thesis topics on varicose veins

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• v.136(4); 2018

Evidence for varicose vein treatment: an overview of systematic reviews

Ricardo de Ávila oliveira.

I MD, MSc. Vascular Surgeon, Adjunct Professor, Universidade Federal de Uberlândia (UFU), Uberlândia (MG), and Postgraduate Student in the Evidence-Based Health Program, Universidade Federal de São Paulo (UNIFESP), São Paulo (SP), Brazil.

Andréa Castro Porto Mazzucca

II BSc. Pharmacist and Postgraduate Student in the Evidence-Based Health Program, Universidade Federal de São Paulo (UNIFESP), São Paulo (SP), Brazil.

Daniela Vianna Pachito

III MD, MSc. Neurologist and Postgraduate Student in the Evidence-Based Health Program, Universidade Federal de São Paulo, (UNIFESP), São Paulo (SP), Brazil.

Rachel Riera

IV MD, PhD. Rheumatologist, Assistant Professor of the Discipline of Evidence-based Health, Escola Paulista de Medicina, Universidade Federal de São Paulo (UNIFESP), and Assistant Coordinator at Cochrane Brazil, São Paulo (SP), Brazil.

José Carlos da Costa Baptista-Silva

V MD, PhD. Full Professor of the Discipline of Vascular Surgery, Universidade Federal de São Paulo (UNIFESP), São Paulo (SP), Brazil.

BACKGROUND:

Varicose veins affect nearly 30% of the world’s population. This condition is a social problem and needs interventions to improve quality of life and reduce risks. Recently, new and less invasive methods for varicose vein treatment have emerged. There is a need to define the best treatment options and to reduce the risks and costs. Since there are cosmetic implications, treatments for which effectiveness remains unproven present risks to consumers and higher costs for stakeholders. These risks and costs justify conducting an overview of systematic reviews to summarize the evidence.

DESIGN AND SETTING:

Overview of systematic reviews within the Discipline of Evidence-Based Health, at Universidade Federal de São Paulo (UNIFESP).

Systematic reviews on clinical or surgical treatments for varicose veins were included, with no restrictions on language or publication date.

51 reviews fulfilled the inclusion criteria. Outcomes and comparators were described, and a narrative review was conducted. Overall, there was no evidence that compression stockings should be recommended for patients as the initial treatment or after surgical interventions. There was low to moderate evidence that minimally invasive therapies (endovenous laser therapy, radiofrequency ablation or foam sclerotherapy) are as safe and effective as conventional surgery (ligation and stripping). Among these systematic reviews, only 18 were judged to present high quality.

CONCLUSIONS:

There was evidence of low to moderate quality that minimally invasive treatments, including foam sclerotherapy, laser and radiofrequency therapy are comparable to conventional surgery, regarding effectiveness and safety for treatment of varicose veins.

INTRODUCTION

Varicose veins are enlarged and tortuous veins. 1 They are part of the chronic venous insufficiency syndrome 2 and are associated with complications such as edema, skin pigmentation, lower-limb ulcers, thrombophlebitis and bleeding. 3 This clinical variability has led to use of a classification system for chronic venous disorders (CEAP), as follows: C0 (no varicose veins); C1 (telangiectasias and reticular varicose veins up to 4 mm in diameter); C2 (trunk varicose veins); C3 (edema relating to varicose veins); C4 (skin pigmentation); C5 (healed venous ulcer); and C6 (active venous ulcer). 2 Eklöf revised the CEAP classification, including modification of the threshold for reticular varicose veins from 4 mm in diameter to a maximum of 3 mm. 4 However, there is no absolute consensus regarding the classification of varicose veins, which imposes limitations on comparisons of results between different studies. 5

The prevalence of varicose veins reaches up to one-third of the Western population. 3 Prevalence rates vary due to different definitions in epidemiological studies, ranging from less than 1% to 73% among women, and from 2% to 56% among men. 6 In Brazil, the prevalence rate reaches around 50%, after excluding CEAP C1. 7 , 8 Lower-limb ulcers affect 1-2% of the world’s population, and this has clinical and economic impacts. 8 , 9

Treatment of varicose veins can be justified by its positive impact on quality of life. 3 The financial burden due to venous ulcers in the United States has been estimated to be 14.9 billion American dollars a year. 10 Moreover, because esthetic concerns impose a need for treatment, such concerns may lead to institution of ineffective and potentially harmful treatments. In Brazil, the cost of treatment increased four-hundredfold between 1995 and 2001. 8

The high prevalence of this disease, the costs, the potential for complications attributed to its treatment and the need to disseminate science among stakeholders justify conducting a high-quality synthesis of systematic reviews on this topic, with the aim of mapping out the current knowledge and identifying gaps in the literature to guide future sound research.

The primary objective of this study was to summarize evidence derived from systematic reviews focusing on interventions to treat varicose veins. In addition, the following secondary objectives were defined:

• To describe comparisons applied in studies;
• To verify outcomes chosen to evaluate treatment;
• To assess the methodological quality of systematic reviews on the topic;
• To describe the strength of evidence according to different outcomes.

This study was an overview of systematic reviews, conducted within the Discipline of Evidence-Based Health, at the Federal University of São Paulo (Universidade Federal de São Paulo, UNIFESP).

The inclusion criterion for the systematic reviews was that they needed to focus on clinical or surgical interventions for lower-limb varicose veins, provided that the abstracts contained the terms systematic review and/or meta-analysis and that a full report was available. In cases of updates of the same review, only the most recent version was considered for inclusion. The following types of study were excluded: narrative reviews, conference proceedings, structured abstracts and systematic reviews focusing on the healing of lower limb ulcers without venous interventions.

A search strategy was run in the following databases: MEDLINE, EMBASE, LILACS and CENTRAL (last updated on September 3, 2017), applying the terms “varicose veins” or “varices” or “telangiectasias”. Regarding the LILACS database, 286 references were retrieved using the term “varicose veins” and synonyms, thus dispensing with the need for filters. For all other databases, a filter that had been developed for retrieval of systematic reviews was used. There were no limitations regarding language or publication date. We conducted a hand search of references presented in the studies included in our review.

Two authors independently screened studies (RAO and ACPM), and any disagreements were resolved by a third author (RR), through use of Rayyan software. 11 Two independent authors conducted data extraction (RAO and ACPM), and disagreements were resolved by reaching a consensus.

The AMSTAR tool (assessment of multiple systematic reviews) was applied to assess the methodological quality of the systematic reviews included. 12 This tool encompasses 11 items for methodological evaluations, each scoring from 0 to 1. Studies with a total score of 0 to 4 were considered to present low methodological quality; 5 to 8, moderate quality; and 9 to 11, high quality. 13

The search strategy yielded 1,245 studies. 107 studies were considered for inclusion after screening of titles and abstracts, with further retrieval of full texts. Among these, 51 reviews fulfilled the inclusion criteria ( Figure 1 ).

