Vascular Surgery: Venous Conditions

Varicose Veins, Reticular Veins and Venous Telangiectasias (Spider Veins)

Varicose veins are dilated superficial veins in the legs that occur because of damage to the vein valves and increased pressure from prolonged standing. There is often a history of varicose veins in the family, suggesting that the tendency to develop them may be inherited. Occasionally varicose veins may result from blockage of the deep veins in the leg, or as a result of a developmental abnormality of the deep veins. It is important to recognize this since, in these circumstances, the varicose veins play an important role and should not be removed. In most cases, however, the deep veins are normal and treatment of varicose veins can help improve symptoms and avoid long-term problems.

Reticular veins and spider veins are generally smaller and located in or just below the skin. Veins that are between 2-4 mm in diameter may also be called reticular veins while smaller veins venous telangiectasias (spider veins). While these may sometimes be associated with varicose veins, they can also occur independently. Reticular and Spider veins are more common in women and may be related, in part, to estrogen levels. Individuals with spider veins should generally be checked to be sure they do not also have varicose veins, since failure to treat the varicose vein will fail to address the underlying problem. On rare occasion, both spider veins and varicose veins can be signs of an underlying developmental abnormality such as an arteriovenous or venous malformation.

Signs and Symptoms of Varicose Veins and Venous Telangiectasias

Most often, individuals actually identify these conditions, since they occur superficially and are often easily visible. These veins can remain asymptomatic, they may also be associated with pain, heaviness of the leg, leg swelling and itching. These symptoms are often worse after prolonged standing or sitting and can be relieved by elevation of the leg or wearing compression stockings. Sometimes patients cannot see their varicose veins and the only sign is an increase in the number of small veins around the foot or ankle. Over time, if varicose veins are not treated, individuals may develop Chronic Venous Insufficiency, which leads to discoloration of the lower leg, swelling and thickening of the tissues around the ankle, and eventually may result in leg ulcers.

Tests for Varicose Veins or Telangiectasias

In general, non-invasive testing with Venous Duplex Ultrasound is recommended for all patients with varicose veins and many patients with reticular veins and venous telangiectasias. The purpose of this test is to determine the condition of both the deep and superficial veins of the leg and to identify the location of abnormal veins that may be targets for treatment. A complete study should look for both obstruction and reflux in deep and superficial veins of the leg. Treatment should be tailored to the specific abnormalities found on the ultrasound study. Some, but not all, patients with venous telangiectasias will benefit from an ultrasound study, based on the degree of suspicion your doctor has that there are associated varicose veins.

Treatment Options for Varicose Veins or Telangiectasias

  • Compression Stockings – using compression stockings is often the first treatment for patients with varicose veins. These stockings—which may go up to the knee, thigh or even waist (pantyhose)—work by compressing the varicose veins and pushing the blood into the deep veins of the leg. These can often provide relief and in many circumstances may be all the treatment needed. However, many patients find compression stockings difficult to put on and uncomfortable to wear on a routine basis, making them less than ideal treatment over the long term. If only the superficial veins are diseased (deep veins are normal), then alternatives to compression may provide good long-term results. However, if there are significant abnormalities in the deep veins, compression over the long term will be required in any case.
  • Ablation or Closure of the Saphenous Vein – this has become the standard treatment for most patients with disease that is isolated to that area. This procedure can be performed under local anesthesia in a vascular surgeon’s office. Using ultrasound, a catheter is placed in the vein and the vein is occluded using radio waves, laser or chemicals. In our practice, we prefer the radio waves, which we believe cause less pain after the procedure. This procedure can be applied to the main saphenous veins when they are the source of the problem. There is less than 24 hours “downtime,” although compression stockings need to be worn for 10 days or so after the procedure. The main complication of this procedure is clot that extends into the deep veins, which occurs in 2% or so of patients. We check our patients at 48-72 hours after the procedure to detect this when it occurs. If a clot does occur, then treatment with anticoagulants is required.
  • Sclerotherapy of Varicose Veins – sclerotherapy is performed in the office, usually without anesthesia, using a very fine needle. This technique is used when the main saphenous vein is normal or in follow up treatment after the main vein has been ablated. This can be done with or without ultrasound guidance. Complications from sclerotherapy include local pain at the injection site and some bruising. On occasion, there may be small clots that persist at the area of injection and this may require microphlebectomy. Staining can occur at the area of injection but this usually resolves over 4-6 weeks.

Treatment Options for Reticular and Spider Veins

If reticular or spider veins are associated with varicose veins, the varicose veins should be treated first. Following this, or when reticular or spider veins alone are present, the two main treatments are:

  • Sclerotherapy – sclerotherapy involves an injection of a chemical solution into the vein using a fine needle to cause damage to the inside of the vein wall, causing the vein to clot. As the clot resolves, the vein is obliterated. This process may take 6-8 weeks. Sclerotherapy is generally used for veins greater than 1 mm in diameter.
  • Laser Ablation – uses laser energy to heat the vein to damage the vein and cause it to close. This is done percutaneously. Laser therapy is most effective in small veins and generally requires more treatments than sclerotherapy.

