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Chronic venous insufficiency affects almost 27 percent of the U.S. population. There are 25 million patients with varicose veins and between 2 million and 6 million with advanced chronic venous insufficiency. More than 500,000 patients have venous ulcers that cost more than $1 billion annually. Although lower extremity varicosities cannot be cured, various treatment modalities offer patients more (and more-effective) options in treatment of this common condition.
"Many of these newer percutaneous procedures can be done in the outpatient setting under local anesthesia, reducing the patient's risk for anesthesia and affording quick recovery, and outcomes are quite comparable to surgical vein stripping," says Henna Kalsi, M.D., a cardiologist in the Gonda Vascular Center at Mayo Clinic in Rochester, Minn.
Appropriate treatment depends on an understanding of the anatomy of the lower extremity venous system. Varicose veins occur when the vessel walls weaken and dilate, preventing coaptation of the valves that prevent backflow. Alternatively, the valves themselves may become damaged from blood clots, resulting in backflow of blood. The pressure created by the force of gravity on the unsupported column of blood then worsens the degree of venous incompetence. If untreated, patients may experience edema, pain, inflammation and ulcer formation.
The three types of veins found in the lower extremities are:
Relationship between veins in the leg
The two large superficial leg veins, the greater and short saphenous veins, along with their tributaries, frequently are involved.
The cause of varicose veins is unknown. More women than men are affected, and there is a genetic predisposition. Injury to the legs, sometimes remote, may contribute to the development of varicosities. Occupations requiring long periods of standing (as opposed to walking) and hormonal factors such as the use of oral contraceptives, pregnancy or menopause appear to be factors. Pregnancy, obesity, right heart failure and tricuspid regurgitation may increase lower extremity venous pressure that may contribute to the formation of varicosities.
Diagnosis can usually be made by clinical examination and noninvasive physiologic and anatomic testing. Spider veins or telangiectasias are small superficial veins near the surface of skin and occur mostly on thighs, ankles or feet. Typically they are small, red and purple, and although they usually do not cause serious health problems, they may cause leg aching and tenderness. In contrast, large varicosities are bulging, ropey and more than 5 mm in diameter. They may cause skin ulcers, stasis dermatitis, thrombosis, bleeding, swelling and pain.
"Noninvasive testing has largely replaced the use of venograms and includes venous Doppler and duplex imaging and plethysmography," says Dr. Kalsi. "The location of valvular incompetence and presence of thrombus can be determined reliably with noninvasive testing."
Endovascular coil at the saphenofemoral junction
Endovenous thermal ablation: catheter inserted
Endovenous thermal ablation: catheter tip heated and withdrawn
Endovenous thermal ablation: vein walls swell then scar
Self-care is an important component of any treatment plan. A walking program, weight loss and compression stockings are recommended, and patients should elevate their legs whenever possible. "Patients who have invasive treatment should understand that while these procedures address established varicosities, they do not prevent new varicose veins from forming," says Dr. Kalsi.
Outpatient sclerotherapy is frequently used in the treatment of spider veins and reticular veins. Morrhuate sodium is used as a sclerosing agent at Mayo Clinic, although other agents are available. Most patients need more than one session. Repeat sessions are performed about a month apart. After each session, compression stockings should be worn for 10 days. There are no activity restrictions, and patients can resume work the same day. The telangiectasias usually disappear in six to eight weeks. The closure rate is between 80 and 90 percent. Potential complications include hyperpigmentation, arterial injury and cutaneous ulcers.
Foam sclerotherapy is used for large varicosities or saphenous veins, with a closure rate of 81 percent for the greater saphenous vein and an overall closure rate of 96 percent. Cutaneous Nd:YAG laser therapy has the advantage of treating varicosities without needles or sclerosant; however, sclerosing therapy has demonstrated superior clinical results in comparative trials.
Phlebectomy, or surgical vein stripping, involves surgically removing the large varicosities. Frequently, it is done in conjunction with thermal ablation to treat large varicosities. Surgical stripping of the great saphenous vein is performed under general anesthesia. Limited procedures involving one or two veins may be done on an outpatient basis with local anesthesia; more-extensive procedures require general anesthesia.
Coil embolization is one approach to treating medium and large veins. Under ultrasound guidance, a catheter is inserted percutaneously and an embolization coil is deployed. Alcohol is then injected into the vein to complete obliteration of the vein.
Endovenous treatment options include radiofrequency ablation and thermal ablation. Endovascular treatments work by delivering thermal injury to the vein wall, which destroys the intimal layer and denatures collagen in media, resulting in fibrous occlusion of vein.
These novel techniques have nearly replaced surgical vein stripping and have been used increasingly in the treatment of varicosities. Endovascular catheters deliver thermal energy to the vein wall to destroy the intima, denature collagen in the media, and result in fibrous occlusion of vein. Tumescent anesthesia reduces the risk of skin burns and paresthesias, helps with vein compression and analgesia, and reduces the need for general anesthesia. Successful vein occlusion with absence of reflux is more than 90 percent.
"Patients note earlier return to work, less postoperative pain, better quality-of-life scores and quicker recovery," says Dr. Kalsi.
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