The reviews included were combined into 13 distinct groups of interventions, which were described as follows:

• Clinical treatment of varicose veins: Amsler and Blättler concluded that compression levels of 10 to 15 mmHg are effective in treating chronic venous insufficiency, despite the weakness of evidence due to heterogeneity across studies. 14 Two studies suggested that the effectiveness of compression stockings is overestimated, since adherence to treatment under real-world conditions is low, only reaching around 37% of the patients. 15 , 16 Thus, it was claimed that there was no high-quality evidence to support use of compression stockings as the initial type of treatment. Smyth et al. found that rutosides, reflexology and water immersion improved the symptoms in pregnant women with edema relating to varicose veins, although those findings were only based on a moderate level of evidence. 17 Boada and Nazco concluded that use of venotonics might alleviate the symptoms of fatigued legs. However, the quality of evidence was not assessed. 18
• Techniques and complications relating to sclerotherapy: Foam sclerotherapy is effective and safe, although the quality of studies has been considered to be low. 19 Cerebrovascular events associated with foam sclerotherapy are a rare but still a possible complication that has mostly been reported in the form of case reports. 20 , 21 These side effects seem to be mild, considering that it has been reported that the majority of patients were discharged from hospital without neurological sequelae. One study evaluated sclerosing agents to treat telangiectasias and concluded, based on very low-quality evidence, that one particular agent is not superior to another. 22
• Liquid versus foam sclerotherapy: Foam sclerotherapy increases the technical success rates (venous occlusion), in comparison with liquid sclerotherapy. 23 The quality of the evidence for this finding was not assessed in that report. Despite methodological limitations to evaluations on appropriate methods, dosages, formulations and compression levels, the current evidence supports the use of sclerotherapy in clinical practice. 24
• Surgical techniques: The CHIVA technique (ambulatory conservative hemodynamic correction of venous insufficiency) reduces disease recurrence in comparison with ligation and stripping and has been correlated with fewer adverse events. 25 These findings are based on a few studies with high risk of bias, because of the impossibility of blinding and the small number of incidents reported. Better esthetic results are achieved through use of transillumination, but with a higher number of hematomas and more intense pain in the postoperative period. 26 The quality of evidence for these findings was not assessed in that report. Studies with high risk of bias have suggested that use of tourniquets reduces bleeding. 27 Mumme et al. described the valvuloplasty technique and concluded that it was suitable for preserving veins in specific patients who were at high risk of atherosclerotic disease. The quality of the evidence was not assessed. 28 Pearson et al. took the view that surgery should continue to be used to treat varicose veins in public healthcare systems, although without indicating the most cost-effective technique. 29 Due to the methodological limitations of the primary studies in that review, no meta-analysis was conducted. Rudström et al. assessed complications relating to the surgical approach and found that despite their infrequency, they were potentially harmful. The most common complication was bleeding after injury to the femoral vein or arterial lesions. The quality of the evidence was not appraised. 30
• Surgery versus sclerotherapy: There was no evidence that one treatment was superior to any other. However, it was suggested that sclerotherapy was associated with lower cost of treatment and better results after one year of follow-up. 31 Surgical outcomes are long-lasting, but it is unknown whether sclerotherapy outcomes also are. The overall quality of the studies included was considered low, mostly due to inadequate randomization. Complications relating to sclerotherapy were infrequent, but the data were deemed to be insufficient for conclusions to be drawn, and the methodological quality of the primary studies was considered low. 32
• Surgery versus endolaser therapy (EVLT): All studies concluded that EVLT was as safe as conventional surgery. Van den Bos et al. 33 and Darwood and Gough 34 found that rare but potentially harmful complications might be associated with EVLT treatment. The mild complications included ecchymosis, pain, superficial thrombophlebitis, nerve lesion, arteriovenous fistula and matting. The wavelengths applied in EVLT treatment ranged from 810 to 1320 nm, and these were associated with recanalization in 5% of the patients in the first year. 34 Liu et al. 35 and Pan et al. 36 concluded that the results from the two types of treatment were similar over a follow-up period of two years when fibers of 810 nm and 980 nm were used. The quality of the evidence was not appraised. Pan et al. 36 found that technical failure (saphenous reflux) was more frequent with EVLT, while Xiao et al. 37 concluded that there were no differences in the results from EVLT and conventional surgery. Risk of bias was assessed in this study, but not the quality of the evidence. Hoggan et al. 38 and Mundy et al. 39 came to contradictory conclusions, based on evidence that was of low quality because of ineffective randomization and losses during the follow-up. 38 Hoggan et al. 38 concluded that the rates of reflux resolution were comparable, and Mundy et al. 39 pointed out that EVLT was associated with higher rates of recanalization. Similarly, Lynch et al. 40 reported that there was a higher risk of recanalization over a twelve-month period, although EVLT was less frequently associated with nerve lesions, infections and skin pigmentation. The findings of that study were based on low-quality evidence. Ruiz-Aragón et al. 41 also reported that there were fewer complications in the EVLT group, although it was assumed that a risk of bias existed due to exclusion of unpublished studies.
• Surgery versus radiofrequency ablation (RFA): Radiofrequency ablation was found to be beneficial over the short term, due to lower risk of ecchymosis, hematoma and pain, a more positive impact on quality of life and faster return to work. 42 On the other hand, radiofrequency ablation increased the risk of recanalization after 12 months. 42 It was noteworthy that there was no reliable evidence supporting superiority of radiofrequency ablation over conventional surgery. 43 The rates of complications like deep venous thrombosis reached 1.8%, and recurrence remained to be clarified. Patient satisfaction and preference were found to favor surgery. In Canada, the costs of radiofrequency ablation were considered lower, based on evidence of low to moderate quality. 44
• Surgery versus thermal ablation (EVLT or RFA): Conventional surgery and thermal ablation were found to share comparable results over the long term, 45 with no difference in recurrent rates. 46 Compared with surgery, thermal ablation was considered safe and effective, with the advantage of being associated with faster recovery over the short and medium terms. 47 The quality of evidence was not appraised in any of these studies.
• EVLT versus RFA: The outcomes were considered comparable over the short term 48 and over a longer term of five years. 49 He et al. 48 concluded that the quality of evidence to support these findings was low, while Balint et al. 49 did not appraise the quality of evidence.
• Surgery versus EVLT, RFA or foam sclerotherapy: Van den Bos et al., Nesbitt et al., and Leopardi et al. 50 , 51 , 52 considered that minimally invasive techniques were as effective and safe as surgery. Thermal ablation was considered superior to surgery. 53 According to Murad et al., 54 surgery and minimally invasive treatments were safe and effective, although minimally invasive procedures resulted in less disability and postoperative pain. Carrol et al. 55 concluded that alternative therapies were a possible substitute for surgery, and pointed out that foam sclerotherapy was probably more cost-effective. Paravastu et al. 56 found that the rate of recanalization of the small saphenous vein over the short term was higher in the conventional surgery group than in the EVLT group, and that the rate was uncertain for foam, compared with surgery. Overall, the quality of evidence either was considered low due to the small number of events and use of surrogate outcomes or was not appraised.
• Compression versus surgery for leg ulcers: One author considered compression to be the first-line treatment for leg ulcers. 57
• Surgery for leg ulcers: Samuel et al. 58 did not identify any clinical trial. Mauck et al. 59 recommended surgery and considered that surgical treatment might improve healing. This finding was mostly based on observational studies. According to Howard et al., 60 surgery was associated with rates of healing similar to those for compression alone, but presented lower levels of recurrence. The quality of evidence was not assessed.
• Any postoperative intervention: Postoperative compression may reduce the extent of hematomas and incidence of thrombophlebitis in treatments for telangiectasias and reticular veins over a three-week period. 61 Conversely, Huang et al. 62 concluded that compressive therapy lasting for more than seven days was not associated with clinical benefits regarding pain, edema, complication rate and absenteeism. In two studies by El-Sheikha et al., 63 , 64 no meta-analysis could be conducted because of substantial heterogeneity. Overall, the quality of evidence was either considered low or was not appraised.

