:~:text=When%20the%20valves%20become%20weakened,stretch%20from%20the%20increased%20pressure.
- Van Rij, A.M.,et al (2008). Obesity and impaired venous function. European Journal of Vascular and Endovascular Surgery, 35(6), 739-744. https://doi.org/10.1016/j.ejvs.2008.01.006
- Waheed S.M., Kudaravalli P., &HotwagnerD.T.. Deep Vein Thrombosis (DVT). StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK507708/
- White, T. (2018). Height may be a risk factor for varicose veins. Retrieved from https://med.stanford.edu/news/all-news/2018/09/height-may-be-risk-factor-for-varicose-veins.html#:~:text=In%20the%20largest%20genetic%20study,risk%20factor%20for%20the%20condition.&text=Varicose%20veins%20affect%2030%20million,and%20can%20cause%20moderate%20pain.
- Anwar, M.A., Georgiadis, K.A.,Shalhoub, J., Lim, C.S.,Gohel, M.S., &Davies, A.H. (2012). A review of familial, genetic, and congenital aspects of primary varicose vein disease. Circulation: Cardiovascular Genetics. 2012(5), 460–466. https://doi.org/10.1161/CIRCGENETICS.112.963439
- Alguire, P.C., &Mathes, B.M. (2013). Pathophysiology of chronic venous disease. Up to date. Retrieved from https://www.uptodate.com/contents/pathophysiology-of-chronic-venous-disease#subscribeMessage
- Labropoulos, N. How Does Chronic Venous Disease Progress from the First Symptoms to the Advanced Stages? A Review. AdvTher 36, 13–19 (2019). https://doi.org/10.1007/s12325-019-0885-3
- Campbell B. (2006). Varicose veins and their management. BMJ (Clinical research ed.), 333(7562), 287–292. https://=doi.org/10.1136/bmj.333.7562.287
- Spiridon, M., &Corduneanu, D. (2017). Chronic Venous Insufficiency: a Frequently Underdiagnosed and Undertreated Pathology. Maedica, 12(1), 59–61.
- Vasudevan B. (2014). Venous leg ulcers: Pathophysiology and Classification. Indian dermatology online journal, 5(3), 366–370. https://doi.org/10.4103/2229-5178.137819
- Czysz, A., &Higbee, S.L. (2020). Superficial Thrombophlebitis. StatPearls. Treasure Island: StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK556017/
- InformedHealth.org. (2019) What can be done about varicose veins, and when is surgery considered? Cologne, Germany: Institute for Quality and Efficiency in Health Care (IQWiG),Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK279246/
- Kahle B, Leng K. Efficacy of sclerotherapy in varicose veins: prospective, blinded, placebo-controlled study.Dermatol Surg. 2004; 30:723–728.
Dr. Nima Azarbehi
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