Varicose and spider veins

Description
Varicose veins are enlarged and twisted veins near the surface of the skin. Spider veins are small superficial varicose veins, also known as telangiectasias or sunburst varicosities.

Causes/associated factors
Veins are blood vessels that carry blood back to the heart. In the legs, veins contain a series of one-way valves that prevent blood from flowing backward and pooling in the legs. If the vein expands or the valve becomes weak, defective or springs a leak, the valve can't close completely. Then the blood flows backward, becomes trapped and pools in the vein. The accumulated blood stretches the vessel wall and creates a varicose or spider vein.
Varicose and spider veins may develop in surface veins because surface veins are not surrounded by muscles that can help squeeze the blood toward the heart. Varicose veins can also develop in deeper veins, however, when there is valve weakness, injury, a blood clot or inflammation.

About 20 percent of adults have varicose veins, often in the legs and pelvic area. Spider veins often appear in the legs or the face. Varicose veins develop in women much more than in men, especially women who've been pregnant. Varicose veins generally appear between ages 30 and 70. People who have a family history of varicose veins are at higher risk for developing them.

The risk for developing varicose and spider veins also increases with:

obesity
prior thrombophlebitis (inflammation of a vein caused by a blood clot in the vein)
prolonged standing
restrictive clothing
Spider veins on the face are usually the result of too much sun exposure.


Signs/symptoms
Most people who have varicose veins notice only the cosmetic appearance of enlarged, deformed, bluish veins that are visible under the skin. Some people, however, may experience:
muscle cramps and aching
itchy skin near the veins
fatigue in the affected muscles
brownish-gray skin discoloration on the ankle
skin ulcers close to the ankle
swelling in the affected leg
heavy feeling in the legs
Spider veins typically have no symptoms. They're often blue or red, and may have the shape of a spider. Sometimes they resemble multiple tiny branches or occur in separate lines.


Diagnosis
In most cases, diagnosis is based on your medical history and a physical exam. If necessary, the doctor may suggest further diagnostic tests, such as a Doppler scan (also called duplex), which monitors blood flow through the use of ultrasound (using sound waves to create an image of internal body parts) or photoplethysymography (PPG, using infrared light to measure changes in blood flow).

Treatment
Various treatments exist for varicose and spider veins. Because these veins have only cosmetic significance in most cases, insurance coverage for invasive therapies varies.
Compression stockings
These special knee-high, thigh-high or waist-high elastic stockings maintain pressure on the veins in the leg, helping the blood return to the heart and keep the legs from swelling. This type of stocking should be worn all day, removed at bedtime, and put on before getting out of bed in the morning.

Sclerotherapy
With sclerotherapy (also called injection therapy), a mild solution is injected into the vein to irritate the vein wall. Eventually, scar tissue forms and closes off the vein. Pressure bandages help keep the vein walls together and route blood flow to healthier veins.

Sclerotherapy sometimes causes brown skin discoloration that may or may not recede. This method works best when you have relatively few varicose veins, especially small ones or spider bursts. The procedure can be done in the doctor's office by a trained and experienced sclerotherapist. Doppler scanning may be used to help guide the placement of the needle in the vein during the sclerotherapy treatment.

Closure technique
Closure technique is a procedure that can be done in a doctor's office. A catheter (small tube) is inserted into the varicose vein through a small puncture in the skin. Radiofrequency energy is sent by the catheter to the wall of the vein, causing it to shrink and seal shut. Slight bruising may occur, but normal activities may be resumed after the procedure.

Laser treatment
With laser treatment, strong, direct bursts of light from a laser damage the varicose vein, causing it to slowly fade and disappear. A pinching sensation is felt when the laser hits the skin. Side effects may include temporary redness or swelling of the skin. Some skin discoloration may also occur, but it usually lasts only one to two weeks. Several types of lasers may be used, and newer technology has made them more accurate and effective. Multiple treatments of 15 to 20 minute sessions are usually needed to remove varicose veins, however. Normal activities may be resumed after treatment.

Surgical treatment
Although surgical treatments are available, many are considered cosmetic and not medically necessary. Common surgical procedures include:

Vein stripping and/or ligation
With this procedure, which is generally done on an outpatient basis, small incisions are made in the groin and ankle. Then, the saphenous vein (one of two superficial veins running through the leg) is pulled from the body with a device called a stripper, which forces the blood to find a new channel. Ligation (a process of "tying" off) of the saphenous vein may also be done, with or without vein stripping. Sometimes, the varicose veins visible near the skin's surface are also removed at the same time through additional small incisions in the leg. Bleeding, infection, scarring or nerve damage are potential complications after vein stripping.

Ambulatory phlebectomy
This outpatient surgical procedure is often done with local anesthesia (numbing of the incision site). The physician locates the damaged veins with a special light source, makes a tiny incision and removes the varicose veins with an instrument shaped like a hook. Slight bruising may occur after the procedure. Other side effects and complications are similar to vein stripping.

Transilluminated power phlebectomy
This is a new outpatient technique developed to improve on the standard ambulatory phlebectomy. With transilluminated power phlebectomy, light is passed through the skin to help the doctor see the varicose vein. A specialized powered surgical device is then used instead of the hook. A tumescence anesthesia technique (which instills solution beneath the skin) helps to decrease blood loss and lift the vein away from the surrounding tissue for better removal. This procedure is less invasive, reduces operating time, reduces the number of incisions, and decreases the pain and recovery time associated with standard phlebectomy.

Endoscopic vein surgery
This type of surgery is only considered in serious cases of varicose veins that have caused leg ulcers (sores). The doctor repairs the weak valve through small incisions with the help of an endoscope (a thin, flexible tube equipped with a camera lens and light). In some cases, this procedure is combined with vein stripping.


Complications
Varicose veins may lead to:
phlebitis (inflammation of a vein)
infection
skin ulcers (open sores on the skin)
eczema (a skin condition characterized by itching and scaling)
bleeding under the skin
continual swelling
reappearance of varicose veins after surgical treatment
deep venous thrombosis (clots in the deep veins)

Pregnancy-specific information
When you're pregnant, the increased weight of the uterus may compress certain veins, creating added pressure in the veins. If you have a history of varicose veins or spend a lot of time on your feet, wear elastic support stockings.

Senior-specific information
As you age, varicose veins are common. It's helpful to rest and elevate your legs often, as well as wear elastic support stockings.

Prevention
To prevent varicose veins, elevate your legs whenever possible. Avoid prolonged periods of sitting or standing. If you must sit for long periods of time, get up frequently to walk around. It's also helpful to walk, run or swim regularly. (Consult your doctor before beginning an exercise program, however.) If you're overweight, lose the extra pounds. Wear sunscreen to prevent spider veins on your face. Finally, avoid constricting clothing and wear support hose.