The methodological quality of the systematic reviews described above was appraised through using the AMSTAR tool. 12 Out of these 51 reviews, 18 presented high methodological quality, 21 were of moderate quality and 12 were of low quality ( Annex 1 ).

H = high methodological quality; M = moderate methodological quality; L = low methodological quality; NA = not applicable; u = unclear. Total score of 0 to 4 was considered to represent low methodological quality; 5 to 8, moderate quality; and 9 to 11, high quality. 12

Potential bias in conducting this overview

No study protocol was developed a priori for this analysis. However, we followed the goals and methods that were initially planned.

No additional search was conducted in the gray literature. However, we did conduct a hand search of references presented in the studies included in our review.

There may also be bias in relation to endolaser technology if studies using interventions at different stages of its development are compared.

This overview revealed heterogeneity in relation to many aspects of varicose disease, including terminology and classification. While some authors described varicose veins as enlarged veins of more than 3 mm in diameter, 4 others defined them as veins larger than 4 mm in diameter 2 or included telangiectasias and reticular veins within the definition. 5 There is still a need for standardization of terminology. 65

Regarding prophylactic issues, Robertson et al. 66 did not find any good-quality studies that would enable assessment of whether lifestyle modifications might be useful as prophylaxis and for avoiding complications of varicose veins. Governments should prioritize topics like this when considering which studies to fund, since this issue may have practical implications at low cost, both for individuals and for healthcare systems.

Studies on surgical interventions frequently focus on ideal patients (with uncomplicated varicose veins of limited diameter, saphenous veins that are not very tortuous and absence of previous thrombophlebitis). In real life, patients present heterogeneous disease concomitantly in the same limb. Therefore, there is frequently a need to make use of a combination of techniques to achieve the best results, 31 based on the characteristics and clinical presentation of the varicose veins. 52 It is crucial to establish criteria for choosing the most suitable technique for different clinical scenarios. 45

Sclerotherapy is currently considered to be the first-line treatment for telangiectasias. Other therapies have been proposed as alternatives, but evidence to justify their choice is sparse and indirect. 16 , 52 , 55 In fact, surrogate outcomes are frequently reported in trials. Thus, conclusions are based solely on technical parameters 38 , 67 for heterogeneous populations 68 with short follow-ups, 54 which serves to increase the uncertainties rather than to resolve them.

Ligation and stripping are frequently chosen as the comparator because of their safety, effectiveness, cost issues and time span, and these have been used as a gold standard. 55 The complications associated with surgery include nerve lesions, hematomas, postoperative pain and pigmentation. However, severe complications are rare. 30

Minimally invasive treatments have been developed with the aim of reducing the risks and discomfort, as well as for reducing the time taken to return to work and optimizing cost-effectiveness. Their efficacy and effectiveness are comparable to those obtained through conventional surgery, regardless of the parameters chosen for this comparison. Minimally invasive therapies or surgery cannot always be applied to particular patients. 60

However, foam sclerotherapy seems to be particularly useful in this context since it can be used alone or in combination with other interventions. For instance, it may improve the results after surgery, bearing in mind that no surgical technique is capable of eliminating all varicose veins. The limitations associated with foam sclerotherapy include higher risk of recanalization and pigmentation, 56 along with the need for multiple sessions in order to obtain satisfactory results. These restrictions are surpassed by the benefits regarding cost-effectiveness. 55 We therefore considered it odd that we did not find any studies focusing on foam sclerotherapy for leg ulcers. Since fibrotic tissue may prevent the possibility of stripping some varicose veins, which consequently could maintain the pathological condition and hence the ulcers, foam sclerotherapy might potentially be a better treatment for this population.

There is no evidence that compressive stockings might bring benefits for patients with primary varicose veins. 15 , 16 Questions arise regarding the technical attributes of stockings (the type of elastic material and level of compression), the anatomical characteristics of the lower limbs and patients’ mobility while using these stockings. 69 Furthermore, there is low compliance due to discomfort, pruritus, skin irritation and edema. 70 , 71 Adherence to compressive treatment over a four-week period is as low as 40%, 70 thus compromising the accuracy of any estimates of treatment effect. 63 To date, the causal relationship between symptoms and varicose veins remains uncertain. 72 These factors may lead to many unnecessary treatments. On the positive side, stockings can be used to reduce the incidence of hematomas and thrombophlebitis 61 and leg ulcers, 57 thereby reducing the time taken for healing 73 and the recurrence rate. However, it is logical to claim that the best intervention should aim to treat the primary cause of leg ulcers. It has been found that surgery is just as effective in healing leg ulcers as are compression stockings, and it additionally reduces the recurrence rate. 60 This should always be considered in cases of leg ulcers that are associated with varicose disease. 74 Even though use of stockings in the postoperative period has been recommended by some authors, 63 the effectiveness of this intervention was not found to be superior over the short term (seven days) or medium term (three weeks). 62

Regarding the implications for practice of our analysis, the important question to be formulated is how much longer should be waited before the paradigms for varicose vein treatment are changed. 75 This question remains to be answered, considering the current body of literature. According to Chalmers and Glasziou, 76 gaps in knowledge occur when study questions are not well formulated, studies are not well designed, studies are not published, or there is still a lack of data on a particular topic. Surgery seems to be the most frequent intervention for varicose vein disease in many countries, but new endovascular techniques may provide an alternative for reducing costs and risks. Nonetheless, the studies underpinning these observations have presented serious limitations that have had a negative impact on the strength of the derived evidence, due to the indirectness, low number of events and small sample sizes of these studies.

