A varicose vein is an abnormal dilatation of a vein. In the lower limbs, varicose veins are visible under the skin. Many hereditary and lifestyle factors favor them. Medical management reduces the likelihood of complications (rupture, thrombosis, dermatitis …). Varicose veins affect about 30 Million people worldwide 1.
The veins of the lower limbs are vessels of different sizes, which drain the blood to the heart.
To prevent the blood from flowing downwards in the upright position, they are equipped with stepped valves, with valves functioning like flaps that open to allow the blood to flow upward and close to prevent it from coming down again.
When these valves are damaged or degraded they let down flow downwards, especially standing, creating pressure which can deform the vein and cause symptoms of varying severity. This is called an incompetent vein.
Symptoms may vary
– Telangiectasia having the appearance of blue, red or purplish threads visible immediately under the skin, whose consequences are mainly aesthetic. Clinically, they are not considered varicose.
– feeling of heavy legs, pain, night cramps
– varicose veins under the skin having the appearance of strings
– edema – change in the appearance of the skin with hyperpigmentation, eczema, inflammation
– ulcer: a break in skin or mucous membrane with loss of surface tissue, disintegration and necrosis of epithelial tissue, and often pus. It may be slow to close or might never close in absence of treatment.
The venous system of the lower limbs is composed of two parts
a deep venous system, comprised of veins located in the middle of the muscles. This is the most important venous network, since it carries 90% of the venous blood flow. While “phlebitis” or thrombosis (formation of a blood clot in a vein) or malformations may arise in the deep venous system, the deep system is not concerned by varicose veins.
a superficial venous system, consisting of veins that are closer to the skin and normally transport only 10% of the venous blood. The saphenous veins are part of this network:
– the great saphenous vein starts from the inner side of the ankle, travels on the inside of the leg and thigh and goes up to the groin, where it joins the deep network;
– the small saphenous vein starts from the outer side of the ankle, continues on the backside of the leg and ends at the back of the knee, where it joins the deep venous system.
Varicose veins occur in the superficial venous system. The two venous systems, superficial and deep, are connected to each other at the groin and knee, but they also have connections called perforating veins, which, when not working properly, let the blood flow back to the superficial venous system instead of leading it to the deep venous system. Malfunctioning perforating veins may cause varicose veins, skin changes, ulcers etc.
In western countries, the prevalence of venous insufficiency is divided by category of clinical severity:
– 70% without clinical sign or purely aesthetic (C0 or C1) – 25% have varicose veins, with or without edema (C2 to C3) – 25% are symptomatic – 5% have a severe pathology with skin modification and / or ulcer (C4 to C6)
30% of the population have clinically visible varicose disease and 11% of the population has symptomatic disease.
Varicose disease may involve 5 types of veins or venous structures if residual stubs of the great saphenous vein are included. Depending on the type of vein, different therapeutic remedies are possible. Surgical options include stripping of the vein or in its ligature. These two treatments are applied to the great saphenous vein in first intention in many cases. Smaller diameter veins can be removed by phlebectomy after ligation, this involves removing the vein in segments through a small number of small incisions along the vein. This treatment is adapted to the removal of very tortuous veins. In addition to these classic treatments, less invasive methods have been developed. Today, they fall into two broad categories: endovenous approaches and injection sclerotherapy. The endovenous approaches aim to occlude the vein either by thermal damage of the venous wall, the heat source may be a laser, a radiofrequency antenna or water vapor, or by mechanical damage to the wall. Sclerotherapy involves injecting into the vein a liquid or foam that, by producing chemical damage to the vein wall, will also lead to venous occlusion. Sclerotherapy can be applied to any type of vein, from the thinnest (telangiectasia) to the largest (provided that foam is used) but with a lower success rate than other approaches and a higher recurrence rate. Endovenous approaches are reserved for veins of medium or large diameter having a rectilinear section sufficient for insertion of the catheter.
* This application does not have FDA approval and is not commercially available in the U.S.
L. H. Rasmussen et al., Randomized clinical trial comparing endovenous laser ablation, radiofrequency ablation, foam sclerotherapy and surgical stripping for great saphenous varicose veins, BJS, Volume 98, Issue 8, 2011