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Getting a leg up on varicose veins - includes related article

FDA Consumer, Feb, 1990 by Evelyn Zamula

During his years in Africa, the renowned British physician Denis Burkitt wondered why he encountered so few cases of varicose veins among his native patients. Being a curious fellow, he sent questionnaires to colleagues in other parts of tropical Africa asking if their experience was similar. It was. In fact, one doctor in Kenya reported that he had seen only three cases of varicose veins in 22 years of practice. That certainly wasn't true for the people back home in England.

It isn't true for Americans, either. It is estimated that 25 percent of adult women and 10 percent of adult men in this country have varicose veins.

For some, varicose veins are merely a cosmetic annoyance that may make them reluctant to wear clothes or participate in sports that show too much leg. Others find them painful, occasionally disabling. At their worst, varicose veins may lead to chronically swollen legs and skin ulcers that never heal. They may become inflamed, a condition known as phlebitis. When a blood clot forms in the inflamed vein, a more serious disease called thrombophlebitis is the result. And though it doesn't happen very often, varicose veins can hemorrhage.

The word varicose means abnormally dilated and twisted. Varicose veins may occur anywhere in the body-hemorrhoids are one example. One of the contributing factors to the development of hemorrhoids is straining during bowel movements, in which increased abdominal pressure is transmitted to veins in the anal area-and, according to Dr. Burkitt, to leg veins. Thus, Burkitt theorizes that constipation might be the primary reason that varicose veins are more prevalent in urbanized Western countries than in more traditionally living Third World agricultural communities.

However, when people speak of varicose veins, they are usually referring to the surface or superficial veins in the leg. Their appearance varies from person to person, but varicosities are commonly bluish and distended. They may be barely visible in people who have a great deal of subcutaneous (under the skin) fat in their legs. In others, they can swell out to resemble bulging, knotty ropes or even a bunch of grapes. Small groups of tiny blue or red veins under the skin called spiderbursts accompany varicose veins. While spiderbursts are not varicose veins, about 80 percent of those with varicosities will also have some spiderbursts. Vein Construction

Why veins become varicosed has to do with the way veins are constructed and how they function. Veins are thin-walled, hollow tubes with only a small amount of elastic and muscle tissue. They are different from arteries, the workhorses of the vascular system. The thick, muscular walls of arteries throb with every heartbeat, conveying oxygenated blood under pressure to every cell in the body. The more fragile veins operate at a more leisurely pace, carrying blood containing carbon dioxide back to the heart, where it will be pumped to the lungs for reoxygenation.

Blood pressure, though lower in the veins than the arteries, is still the main driving force in circulation. But in the areas farthest from the heart-the feet and legs-venous blood needs assistance in returning uphill against the force of gravity. The body has a few mechanisms to help out.

Veins have tiny folds of tissue called valves in their inner walls. These cuplike structures open when blood flowing upward pushes through, but close tightly if blood from above falls back, thus insuring a one-way flow. Valves are spaced at irregular intervals along the veins' inside walls. The number of vein valves varies from person to person. Up to 20 may be found in the long saphenous vein, the main surface vein that runs along the whole length of the leg; and there are from 9 to 12 in the short saphenous vein, which runs from the foot up to the back of the knee. The veins that branch off from the saphenous veins, called tributaries, are the ones that most frequently become varicosed.

Blood also gets a boost upward by the actions of leg muscles, which squeeze the deep veins in the leg during exercise, pumping blood toward the heart. These groups of muscles in the foot, calf, thigh and abdomen are so effective that they have been called a peripheral heart. Their strength also helps support the heavy column of blood from ankle to the heart.

Another factor that assists in returning blood to the heart is the act of inhaling, which creates a negative pressure in the chest that draws the blood upward.

The surface veins are linked with the deep veins in the leg through a set of connecting veins called perforators. Thus, venous blood normally flows from the surface veins through the connectors to the deep veins, where it is pumped upward by the action of the leg muscles. Disorderly Conduct

Sometimes, however, things happen that disrupt this orderly sequence. It is thought that a defective valve may start the process. Experts don't know where the first valve fails, though some believe this occurs in one or more of the connecting veins in the lower leg. Others think valve failure begins higher up in the groin, where the large saphenous vein meets the femoral vein. Still others theorize that weak vein walls cause valves to fail.