CONCLUSIONS

There is evidence of low to moderate quality to suggest that minimally invasive treatments, including foam sclerotherapy, laser and radiofrequency are comparable to conventional surgery, regarding their effectiveness and safety in treating lower-limb varicose veins.

Acknowledgements:

Cochrane Brazil and the Department of Evidence-Based Health of the Federal University of São Paulo, for technically supporting the development of the present work

Discipline of Evidence-Based Health, Universidade Federal de São Paulo (UNIFESP), São Paulo (SP), Brazil

Place and venue of the event at which the paper was presented: CICE 2017 - International Congress of Endovascular Surgery, in São Paulo (SP), Brazil, on April 5-8, 2017

Sources of funding: None

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Clinical Presentation of Varicose Veins

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Varicose vein is one type of venous insufficiency that presents with any dilated, elongated, or tortuous veins caused by permanent loss of its valvular efficiency. Destruction of venous valves in the axial veins results in venous hypertension, reflux, and total dilatation, causing varicosities and transudation of fluid into subcutaneous tissue. The first documented reference of varicose veins was found as illustrations on Ebers Papyrus dated 1550 B.C. in Athens. Evidence of surgical intervention was found in the 1860s. However dramatic advances of varicose vein management occurred in the latter half of twentieth century. Varicose veins affect from 40 to 60% of women and 15 to 30% men. Multiple intrinsic and extrinsic factors including age, gender, pregnancy, weight, height, race, diet, bowel habits, occupation, posture, previous DVT, genetics, and climate are considered to be the predisposing factors for formation of varicose vein. Other reported factors are hereditary, standing occupation, chair sitting, tight underclothes, raised toilet seats, lack of exercise, smoking, and oral contraceptives. Common symptoms are unsightly visible veins, pain, aching, swelling, itching, skin changes, ulceration, thrombophlebitis, and bleeding. The signs of varicose vein disease are edema, varicose eczema or thrombophlebitis, ulcers (typically found over the medial malleolus), hemosiderin skin staining, lipodermatosclerosis (tapering of legs above ankles, an “inverted champagne bottle” appearance), and atrophie blanche. Varicose vein is classified according to CEAP classification, the components of which are clinical, etiological, anatomy, and pathophysiology. The revised CEAP classification was published on 2020 based on four principles which were preservation of the reproducibility of CEAP, compatibility with prior versions, evidence-based medicine, and practicality.

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Varicose Veins

Primary Varicose Veins: Symptoms and Diagnosis

Varicose Veins—How to Investigate

Roy Varghese, Malay Patel, … Ajay K. Khanna

Avoid common mistakes on your manuscript.

Introduction

Varicose veins constitute a progressive disease, and remission of the disease does not occur, except after pregnancy and delivery. During its course, the disease produces complication; most frequent are superficial thrombophlebitis, acute bleeding originating in one of the thin-walled varices, eczema, and, finally, skin ulceration [ 1 ].

The first documented reference of varicose veins was found as illustrations on Ebers Papyrus dated 1550 B.C. in Athens [ 2 ]. First patient who underwent operation for his varicose vein appears to be Canus Marius, the Roman tyrant. Greek philosopher Hippocrates (460–377 B.C.) described the use of compressive bandages and was advisor of small punctures in varicose veins. Aurelius Cornelius Celsus 25 B.C.–A.D.50) used linen bandages and plasters for leg ulcers. He treated them by exposure followed by avulsion with a blunt hook. Claudius Galen (A.D. 130–200) developed a method of bandaging which held the wound edges together. Galen’s theory of circulation remained standard theory for next 1400 years. William Harvey (1578–1657) proposed the theory of unidirectional blood circulation [ 3 ]. Giovanni Rima (1777–1843) introduced midthigh ligation of the saphenous vein.

The era of vascular intervention for varicose veins was modernized by Friedrich Trendelenburg, in the 1860s, who not only popularized his eponymous Trendelenburg test for saphenous reflux but also performed great saphenous vein (GSV) ligation by making a transverse upper thigh incision to ligate and divide the proximal GSV [ 1 ]. William Moore, an Australian surgeon, moved the site of ligation cephalad to the sapheno-femoral junction [ 1 ]. Ligation of the sapheno-femoral junction as it is practiced today was first described by John Homans in his paper in 1916 [ 1 ]. The Mayo Brothers, postulating that there would be additional benefit in removing the saphenous vein, pursued excision of the GSV through an incision extending from the groin to below the knee. This technique was initially improved by the use of an external “ring vein enucleator” [ 1 ]. The final technologic leap was introduction of the intraluminal stripper by Babcock [ 1 ]. The latter half of the twentieth century saw dramatic advances in diagnostic testing; however, surgical treatment of varicose veins benefited from only modest refinements after this innovation.

The twenty-first century has begun with a resurgence of interest and innovation in venous disease. Although sclerotherapy and endovenous thermal ablation occupy preeminent roles in the contemporary management of superficial venous disease, surgical approaches remain relevant when applied appropriately and executed expertly [ 4 ].

Epidemiology

It is generally agreed that varicose veins affect from 40 to 60% of women and 15 to 30% men [ 5 ]. In a study published on 1994, it was found that half of the adult population had minor stigmata of venous disease (women 50–55%; men 40–50%), but fewer than half of these will have visible varicose veins (women 20–25%; men 10–15%) [ 6 ]. However, more recently, large population studies such as Edinburgh Vein Study demonstrated an age-adjusted prevalence of truncal varices of 40% in men and 32% in women [ 7 ].

Varicose vein is one type of venous insufficiency which falls under the broad heading superficial venous disease [ 8 ]. In Western populations, the incidence of varicose veins varies with the definition applied. Most investigators favor the definition of Arnoldi, who said that varicosities are “any dilated, elongated, or tortuous veins, irrespective of size” [ 9 ] (Fig. 1 ).

Development of varicose veins: healthy vein (1) and varicose vein (2)

The definition of Arnoldi is particularly useful because it presents a unifying concept for reticular varicosities, telangiectasias, and major varicose veins. Since all three are elongated, dilated, and have incompetent valves, they probably have a common origin and respond to the same physical forces and acquired influences [ 5 ]. The dilation and elongation implies that these abnormal veins have been responsive to effects of pressure. The dilation of a vein and valve annulus stretches beyond the capability of its leaflets to close together. Dodd and Cockett defined varicose veins, saying “a varicose vein is one which has permanently lost its valvular efficiency” [ 10 ] (Fig. 2 ). It was pressure over a course of time that causes a varix to become elongated, tortuous, pouched, and thickened.