Both of these treatments are office procedures and performed with, at most, mild sedation. Both procedures result in destruction of the vein(s) and are generally well tolerated without anesthesia. Complications of these procedures may include some staining of the skin and soft tissue, which resolves over time. Occasionally in the case of sclerotherapy, some superficial scabbing may occur at the site of treatment. Resolution of veins may take several weeks and multiple sessions may be required. In general, laser ablation treatment is more likely to require repeat sessions than sclerotherapy.

Pelvic Venous Congestion Syndrome (PCS)

PCS is an unusual type of venous insufficiency involves the ovarian or gonadal veins. In this circumstance, the veins that drain the pelvis (in particular the ovaries or testes) are not functioning properly and blood backs up in the pelvis. This is most common in women of childbearing age and often disappears after menopause. PCS has been recognized with increasing frequency as a cause of pelvic pain. Since there are many other causes of pelvic pain, these must be evaluated before PCS can be diagnosed. PCS usually is aggravated by standing and may be associated with excessive menstrual bleeding, pain on intercourse and bladder urgency. Varicose veins may be seen in the genital area (varicoeles in men). Patients may be treated with a variety or medications including progesterone. If this fails percutaneous embolization of the varices, with or without sclerotherapy is an effective treatment.

Venous Compressive Syndromes

These conditions occur when a major vein is obstructed by another structure. This can lead to compression of the vein or even thrombosis (clotting) of the vein. When these occur, surgical treatment with stenting or vein bypass is often recommended. The major venous compression syndromes are listed below:

  • Renal Vein Compression (“nutcracker syndrome”) occurs when the left renal vein is compressed by the superior mesenteric artery. This can cause flank pain, blood in the urine, or varicose vein in the groin or testicle in a man and is diagnosed using a CT or MR Venography. Surgery or stenting should be considered in severe cases.
  • Iliocaval Compression (May Thurner syndrome) occurs when the left iliac vein is compressed or occluded by the right renal artery. This is a relatively common condition that should be suspected whenever there is significant left leg swelling or a left leg DVT. This problem can be treated with angioplasty and stenting of the left iliac vein.
  • Subclavian Vein Compression (Paget Schrotter Syndrome) occurs when the subclavian vein is compressed or occluded by the first rib and a hypertrophic subclavius muscle. This usually occurs in athletes or people who use their upper extremities extensively and is most often seen in the dominant arm. It can be treated by removing the offending rib and muscle.

Deep Vein Thrombosis (DVT)

DVT is estimated to occur about 900,000 times annually. About 250,000 individuals have a first-time DVT per year, the remainder occurring in patients with prior DVT. DVT can lead to a life threatening Pulmonary Embolism if not diagnosed and treated in a timely fashion. About 1/3 of patients who have a first time DVT will have a recurrence within 10 years and 1/3 to 2/3 of patients who have DVT will develop some evidence of Chronic Venous Insufficiency.

Risk Factors for DVT

Risk factors for DVT include immobility (including long plane or car rides), trauma (including surgery), cancer, prior venous thrombosis, pregnancy, congestive heart failure, varicose veins and venous compressive syndrome. In addition, individuals may have an inherited tendency to form blood clots (thrombophilia). This should be considered in any patient with a DVT who has a positive family history of DVT, who experienced a first-time DVT without any of the abovementioned risk factors, or who has had a recurrent DVT. Many of these conditions can be identified by simple blood tests, although some remain undiagnosed.

Symptoms of DVT

The signs of DVT are generally fairly nonspecific and can include: pain or swelling in the leg and pain on stretching the calf muscle. However, there are many reasons for these symptoms and DVT can often remain asymptomatic. Some patients with severe DVT may have sudden massive swelling of an arm or leg, bluish discoloration in the extremity, and the appearance of superficial veins.

Diagnosis of DVT

DVT is usually best diagnosed by a Venous Duplex Ultrasoundalthough other tests such as CT or MRI may be used to look at the veins in the abdomen or chest.

Treatment for Acute DVT

The initial treatment for DVT is anticoagulation (“thinning the blood”). This is most commonly done immediately with Heparin or Low Molecular Weight Heparin (LMWH, Lovenox). These drugs must be administered either intravenously (requiring hospitalization) or by injection under the skin. At the same time that these drugs are started, an oral drug (Warfarin or Coumadin) is also started and there is a transition to oral medication over 4-5 days. The dosage of Coumadin is adjusted by repeated blood tests.