A weakened valve that doesn't close properly permits blood to flow the wrong way-from the deep veins to the surface veins instead of the other way around. This extra weight of blood presses on the surface vein walls, stretching them. Valves in this stretched area may be pulled apart one by one by pressure from above, causing blood to fall backward and pool in the veins. More pressure is put on the remaining healthy valves and the vein wall, which must now support a longer column of blood. This pressure eventually causes some of the surface vein walls to balloon out into varicose veins.

The severity of varicose veins often has no relationship to the symptoms. People with unsightly veins may have no discomfort, while others with minor varicosities suffer torments. Many experience aching, tired legs, especially after being on their feet a long time. Other common symptoms are a feeling of fullness or a burning sensation. Others may have swollen or itchy ankles, leg cramps at night, stabbing pains that become worse at the end of the day, or tenderness along the veins. Women may feel more discomfort during their menstrual periods.

When legs ache or are painful, a visit to the doctor is in order to rule out other possible problems. A condition called intermittent claudication, due to obstructions of the leg arteries, may cause pain during exertion and relief with rest. An irritated nerve in the back may cause an aching sensation in the calf. But it's probably varicose veins if pain is relieved when legs are elevated. Treatment

The most conservative treatment is no treatment. If varicose veins cause no problems, and a physician determines that the deep vein system is healthy, nothing needs to be done. When legs ache slightly, elevating them to drain pooled venous blood may give all the relief that is needed.

Sometimes the doctor will prescribe the use of graduated compression stockings. This type of elastic stocking exerts the greatest pressure at the ankle, with gradually lessening pressure as it goes up the leg, and can be knee-high, thigh-high, even waist-high. Elastic stockings put pressure on vein walls, forcing blood from the superficial veins back into the deep veins and squeezing valves closer together. When combined with regular leg elevation and exercise such as walking or swimming, elastic stockings may be a good choice for people who must be on their feet all day long and for those with mild varicosities. Sometimes they are the only treatment advisable for those too ill or too old to tolerate other forms of therapy. They can be uncomfortable, though, in warm weather.

Another type of nonsurgical treatment is sclerotherapy, or injection therapy, which can be done in the doctor's office. In this procedure, a mild solution of a sclerosing (sclero = hard) agent, such as sodium tetradecyl sulfate, is injected into the vein. The solution irritates the inner vein walls so that scar tissue forms and closes it off. Pressure bandages applied on the leg after injection keep the vein walls together and prevent blood flow. The shrunken vein remains in the leg, and blood flow is routed to other veins.

Injection therapy works best on smaller veins, spiderbursts, and on people with relatively few varicosities, but it can be used on almost all varicose veins. However, sclerotherapy is never used on people who have many incompetent valves or deep vein disease, which can usually be determined by simple tests performed in the doctor's office.

After a year's follow-up, about 90 percent of patients report good to excellent results, providing that appropriate selection for sclerotherapy has been made, according to Andrew M. Gage, M.D., and Andrew A. Gage, M.D., in the September 1987 issue of Hospital Medicine. One disadvantage is that the procedure sometimes causes a brown discoloration of the skin that may or may not fade. Another drawback is that in some cases the closed-off veins reopen in a few years. If this happens, injection therapy can be safely repeated. Surgery

Sometimes varicose veins need more aggressive treatment. Valves in the long saphenous vein may fail, causing its tributaries and smaller veins to varicose. Or the long saphenous vein itself may become varicosed. Such cases may call for a surgical procedure called "stripping." The saphenous vein is removed with a device called a vein stripper that actually pulls the vein out of the body. With the diseased vein gone, the blood is forced to find new channels to the deep vein system and circulation is improved.

"Varicose vein surgery is quite safe," says David Calcagno, M.D., assistant professor of surgery at Georgetown University School of Medicine, Washington, D.C., and co-director of Georgetown's Center for Vascular Disease. "We use epidural anesthesia, so the patient isn't put to sleep. We make two incisions, one at the level of the groin and one at the ankle level, separate out the saphenous vein, and then take it out. But then we usually have to make multiple other incisions in the leg to take out the remaining varicose veins."

The incisions are tiny and heal rapidly, usually with little or no scarring. The main tributaries of the saphenous vein, which are cut and tied off during surgery, eventually dry up and disappear. Many of the smaller tributaries tear and bleed when the vein is pulled out, though they quickly seal themselves off. The leg is then wrapped with Ace bandages and elevated.