Varicose veins develop from valvular incompetence, resulting in dilation of the superficial venous system

Risk Factors

Among the theories that have been proposed to explain the cause of varicose veins is the hypothesis regarding weakness in the vein wall. Significantly reduced vein wall elasticity has suggested that the role of venous valves in development of varicose veins is secondary to changes in the elastic properties of the vein wall [ 11 ]. Estrogens, progestogens, or their associative action facilitate varicose vein development in individuals with factors which predispose them to vascular disorders (familial history, prolonged standing, obesity, and sedentary). They also aggravate the superficial venous state in these patients [ 12 ]. Wearing of tight undergarments produces proximal limb venous hypertension. A low-fiber diet predisposes to constipation and increased abdominal straining. Raised toilet seats prevent squatting during defecation. All these theories are related to venous hypertension, which itself is linked to development of venous insufficiency.

Common Predisposing Factors for Formation of Varicose Vein

Multiple intrinsic and extrinsic factors including age, gender, pregnancy, weight, height, race, diet, bowel habits, occupation, posture, previous DVT, genetics, and climate are the predisposing factors for formation of varicose vein [ 2 ]. Other factors documented in various studies are hereditary, standing occupation, chair sitting, tight underclothes, raised toilet seats, lack of exercise, smoking, and oral contraceptives.

Pathogenesis

Destruction of venous valves in the axial veins results in venous hypertension, reflux, and total dilatation, causing varicosities and transudation of fluid into subcutaneous tissue [ 2 ].

Development of Varicose Vein

All leg veins are equipped with valves at regular intervals. Together with the leg muscles and the pump function of the heart, these valves ensure that blood flows back to the heart against the force of gravity. Activating the leg muscles, for example by walking, compresses the deep veins lying between the muscles and forces the blood out of them. Healthy valves ensure that the blood flows in only one direction towards the heart and prevent any backflow to the feet. Most of the blood returns to the heart in the deep vein system. The superficial veins merely have a supporting role in blood transport, although they often develop into varicose veins. When superficial veins enlarge because of hereditary connective tissue weakness, the valves do not expand at the same time. This disrupts valve function, as the valves are no longer big enough to close the dilated vein (Fig. 2 ). As a result, there is a constant backflow to the feet that causes the vein to enlarge even further and varicose veins to develop (Fig. 3 ).

Overview of the positions of the different types of varicose veins in and under the skin

Saphena Varix

A saphena varix is a dilatation of the saphenous vein at the sapheno-femoral junction in the groin. As it displays a cough impulse, it is commonly mistaken for a femoral hernia; suspicion should be raised in any suspected femoral hernia if the patient has concurrent varicosities present in the rest of the limb. These can be best identified via duplex ultrasound and management is via high saphenous ligation.

Classifications

Ceap classification—creation.

CEAP was suggested by John Porter in 1993 at the American Venous Forum. A consensus conference was held at the Sixth Annual Meeting of AVF in February, 1994. An international ad hoc committee chaired by Andrew Nicolaides with representatives from Australia, Europe, and the USA developed the first CEAP consensus document in 1994—“CEAP classification” [ 13 ]. It was accepted around the World by venous authorities of Europe, America and Asia. It was published in 11 languages in 5 continents. CEAP was updated in 1996 and revised in 2004 [ 13 ] (Table 1 and Table 2 ).

Since its introduction, CEAP has been demonstrated to be an excellent discriminative instrument and has become an accepted reporting standard for CVD research [ 14 ]. With time management of venous diseases has progressed, and many new modalities have been introduced which became popular in many fields. Over the years, criticisms of the instrument have included a lack of precise definitions resulting in a lack of reproducibility in assigning patients to specific clinical classes [ 15 , 16 ]. In the 16 years since the last revision, an enhanced understanding of aspects of venous disease has identified gaps in the ability of CEAP to separately group patients with unique clinical attributes [ 17 ]. The necessity of further revision of CEAP was due with the advancement of phlebology. To address these advances, a taskforce was created for necessary revisions of CEAP classification. This task force comprised an international group of experts, as well as an advisory group of those who were involved in the creation and previous revision of the CEAP classification. Following a modified Delphi process, the task force adopted the following four “guiding principles”: preservation of the reproducibility of CEAP, compatibility with prior versions, evidence based medicine, and practicality. The revised CEAP remains a descriptive classification [ 18 ].

Changes in CEAP 2020

The CEAP 2020 taskforce adopted the following changes [ 19 ] (Table 3 ).

Clinical Domain

Revision in the “C” domain was done for the better understanding of the natural history between the subclasses. Corona phlebectatica appears to be a predictor of venous ulcer similar to other advanced skin changes and was placed as a subclass C4c in the class C4. The tendency of recurrence of varicose vein and venous ulcer was reflected by “r” in the revised CEAP. C2r indicates recurrent varicose vein, and C6r indicates recurrent venous ulcer.

Etiology Domain

Previously those patients who had no venous abnormality were classified as “En” (none). According to the modified CEAP, patients with clinical signs typically associated with venous disease will come under this subclass, if no other typical venous etiology is found. After the last revision of CEAP, the diverse of causality and development of newer treatment techniques raised the necessity to revise the secondary chronic venous disease (CVDs). To make it easily understandable, “Es” was separated into intravenous (Esi) and extravenous (Ese). The subclass “Esi” includes post-thrombotic changes, traumatic arteriovenous fistulas, primary intravenous sarcoma, or other luminal changes inside the vein. Unlike “Esi,” “Esc” does not reflect on conditions due to venous wall or valve damage, rather due to conditions affecting venous hemodynamics. It may be systemic (e.g., obesity and congestive heart failure) or locally by extrinsic compression (e.g., extravenous tumor and local perivenous fibrosis), or, at a distance, by muscle pump dysfunction due to motor disorders (paraplegia, arthritis, chronic immobility, and frozen ankle) [ 18 ].

Anatomy Domain

Previously 18 numerical designations were used to describe the venous segments of abdomen, pelvis, and lower extremities. Now it has been described by abbreviations which is more practical and easier for professional communication and publications. Anterior accessory saphenous vein was also included in the list of anatomical segments.

Pathophysiology Domain

The “P” component of CEAP was kept unchanged.

Venous Severity Scoring

The CEAP scoring was limited by several factors and was not popular. Rather it was found that severity scoring system based on CEAP was more desirable for research and daily practice. In 2000, the American Venous Forum (AVF), Ad Hoc Committee on Venous Outcomes Assessment, proposed the three-part Venous Severity Score: Venous Clinical Severity Score (VCSS), Venous Segmental Disease Score (VSDS), and Venous Disability Score (VDS)—a modification of the original CEAP disability score [ 20 ]. These scorings had been used to evaluate the severity of venous disease and to provide standardized evaluation of treatment effectiveness.

Venous Clinical Severity Score

The VCSS system includes 10 clinical descriptors (pain, varicose veins, venous edema, skin pigmentation, inflammation, induration, number of active ulcers, duration of active ulceration, size of ulcer, and compressive therapy use), scored from 0 to 3 (absent, mild, moderate, severe; total possible score, 30) that may be used to assess changes in response to therapy [ 21 ]. The revised VCSS score was published in 2010 and is currently being evaluated in studies for its validity and reliability.

