Varicose veins are enlarged, dilated, visibly obvious veins and considered to be the most common chronic condition of the venous system. It is estimated that approximately 20% of adults in western countries have varicose veins. In over two thirds of patients with the condition, varicose veins first appear before the age of 25 and up to 75% are found to have a family member with the condition as well. In the superficial venous system, the greater and lesser saphenous veins are the large primary vessels, which give rise to other venous branches and tributaries. As the venous branches divide and become more superficial (towards the direction of the skin surface), they form a network of reticular veins located just under the dermis layer of the skin. Intradermal (within the substance of the skin itself) veins which become dilated and varicose are known as telangiectasias.
The basic underlying problem is vein valve failure (venous insufficiency), and the effects high pressure within the normally low pressure venous system. Under higher pressure, the veins swell up and become “stretched out” over time in order to accommodate the increased blood flow. What causes valve failure and varicose veins to develop is not entirely understood. Prior DVT or injury are known causes but for most people with varicose veins, they occur as the result of genetic and hormonal influences. Varicose veins often are associated with symptoms that may include tiredness, aching, pain, swelling, or a heavy feeling in the legs. Symptoms are related to the additional fluid pressure, blood flow, and the local effects of the distended enlarged veins. Within superficial, dilated veins, complications such as bleeding or clot formation (superficial phlebitis) can also occur. On the other end of the spectrum, dilated reticular veins and telangiectasias may be entirely non-symptomatic, and associated with unsightly cosmetic changes.
The evaluation of varicose veins begins with a clinical examination and documentation of the associated symptoms and areas of dilated veins. Non-invasive evaluation with ultrasound is an important step in evaluating the presence of upstream obstruction, patterns of normal and reversed blood flow, and overall valve function. The goal of the evaluation is to determine all points of underlying high pressure reflux that feed each region of varicose veins. Proper varicose vein treatment really means treating the entire path of abnormal venous pressure from beginning to end. In symptomatic patients, this often includes treating abnormalities of the greater or lesser saphenous veins, or perforating veins, in addition to the visible varicosities themselves
The objectives of therapy are to provide symptomatic relief and optimally, to eliminate the routes of abnormal venous hypertension and debulk the large redundant mass of excess venous tissue. Treatment options include wearing graded compression stockings, injection sclerotherapy, superficial laser therapy, surgically ligating (tying off or disconnecting) perforating veins or the greater or lesser saphenous veins, vein stripping, surgical removal of clusters of varicose veins, and endovenous ablation. For most individuals, combination therapy using several of these techniques are required for adequate treatment.