Many people have a choice of treatment. "We do both injection therapy and surgery," says Calcagno. "It depends on the anatomic situation and the patient's preference. Surgery is better if there's a lot of underlying valvular incompetence or just a very large number of varicose veins. In the last instance, surgery may be more expeditious in that it takes care of the problem in one sitting rather than in multiple visits for vein injection."

After surgery, most doctors recommend walking to help the circulation and wearing elastic stockings or bandages for a short time. Injection therapy can be used on the remaining small varicosities.

When deep veins are blocked or have been damaged by accidents or diseases, such as phlebitis or thrombophlebitis, they cannot pump blood to the heart efficiently enough to compensate for the removal of superficial veins. In these cases, varicose veins should not be removed.

"If we are at all suspicious that the trouble lies in the deep veins, we perform noninvasive vascular testing in the vascular lab. We use both the Doppler probe and IPG [impedance plethys-mography]." These techniques are used to determine if the deep leg veins are obstructed and to evaluate the extent of the obstruction. Easing the Pain

People predisposed to varicose veins may not be able to prevent them, but they can do a number of things to prevent symptoms or complications: * Elevate the feet whenever possible, such as when watching television or reading. * Try to avoid prolonged periods of sitting or standing, which cause blood to accumulate in the lower legs, and cause ankles and veins to swell. * On long trips, walk up and down the aisles of the plane or train every hour or so or stop the car occasionally to stretch the legs. If elastic stockings have been prescribed, be sure to wear them while traveling. * Walk, run or swim regularly to get the leg muscles pumping and blood moving up the veins. * Avoid constricting clothing. Tight garters, girdles, pantyhose, and high boots can impede the circulation in the legs. * Lose weight, if necessary. * Evelyn Zamula is a free-lance writer in Potomac, Md. The "Haves" and Have Nots"

Experts find it hard to say exactly what predisposes some people to varicose veins, though heredity is probably the most important factor. Some people are born with veins or valves that have a tendency to weaken. Others have too few valves, so that the individual valve must support more than its share of stress. Many families have more than one member with varicose veins.

Is aging a factor? Definitely. Just as skin becomes less elastic with age, veins also lose elasticity and muscles weaken. Varicose veins are not common in people under 25, except for women who have had multiple pregnancies. According to the results of the Framingham Study, which keeps track of the development of cardiovascular disease among residents of Framingham, Mass., varicose veins most often develop in women between 40 and 49 years and in men between 70 and 79.

Is inactivity an accelerator? Leg veins need the pumping action of the muscles to return blood efficiently to the heart. Varicose veins are rare in developing countries where people work hard physically. The Framingham Study confirmed that varicose veins were more common in men and women who were not physically active.

Is pregnancy a precipitator? One woman interviewed for this article told of her experience. "Varicose veins run in my family so I wasn't too surprised when veins started to pop out early in my pregnancy, but only in one leg," she said. "When I was pregnant with my second child they popped out in the other leg."

Pregnant women have about 20 percent more blood in their bodies than nonpregnant women. This extra volume of blood, combined with the weight of the unborn baby pressing down on the pelvic veins can stress vein walls and impede circulation. Hormone levels, which rise during pregnancy, may relax the muscles in vein walls, causing veins to dilate and valves to separate. Varicose veins often improve after delivery.

Does flab figure in? Overweight people have a higher proportion of fat to muscle, which means less muscular support for the veins and less muscle to do the pumping. As in pregnancy, extra poundage in the abdominal area puts pressure on vein walls and may aggravate existing cases of varicose veins. A number of population studies have reported that both women and men with varicose veins are more often obese.

Is it a dietary deficiency? Dr. Burkitt thought so. Low dietary fiber may cause constipation, which in turn leads to abdominal straining that may damage vein valves in the leg, or so Burkitt theorized. He postulated that one reason varicose veins were rare in Africa is that diets in developing countries are generally high in fiber, as opposed to Western diets. However, this doesn't explain why the African Masai, who subsist on a diet of milk and blood (which contains plenty of fiber in the form of fibrin, an insoluble material that is the basic component of a blood clot), have few leg varicosities though as many as 45 percent of the Masai complain of constipation.

Is the chair the culprit? People who squat or sit on the ground, as in some African and Asian agricultural communities, have stronger leg vein walls than people in more industrialized communities. It will be interesting to see how Westernization and affluence affect the leg veins of the Japanese, who had few varicose veins in the past when they were accustomed to sitting on the floor. *

COPYRIGHT 1990 U.S. Government Printing Office
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