Venous Segmental Disease Score

Venous Segmental Disease Score combines the anatomic and pathophysiologic components of CEAP. Major venous segments are graded according to presence of reflux and/or obstruction. It is entirely based on venous imaging, primarily duplex scan but also phlebographic findings. This scoring scheme weights 11 venous segments for their relative importance when involved with reflux and/or obstruction, with a maximum score of 10 [ 20 ].

Venous Disability Score

This modification to the original CEAP disability score substitutes prior normal activity level for the patient rather than ability to complete an 8-h workday.

Clinical Features

The common symptoms of varicose veins are unsightly visible veins, pain, aching, swelling (often worse on standing or at the end of the day), itching, skin changes, ulceration, thrombophlebitis, and bleeding. Edema, varicose eczema or thrombophlebitis, ulcers (typically found over the medial malleolus), hemosiderin skin staining, lipodermatosclerosis (tapering of legs above ankles, an “inverted champagne bottle” appearance), and atrophie blanche are common signs. Treatment should be considered when the patient is complaining of aching pain, leg heaviness, easy leg fatigue, superficial thrombophlebitis, external bleeding, ankle hyperpigmentation, lipodermatosclerosis, atrophie blanche, and venous leg ulcer.

Complications

Most common complications of varicose vein include aching pain, leg heaviness, and easy leg fatigue. Other complications are superficial thrombophlebitis, ankle hyperpigmentation, lipodermatosclerosis, atrophie blanche, and venous ulcer. Complications that require urgent management are superficial bleeding and superficial venous thrombosis. Rarely superficial venous thrombus may propagate to deep venous system.

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Ghosh, S.K., Al Mamun, A. & Majumder, A. Clinical Presentation of Varicose Veins. Indian J Surg 85 (Suppl 1), 7–14 (2023). https://doi.org/10.1007/s12262-021-02946-4

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DOI : https://doi.org/10.1007/s12262-021-02946-4

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Varicose veins : epidemiology and outcomes

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• Kurz, Xavier.
• Abenhaim, L. (Supervisor)
• Varicose veins are among the most prevalent medical conditions in western populations, with a prevalence estimated at 25--35% in women and 10--20% in men. Until now, few studies have regarded varicose veins as a distinct clinical entity and have investigated specific risk factors. Their consequences for the patients have not been adequately investigated. The main objective of this thesis was to examine the association between varicose veins and specific risk indicators and outcomes, taking into account the effects of more severe venous disorders often found in combination with varicose veins. This work is based on the VEnous INsufficiency Epidemiological and economical Study (VEINES), a one-year cohort study on venous disorders carried out in Belgium, France, Italy and Quebec. It included 1531 patients sampled among 5688 consecutive patients consulting a physician for a venous disorder. A sub-sample of 150 patients were referred to specialists for clinical examination and duplex investigation of venous incompetence. This study illustrated the problems of the diagnosis and classification of varicose veins, with a specificity of 45% for the diagnosis made by general practitioners. In a case-control analysis, the strongest risk indicators of varicose veins were pregnancy, age and family history. No association was found with other hypothesised determinants (obesity, smoking, history of thrombophlebitis, blood group A). Results of duplex studies support the hypothesis of a distal onset of venous reflux and varicose veins. Using a classification of varicose veins proposed to take account the concomitant presence of other signs of venous disease, varicose veins alone had no impact on a symptom score and on generic (SF-36) and disease-specific quality of life scores. The results suggest that symptoms and presence of varicose veins are independent outcomes, which has implications for clinical practice. A detailed analysis of health service utilisation performed in Belgium also showed that both are independent predictors of resource use.
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Varicose veins: a clinical study

2017, International Surgery Journal

Background: Varicose veins are a common condition affecting the lower limbs. Apart from being a cosmetic problem, it can have some serious complications if not treated in time. Multiple modes of surgical management exist for the disease. Complications of the surgery are troublesome and difficult to treat.Methods: This is a prospective study done in inpatients of SDM college of Medical Sciences, Dharwad, Karnataka, India. A total of 70 patients were included in this study and various general, demographic, clinical and surgical data outcomes were studied over a period of 4 years.Results: In our study of 70 patients we found the mean age of the study population to be 45.6% with a range of 21 to 70 years. Male patients (80%) outnumbered the females (20%). Among the 70 limbs studied, 30 (42.85%) patients had the involvement of GSV and communicating system, 6 (8.57%) had involvement of GSV and SSV systems, whereas SSV and CS were affected in 2 (2.85%) patients. 2 (2.85%) had all the three...

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IOSR Journals

Background and objectives: Venous diseases of lower limb remain commonaffecting 20% of adult population. Objective of this study is to identify cases with primary varicose veins, evaluate with appropriate investigations, collect data and establish the clinical spectrum of complications in this population. Methods: Study was conducted on 50 consecutive patients with primary varicoseveins at Govt. thiruvarur medical college, thiruvarur. All cases of varicose veins presenting to the OPD were subjected to duplex scan to rule out secondary causes. Patients admitted with varicose veins who satisfied the inclusion and exclusion criteria were included in the study.. Patients who presented with bilateral disease got their symptomatic limb operated first while the other limb was treated conservatively Patients with saphenofemoral incompetence were treated with saphenofemoral junction ligation and stripping of long saphenous vein. Patients with saphenopopliteal junction incompetence were treated with saphenopopliteal junction ligation with or without stripping of short saphenous vein. Patients with perforator incompetence were treated with subfascial ligation of perforators Results: Out of 50 patients studied, 39 (78%) patients were agriculturists, whoadmitted of having been exposed to prolonged hours of standing .Among the 50 cases studied, 70 limbs showed varicose veins, of which 32 limbs had long saphenous vein and communicating system involvement (45.7%). 20 limbs had long saphenous vein involvement (28.5%) alone. Among 32 limbs with long saphenous and communicating system involvement, 24 had pain (75%), 7 had oedema (21.8%), 18 had disfigurement (56.2%), 8 ulcers (25%). Among 20 limbs with only long saphenous involvement 10 had pain (50%), 3 had oedema (15%), 4 had disfigurement (20%), 2 had ulcer (10%).Of the 48 limbs that underwent surgery 26 (54.1%) underwent saphenofemoral flush ligation with stripping of LSV and subfascial ligation of perforators Conclusion: Definite relationship exists between occupation involving prolongedstanding and primary varicose veins.The involvement of long saphenous and communicating system together is commonest followed by long saphenous involvement alone. Patients with involvement of long saphenous and communicating system or long saphenous and short saphenous system were more symptomatic than others Complications of varicose veins were responded well to operative treatment. Results of surgical treatment are good

Journal of Evidence Based Medicine and Healthcare

Venkat Vineeth

Scholar Science Journals

Varicose veins and their associated symptoms and complications constitute the most common chronic vascular disorders leading to surgical treatment. Though considerable advances in understanding of venous patho physiology and modern imaging techniques have revolutionized the concept of management of varicosity of lower limb, whether these inferences hold good for our population is a pertinent question. The objective of the study is: 1) Analysis of the clinical features of varicose vein. 2) To know the various treatment modalities adapted for the management of varicose veins. Varicosity of the lower limb is a common clinical entity with, age group of 31-40 being commonly affected. The involvement of long saphenous vein is the commonest. Clinical examination has a high predictive accuracy. The use of color Doppler is a valuable supplement to clinical examination for effective treatment of varicose veins. Operative line of treatment is a primary procedure in the management of varicose veins of lower limbs. LSV stripping up to mid calf is associated with less morbidity so also non-stripping of SSV. The present procedures enable the patient to lead almost normal life after surgery and the mortality rate is very negligible.

