The intriguing problem of varicose veins

New methods of investigation have given a fresh understanding of varicose veins. Aspects of this are described based on findings in patients investigated by Doppler flowmetry, functional phlebography and photoplethysmography. All observations refer to the upright position where various forms of failure in pumping blood upwards against gravity may arise. Simple varicose veins conduct flow from above a pumping mechanism to the low pressure area beneath it. Thus, saphenous incompetence allows downflow from the groin to below the musculovenous pumps of the calf and the foot. It is this reversed flow that creates tortuosity in the branch veins and sacculation beneath leaking saphenous valves. Perforator incompetence is often incidental and a concealed saphenous incompetence, without varicosites, is easily overlooked. Functional phlebography has shown that many patients with varicose veins also have inadequate deep vein valves so that the pumping mechanisms are soon overwhelmed and this may explain why some develop ulceration and others do not. Complex patterns of flow in superficial veins have been demonstrated, for example: strong collateral upflow past deformed deep veins whilst other veins allow spillage downwards: crossover incompetence with flow to the opposite limb and down its incompetent saphenous vein. The special investigations can accurately predict the outcome of surgery and are an important addition to successful management.     

Treatment of varicose veins

Opinion statement  Varicose veins (VVs) are the most common manifestation of chronic venous insufficiency, affecting 25% of women and 15% of men. Reticular veins and telangiectasias (spider veins) are found in more than 80% of the general population. VVs produce symptoms of pain, swelling, heaviness, fatigue, and pruritus and predispose patients to complications including bleeding, superficial thrombophlebitis, and ulcerations that interfere with activities of daily living and result in lost time from work. Current treatments for VVs include conservative measures, and when these are unsuccessful, more invasive surgical and endovenous interventions primarily aimed at reducing venous hypertension and preventing progression to chronic inflammation and ulcerations. Surgical procedures including saphenous vein stripping, ligation of the saphenofemoral junction, and ambulatory phlebectomy are effective in the treatment of VVs but are associated with a high complication rate and recovery time. Emerging endovenous therapies, including endovenous laser therapy, radiofrequency ablation, and endovenous foam sclerotherapy, have shown similar efficacy in the treatment of VVs compared with more invasive surgical procedures, with lower complication rates and less time lost from work.     

The development of varicose veins in children and adolescents

The aim of the present prospective epidemiological study was to find the genesis of varicosis in pupils of the same age group in 11 secondary schools of the town of Bochum. The studies were always carried out in the same pupils of the 5th, 9th and 13th grades (Bochum studies I, II, III). The results of the first and second studies on 518 pupils are compared. In the children aged between 10 and 12 years of Bochum study I, isolated refluxes were found at the saphenofemoral junction (internal saphenous vein 2.9%, external saphenous vein 0.2%), but no varicose vein was yet visible at the trunk level or that of the lateral branches. In the adolescents aged between 14 and 16 years of Bochum study II, the number of refluxes of the internal and external saphenous vein had greatly increased, and isolated varicose veins were found at the trunk level or that of the lateral branches, as well as insufficient perforating veins. The varicose veins visible at the trunk level are obviously preceded by the refluxes. For the first time, an easily detectable preclinical sign offering new perspectives for a primary prophylaxis in thus available. Discrete reticular varicose veins were already found in Bochum study I (10.2%). A photoplethysmographic discrimination between the normal results and the various forms of a starting varicosis revealed in the course of Bochum study II has not been possible. Up to now, no statistical proof of a family taint has been established.     

Current treatment of varicose veins

Opinion statement Varicose veins (VVs) of the lower limbs are a common complaint that can take many forms, ranging from a nonpathologic condition to an invalidating chronic disorder. When they have not been neglected, uncomplicated VVs have often been treated by sclerotherapy or surgery, with variably successful results. Currently, the best way of assessing VVs has been to carry out routine ultrasound investigations. The approach to VVs has changed due to recent awareness of cosmetic considerations and the way they can affect quality of life, as well as the development of new treatments (ie, echo-guided sclerotherapy, foam sclerotherapy, endovascular obliteration) and ambulatory care practices. In some cases, the evolution of the disease can be disconcerting, if not entirely hopeless. However, in most cases, poor results have been obtained because of perfunctory assessment, inappropriate treatment, and lack of follow-up. The treatment of complicated VVs has been improved by combining clinical and ultrasound examinations, which make for a quick, accurate diagnosis, pointing the way to the right treatment. Venous ulcers resulting from primary saphenous vein insufficiency, which account for 50% of all venous ulcers, and recurrent venous ulcers should all be a thing of the past, apart from those associated with deep valvular insufficiency disease. The quality of care and the scientific standard of clinical studies on chronic venous insufficiency and VVs have both increased considerably. Although there is still a need to set up scales for assessing symptoms and quality of life, progress is being made in clinical studies that now meet the standards of evidence-based medicine.     

