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, , , | ICD9 = -, | ICDO = | OMIM = 192200 | MedlinePlus = 001109 | eMedicineSubj = med | eMedicineTopic = 2788 | MeshID = D014648 |Varicose veins are veins that have become enlarged and twisted. The term commonly refers to the veins on the leg, although varicose veins occur elsewhere. Veins have leaflet valves to prevent blood from flowing backwards (retrograde). Leg muscles pump the veins to return blood to the heart. When veins become enlarged, the leaflets of the valves no longer meet properly, and the valves don't work. A common cause of valve failure is Deep Vein Thrombosis (DVT), which can cause permanent damage to the valves. The blood collects in the veins and they enlarge even more. Varicose veins are common in the superficial veins of the legs, which are subject to high pressure when standing. Besides cosmetic problems, varicose veins are often painful, especially when standing or walking. They often itch, and scratching them can cause ulcers. Serious complications are rare. Non-surgical treatments include sclerotherapy, elastic stockings, elevating the legs, and exercise. The traditional surgical treatment has been vein stripping to remove the affected veins. Newer surgical treatments are less invasive (see radiofrequency ablation) and are slowly replacing traditional surgical treatments. Since most of the blood in the legs is returned by the deep veins, and the superficial veins only return about 10%, they can be removed or ablated without serious harm.Merck Manual Home Edition, 2nd ed.[http://www.merck.com/mmhe/sec03/ch036/ch036d.html] NHS Direct[http://www.nhsdirect.nhs.uk/articles/article.aspx?articleId=387§ionId=28131] Varicose veins are distinguished from reticular veins (blue veins) and telangiectasias (spider veins) which also involve valvular insufficiency,Weiss R A, Weiss M A, Doppler Ultrasound Findings in Reticular Veins of the Thigh Subdermic Lateral Venous System and Implications for Sclerotherapy, Journal of Derm Surg Onc, Vol 19 No 10 (Oct 1993) p947-951. by the size and location of the veins.
Complications Most varicose veins are relatively benign, but severe varicosities can lead to major complications, due to the poor circulation through the affected limb.
Causes Varicose veins are more common in women than in men, and are linked with heredity. Other related factors are pregnancy, obesity, menopause, aging, prolonged standing, leg injury and abdominal straining. Varicose veins are bulging veins that are larger than spider veins, typically 3 mm or more in diameter.
Non-surgical treatment Elevating the legs provides relief. "Advice about regular exercise sounds sensible but is not supported by any evidence." BMJ 2006;333:287-292 (5 August), Varicose veins and their management, Bruce Campbell (subscription) The wearing of graduated compression stockings with a pressure of 30–40 mmHg has been shown to correct the swelling, nutritional exchange, and improve the microcirculation in legs affected by varicose veins.Curri SB et al. Changes of cutaneous microcirculation from elasto-compression in chronic venous insufficiency. In Davy A and Stemmer R, editors: Phlebology '89, Montrouge, France, 1989, John Libbey Eurotext. They also often provide relief from the discomfort associated with this disease. Caution should be exercised in their use in patients with concurrent arterial disease.The symptoms of varicose veins can be controlled to an extent with either of the following:
Surgical treatment Some doctors favor traditional open surgery, while others prefer newer methods.
Newer methods for treating varicose veins, such as Endovenous Laser Treatment, radiofrequency ablation, and foam sclerotherapy are not as well studied, especially in the longer term."Open Surgery Is Still The Best Technique To Ablate The Great Saphenous Vein," Vascular, Vol. 14 (Nov. 2006), Suppl. 1, p. S. 25
Open surgery has been performed for over a century. Complications include deep vein thrombosis (5.3%)van Rij AM et al. Incidence of Deep Venous Thrombosis after Varicose Vein Surgery, Br J Surg 2004 Dec;91(12):1582-5, pulmonary embolism (0.06%), and wound complications including infection (2.2%). Two prospective randomized trials found speedier recovery and fewer complications after radiofrequency obliteration (AKA radiofrequency ablation). Rautio, T, et al., Endovenous oblitration versus conventional stripping operation in the treatment of primary varicose veins, J Vasc Surg 2002:35:958-65Lurie F, et al., Prospective randomized study of endovenous radiofrequency oblitration (closure) versus ligation and vein stripping (EVOLVeS: two-year follow-up. Eur J Vasc Endovasc Surg 2005;29:67-73. MyersKenneth Myers, An opinion —surgery for small saphenous reflux is obsolete!" Australian and New Zealand Journal of Phlebology, Vol 8, Number 1 (Dec 2004) wrote that open surgery for small saphenous vein reflux is obsolete. (The great saphenous vein is the vein that runs along the inside of the leg from ankle to groin; the small saphenous vein is the vein that runs along the back of the calf.) Myers said these veins should be treated with endovenous techniques, citing high recurrence rates after surgical management, and risk of nerve damage up to 15%. In comparison, radiofrequency ablation has control in 80% of cases of small saphenous vein reflux at 4 years, said Myers.Endovenous laser and radiofrequency ablation require specialized training for doctors and expensive equipment. Doctors must use ultrasound during the procedure to see what they are doing. Follow-up treatment to smaller branch varicose veins is often needed in the weeks after the initial procedure. Some practitioners also perform traditional surgery at the time of endovenous treatment. Complications for radiofrequency ablation include bruising, burns, paraesthesia, clinical phlebitis, and slightly higher rates of deep vein thrombosis (0.57%) and pulmonary embolism (0.17%). Complications for endovenous laser treatment also include brusing (24%-100%), burns (4.8%), paraesthesia (1%-36.5%), and induration along the length of the saphenous vein (55-100%). Another concern in varicose vein surgery is the recurrence rate. For traditional surgery, reported recurrence rates, which have been tracked for 10 years, range from 5-60%. Because the new treatments haven't been studied that long, their recurrence rates aren't known that well. One 3-year study compared radiofrequency, with a recurrence rate of 33%, to open surgery, which had a recurrence rate of 23%. The longest study of endovenous laser ablation is 39 months. Other treatments are:
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