Gundavajhula Laxmana Sastry

Varicose veins constitute a progressive disease that becomes steadily worst. IntheINDIAN subcontinent,anestimated 23%ofadultshave varicose veins, and6%havemoreadvancedchronicvenous disease(CVD), includingskinchangesandhealedoractive venousulcers. The study has been taken up to know the distribution & severity of varicose veins of lower limbs & modalities of treatment in prevention of complications.

The aim of study is to study the clinical presentations, surgical management and its outcome and complications associated with varicose veins in lower limbs. Patients and methods:This randomized prospective study includes 50 patients with primary varicose veins admitted in surgical units of SiddharthaMedicalcollege/ Govt. general hospital VijayawadafromOctober 2015toSeptember 2017.Results:In the study, it was noted that the varicose veins more commonly affect the young adult and middle age population (20-60yrs). Most of the patients were males (88%). Long saphenous vein involvement was seen in 88% of patients. A great number of patients had perforator incompetence. Sapheno-femoral flush ligation with stripping appears to be best option for LSV truncal involvement with no recurrence in followup. Conclusion: Majority of the patients with varicose veins associated with complications and surgical management with stripping of path of incompetence (i.e., LSV trunk) with incompetent perforator ligation appear to be best option for lower limb varicose veins under our settings.

International Surgery Journal

VIVEK CHAUDHARI

Background: Varicose veins are common problem and are present in at least 10% of the general population. So far as the aetiology is concerned varicose veins mostly occur due to incompetence of their valves. Risk factors for varicose veins include obesity, female sex, inactivity, and family history. Varicose veins do not threaten life and are seldom disabling, but it causes a considerable demand on medical care.Methods: The study was prospective observational single center study. 30 patients were selected for the study which fit in the selection criteria laid down at the beginning of the study. Informed consent was obtained from each patient before any investigations and treatment.Results: The study revealed that the varicose veins of lower limbs are a disease of younger age group, occurring more commonly during third and fifth decades of life. The involvement of long saphenous system was more common.Conclusions: Results of our study are comparable with various other studies in liter...

International Journal of Surgery Science

Pradeep Tenginkai

Varicose veins are a common encounter in a surgical out-patient department. The vivid range of presentations can leave the surgeon perplexed about the approach to be taken.Despite this, little epidemiological research has been carried out on venous disease, perhaps partly because of society’s perception that venous disease is not a major problem and it is not normally a cause death. More recently however, efforts have been made conduct structural epidemiological studies to identify risk factors and to clarify the geographical variations suggested in the past by anecdotal the prevalence of varicose veins and presents evidence for an against the different theories of causation. The study emphasizes on a sample of the society presented to us, who were diagnosed with varicose veins and patterns with respect to their age, sex, social status, occupations, recurrence, and involvement of the limbs were assessed. The outcomes based on the time of presentations, improvement in the quality of life including conservative regimens were briefed. The ultimate aim of the study being to assure a life of normal quality.

Abhilash Vemula

Background: Disorders of veins which are chronic in nature and very common are the varicose veins. Surgery is required at any one stage of the disease. There have been considerable advances that took place in the diagnostics of the varicose veins, but the treatment outcomes may not be good in many cases. To study the management and outcome of lower limbs varicose veins. Methods: This was a hospital based follow up study. Patients who presented with varicose veins signs and symptoms were included. During the study period it was possible to include 40 patients who were willing to get included in the present study. Various presentations, complications and treatments were noted and finally followed up for minimum of 3 months. Results: Most commonly affected age group was 36-45 years. Males were four times more affected than females. Most commonly affected limb was left side in 48%. Long saphenous system was involved in 55%. The predominant symptom was dilated and tortuous veins (32%) followed by pain (25%). 65 incompetent perforators identified by clinical examination and 130 by Doppler with above ankle being the commonest incompetent perforator. With the mean follow up of six months, no serious complications were noted. It was found that the sensitivity of the clinical examination was 82% when doppler scan was taken as gold standard. On follow up no one developed deep vein thrombosis. Incompetence recurrence rate at SFJ was 8% and at SPJ was 18%. Conclusions: We conclude that surgery is the first line of management and if done accurately, complications are minimal.

https://www.ijhsr.org/IJHSR_Vol.11_Issue.8_Aug2021/IJHSR-Abstract.02.html

International Journal of Health Sciences and Research (IJHSR)

Introduction: Varicose veins are part of the spectrum of chronic venous diseases and include dilated, tortuous veins of lower limbs, spider telangiectasia and reticular veins. Varicose vein disease is a very common problem of the western world and mostly their patients come for treatment because of cosmetic reasons. Indian scenario is different as mostly patients from lower socioeconomic strata of the society come for complications like ulceration, dermatitis etc. of varicose veins come for treatment. This problem sometimes results in chronic absenteeism from work, economic losses and change of occupation in many individuals. Methods: This observational study was carried out from 1 st January 2017 to 30 th June 2018 in Sri Aurobindo Medical College and Postgraduate Institute, Indore. Clinical profile of 52 patients of varicose vein disease was studied. All the patients were thoroughly examined and the pertaining data recorded. This data was tabulated and compared with the available literature on this subject. Results: Fifty two cases of varicose vein disease were studied. The commonest age group affected with the disease was between 41 to 50 years. Male patients were more and comprised of 84.6% of total number. Sapheno femoral junction valve was incompetent in 73.1 % cases as compared to saphenopopliteal junction[34.6%].Obesity was an important factor in causation of varicose vein disease. Flush ligation at SFJ with stripping was the commonest surgical procedure carried out our center. Conclusion: It is found that varicose vein disease with its associated sequelae brings the patient for treatment in our scenario. Long saphenous vein is the commonly affected part of the superficial venous system because of incompetency of the valve at SFJ. Although various etiological factors can be attributed to varicose vein disease but occupation and obesity remain the main factors. Accurate assessment of problem and adequate surgery will prevent recurrence.