Recently some new drugs (e.g., rivaroxaban, dabigatran) have been approved as an alternative to the combination of Heparin and Coumadin. First used for the treatment of atrial fibrillation, they are now being used in some patients as primary treatment for DVT. Over 30-90 days, between 50-80% of occluded veins will reopen when a patient is placed on anticoagulation therapy. As such, this remains the mainstay of treatment for most cases. However, when there is extensive clotting, especially in the larger veins, one can consider actively dissolving the clot by use of thrombolytic (“clot busting”) therapy. This is particularly attractive when the patient has significant symptoms or is very young and active, since this therapy may reduce the incidence of CVI. In general, clots in the iliac, femoral or subclavian veins in younger active patients should be considered for thrombolytic therapy.

As noted below, (CVI section) acute swelling of the left leg or a dominant arm may suggest venous obstruction, which generally responds well to clot busting treatment if given within one week. Patients may experience acute superficial thrombophlebitis, which usually presents symptoms of a painful, hard lump in the medial thigh or calf. This can be treated with NSAIDS although sometimes anticoagulation is required.

Treatment for Chronic DVT

In general, the treatment of chronic DVT is discussed under CVI. Patients who have a first episode of DVT should be treated with anticoagulants for at least three months. If there is still DVT on ultrasound at that time, another three-month course is reasonable. Patients who have a risk factor (trauma, surgery, long car ride) associated with their first DVT do not require lifelong anticoagulation after their initial treatment. However, they should consider prophylaxis if they are going to experience another high-risk situation (surgery, long travel time in plane or car). Patients who have a first DVT without identifiable risk factors, or who have a positive family history, should be checked for blood abnormalities (thrombophilia). They may require long-term anticoagulation and should be evaluated by a hematologist. Patients with a second, or recurrent, DVT should be treated with anticoagulants indefinitely to prevent further recurrences.

Chronic Venous Insufficiency (CVI)

CVI is a common condition affecting more than 6 million adults in the United States. CVI results when veins no longer perform their normal function, which is to return blood to the heart. This can occur because the veins are obstructed by clots, are open but scarred form prior clots, or have valves that are no longer working. This causes blood to pool, usually in the legs but sometimes in the pelvis and leads to swelling and a feeling of heaviness or congestion, particularly with prolonged sitting or standing. Occasionally blockage can be severe enough to cause a bursting pain when walking.

Symptoms of CVI

The most common symptoms of CVI are pain and swelling of the legs that is usually aggravated by standing and relieved by elevation of the legs. There are a number of other causes of leg swelling, the most common being fluid retention, often associated with excess salt intake or heart failure. Another cause of leg swelling may be lymphedemaCVI should be suspected in an individual who has had prior blood clots (DVT) in the legs. In addition, when leg swelling is associated with varicose veins and or development of small veins around the ankles, CVI is more likely. Finally, when individuals develop darkening of their skin in their lower legs, especially around the ankles, or develop thickening of the issues or skin breakdown around the ankles, CVI is the most likely cause.

Diagnosis of CVI

A Venous Ultrasound Examination performed in a vascular laboratory is the best way to diagnose CVI. This noninvasive study tests the veins for blockage, scarring and valve function. By determining the extent and location of any venous abnormalities, a vascular specialist can determine the best options for treatment. CVI can result from abnormalities in the deep veins, the superficial veins or the connecting (“perforator”) veins. Sometimes there can be abnormalities in several areas.

Treatment for CVI

The initial treatment for CVI is compression therapy usually with special stockings that reduce swelling and improve flow of blood to the heart. Additional treatment options depend on whether the major problem is blockage (“obstruction”) or poor valve function (‘insufficiency”), and whether the problem is in the superficial, deep or perforating veins. When obstruction is the main problem and compression cannot control it, the obstructed veins need to be opened with a stent or, less often, bypassed with surgery.

Most cases of obstruction will resolve at least partially over time and can be managed by compression alone. Obstruction of the renal, iliac or subclavian veins can occur from external compression from muscles, bones, or arteries. When this occurs, relief of the obstruction by surgery or stenting can provide significant symptom relief. When insufficiency is the problem, removing the malfunctioning veins may be an option. This is usually only recommended when the deep veins are normal and the abnormalities are confined to the superficial veins. About 30% of CVI is due to superficial venous abnormalities (“varicose veins”) and can be effectively treated by ablation of the veins.

Medical Treatments for CVI

A variety of medication may be appropriate for individuals with CVI. Patients who have CVI from prior DVT may be prescribed anticoagulants. Flavonoids and saponosides (horse chestnut extract) are used in Europe, but are not approved by the FDA for use in the United States. These drugs should be used in conjunction with compression therapy. Pentoxifylline (Trental) may be added to compression therapy to improve ulcer healing. Regular exercise can improve symptoms of CVI by using the muscles in the calf to pump blood out of the leg. Patients with CVI should be encouraged to walk, although they should avoid prolonged standing in a stationary position. While elevation will reduce swelling and improve symptoms, individuals with CVI should not be encouraged to lay down for long periods of time or avoid activity. Obesity can increase pressure in the veins and obese individuals are encouraged to enter an active weight loss program.