Ultrasonic treatment of varicose veins

Varicose veins and venous ailments are common among adult Americans. Treatment procedures vary but are mostly invasive. The current investigation utilizes focused high-intensity ultrasound for producing destruction of the venous wall in experimental dogs and in patients with varicose veins. Results are encouraging and suggest that focused ultrasonic irradiation can be an efficacious means of treating varicose veins and other venous disorders.     

Histochemical comparison of the enzyme profiles of healthy veins and varicose veins

In the context of studies bearing on the enzymatic activity in healthy veins and varicose veins, sample sections of veins were excised in eight patients with primary varices of the long saphenous vein. The veins were subjected to histochemical methods for identifying enzymes. The histochemical dosage related to lactate-dehydrogenase, alkaline phosphatase, adenosine triphosphoric acid enzymes, as well as lysosomal beta-glucuronidase, non-specific esterase and phosphatase acid enzymes. The authors deal with the specific problems involved in the different enzymatic methods, and their relevance to prognosis. In conformity with the results of our histochemical studies, the comparison between the enzymatic profiles of healthy and varicose veins showed an increase in lysosmal enzyme activity in the vein walls leading to varicose degeneration. The increase in activity was more pronounced in the media than in the intima. A reverse pattern was observed in the behaviour of enzymes involved in energetic metabolism. The enzymatic activity in the venous wall leading to varicose degeneration proved to have decreased. This reduction in the enzymatic activity was more marked in the intima than in the media and was particularly pronounced in the case of the histochemical identification of adenosine triphosphoric acid Ca++.     

Guidelines for the management of varicose veins

Recently published evidence-based guidelines of the Society for Vascular Surgery (SVS) and the American Venous Forum (AVF) include recommendations for evaluation, classification, outcome assessment and therapy of patients with varicose veins and more advanced chronic venous insufficiency (CVI). The need for such guidelines has been evident since imaging techniques and minimally invasive technologies have progressed by leaps and bounds and radiofrequency ablation, laser and sclerotherapy have largely replaced classical open surgery of saphenous stripping. This report reviews the most important guidelines recommended by the SVS/AVF Venous Guideline Committee. It is obvious, however, that some of the technology that is recommended in North America is either not available or not affordable in some parts of the world for patients with varicose veins and CVI. The readers are urged therefore to also consult the guidelines of their national societies, recent publications of the National Institute for Clinical Excellence and the Venous Forum of the Royal Society of Medicine. Venous specialists should also keep in mind that scientific evidence should always be combined with the physician's clinical experience and the patient's preference when the best treatment is selected for an individual patient.     

Management of patients with varicose veins presenting with a history of deep venous thrombosis

The notion of a history of deep venous thrombosis in patients with varicose veins has often been at the origin of a contemplative attitude toward this pathology. What used to be an act of vigilance has now become plain negligence, if not a therapeutic error. Indeed, the difficulty in diagnosing an acute episode explains the many false positive results obtained; moreover, the variability of the evolution of true venous thrombosis should no longer cause one to adopt a monolithic attitude. In this indication, noninvasive investigating procedures allow distinguishing quite different situations occurring in these patients. In a substantial number of cases, no deep vein circulatory abnormality can be found. Treatment should address primary varicose veins. For those patients with deep venous thrombosis sequelae, such studies allow us to differentiate between occlusion/restriction states from devalvulation, and to detect the precise location of such sequelae, as well as their impact on circulatory function. When occlusion is found, varicose veins, which may be supplementary veins, are left untouched. When devalvulation occurs as an isolated phenomenon, superficial vein insufficiency is of primary importance. Treatment is the more complete that deep reflux will promote relapse through all existing leakage points. If, regardless of this treatment, deep reflux causes significant disturbances, surgical revalvulation should be recommended. More complex cases combining persisting occlusion with devalvulation call for a graded attitude. Noninvasive investigating procedures coupled with phlebography allow us to assess the part played by the various anomalies in causing the disorders.(ABSTRACT TRUNCATED AT 250 WORDS)     

The role of phlebography in pre and peri-surgical varicose veins

The author has given up per-operative phlebography of varicose veins, since many years. It causes complications and is subject to errors of interpretation. Pre-operatively, the conventional ascending phlebography is not justified. On the contrary, a selective dynamic phlebography is indicated before any procedure for venous insufficiency of the calf in order to specify the morphology and function and the external saphenous veins and veins to the gastrocnemius and the soleus. Selective phlebography is sometimes useful in case of recurrence of the varices.