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• Varicose veins

Veins return blood from the rest of the body to the heart. To return blood to the heart, the veins in the legs must work against gravity. Weakened valves, also called incompetent valves, within the veins might cause varicose veins. The weakened valves let blood pool in the veins instead of traveling to the heart. When blood pools in the veins, the veins become larger, making them show under the skin.

Varicose veins are bulging, enlarged veins. Any vein that is close to the skin's surface, called superficial, can become varicosed. Varicose veins most often affect the veins in the legs. That's because standing and walking increase the pressure in the veins of the lower body.

For many people, varicose veins are simply a cosmetic concern. So are spider veins, a common, mild form of varicose veins. But varicose veins can cause aching pain and discomfort. Sometimes they lead to more-serious health problems.

Treatment involves exercising, raising legs when sitting or lying down, or wearing compression stockings. A procedure may be done to close or remove veins.

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• Spider veins

Spider veins appear as thin, red lines or as weblike networks of blood vessels on the surface of the skin. Spider veins, a mild form of varicose veins, most often appear on the legs and feet.

Varicose veins might not cause pain. Symptoms of varicose veins include:

• Veins that are dark purple, blue or the same color as the skin. Depending on skin color, these changes may be harder or easier to see.
• Veins that look twisted and bulging. They often look like cords on the legs.

When there are painful symptoms of varicose veins, they might include:

• An achy or heavy feeling in the legs.
• Burning, throbbing, muscle cramping and swelling in the lower legs.
• Worse pain after sitting or standing for a long time.
• Itching around one or more of the veins.
• Changes in skin color around a varicose vein.

Spider veins are like varicose veins, but they're smaller. Spider veins are found closer to the skin's surface and might look like a spider's web.

Spider veins occur on the legs but also can be found on the face. They vary in size and often look like a spider's web.

When to see a doctor

If you worry about how your veins look and feel and self-care measures haven't helped, see your healthcare professional.

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Weak or damaged valves can lead to varicose veins. Arteries carry blood from the heart to the rest of the body. Veins return blood from the rest of the body to the heart. To return blood to the heart, the veins in the legs must work against gravity.

Muscles tighten in the lower legs to act as pumps. Vein walls help blood return to the heart. Tiny valves in the veins open as blood flows toward the heart, then close to stop blood from flowing backward. If these valves are weak or damaged, blood can flow backward and pool in the veins, causing the veins to stretch or twist.

Risk factors

The two main risk factors for varicose veins are:

• Family history. If other family members have varicose veins, there's a greater chance you will too.
• Obesity. Being overweight puts added pressure on veins.

Other things that might increase the risk of varicose veins include:

• Age. Aging causes wear and tear on the valves in the veins that help control blood flow. Over time, that wear causes the valves to allow some blood to flow back into the veins, where it collects.
• Sex. Women are more likely to get the condition. Hormones tend to relax vein walls. So changes in hormones before a menstrual period or during pregnancy or menopause might be a factor. Hormone treatments, such as birth control pills, might increase the risk of varicose veins.
• Pregnancy. During pregnancy, the blood volume in the body increases. This change supports the growing baby but also can make the veins in the legs bigger.
• Standing or sitting for long periods of time. Movement helps blood flow.

Complications

Complications of varicose veins are rare. They can include:

• Ulcers. Painful ulcers can form on the skin near varicose veins, mostly near the ankles. A discolored spot on the skin often begins before an ulcer forms. See your healthcare professional right away if you think you have a leg ulcer.
• Blood clots. Sometimes, veins deep within the legs get larger. They might cause leg pain and swelling. Seek medical help for ongoing leg pain or swelling. This can mean a blood clot.
• Bleeding. Rarely, veins close to the skin burst. This mostly causes only minor bleeding. But it needs medical help.
• Leg swelling. Longtime varicose veins can cause the legs to swell.

Getting better blood flow and muscle tone might lower the risk of having varicose veins. The same ways you treat the discomfort from varicose veins can help prevent them. Try the following:

• Don't wear high heels or tight stockings, other than compression stockings.
• Change how you sit or stand often.
• Eat a high-fiber, low-salt diet.
• Raise your legs when sitting or lying down.
• Keep a healthy weight.

Varicose veins care at Mayo Clinic

• Papadakis MA, et al., eds. Varicose veins. In: Current Medical Diagnosis & Treatment 2023. 62nd ed. McGraw Hill; 2023. https://accessmedicine.mhmedical.com. Accessed July 11, 2023.
• Varicose veins. National Heart, Lung, and Blood Institute. https://www.nhlbi.nih.gov/health-topics/varicose-veins. Accessed July 11, 2023.
• AskMayoExpert. Varicose veins (adult). Mayo Clinic; 2023.
• Varicose veins and spider veins. Office on Women's Health. https://www.womenshealth.gov/a-z-topics/varicose-veins-and-spider-veins. Accessed Dec. 13, 2023.
• Kabnick LS, et al. Overview of lower extremity chronic venous disease. https://www.uptodate.com/contents/search. Accessed July 11, 2023.
• Kang S, et al., eds. Treatment for varicose and telangiectatic lower extremity vessels. In: Fitzpatrick's Dermatology. 9th ed. McGraw Hill; 2019. https://accessmedicine.mhmedical.com. Accessed Dec. 13, 2023.
• Fukaya E, et al. Evaluation and l management of chronic venous insufficiency including venous ulcer. https://www.uptodate.com/contents/search. Accessed July 11, 2023.
• Ami TR. AllScripts EPSi. Mayo Clinic. Accessed Sept. 4, 2023.
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Beat varicose veins naturally

Understanding the risks of varicose veins

Varicose veins commonly develop in the legs. They arise from amplified pressure and the force of blood pushing against the vein walls. This causes inflammation, stretching and weakening of the venous walls, stagnation of blood, and impairment of the venous valves.

Situations increasing the chances of developing varicose veins are genetic predispositions, smoking, a sedentary lifestyle, use of hormonal contraception, obesity, past vein thrombosis, menopause, and advanced age.

Related topic: More harmful than sugar. How it damages your metabolism and can cause cancer.

The symptoms of varicose veins feature swelling, a feeling of heaviness or fatigue in the legs, pain, muscle cramps, skin itching, discoloration, and the development of ulcers . If left untreated, varicose veins can lead to serious complications such as pulmonary artery embolisms and thrombophlebitis of both superficial and deep veins.

What can you do to help yourself?

Using horse chestnut extract (which reduces itching, decreases blood thickness, improves circulation, and has anti-inflammatory properties) and extracting from bitter orange (which constricts blood vessels, has antioxidant features, and reduces leg tiredness) may help.

The effectiveness of these extracts may vary based on individual factors and the severity of the vein issues. Consulting with a phlebologist is advised before beginning any supplemental, topical, or medication treatment. This specialist can evaluate your situation and suggest specific treatments or other methods such as sclerotherapy, laser therapy, or surgical removal of varicose veins.

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