Varicose veins of the legs (varicosis, varices)

Varicose veins (varicosis, varicose veins) are dilated, superficial and, in most cases, tortuous veins. Externally, they can be recognized as nodular, bluish shimmering blood vessels, which can also often be the cause of painful legs or swollen ankles. In general, varicose veins can develop in all veins, but they usually occur in the superficial leg veins. The name "varicose vein" is derived from the Middle High German word for "crooked vein".

Varicose veins are very common. According to experts, around 20 percent of adults are affected by at least slight changes in the leg veins. Such fine superficial varicose veins are called spider veins. With increasing age, vein changes, as well as their severity, increase. Women are affected by varicose veins three times as often as men. They usually appear between the ages of 30 and 40.

They usually appear between the ages of 30 and 40. Normally, varicose veins are mild and do not cause any health problems. As the age of the affected person increases, the severity of the symptoms also increases, making treatment unavoidable.

Varicose veins occur when the veins no longer do their job efficiently. Their main task is to transport blood to the heart against the force of gravity. Most of the pumping is done by the heart, but the calf muscles and the elastic wall of the blood vessels do a not inconsiderable amount. With every movement, a process takes place in which the blood is pressed through the muscles and vein walls towards the heart. Valves are located in the veins, which are similar to valves in their function and prevent a backflow of blood. The superficial veins have the task of transporting the blood into the deep leg veins via connecting channels known as perforating veins.

If there is blood congestion in the legs, for example as a result of a long day of standing at work, the veins can overstretch and bulge. This strain causes the vein wall to remodel and lose elasticity. Over time, the valves in the veins no longer close completely, leading to increased blood stasis.

The factors for the development of varicose veins vary. Approximately 95 percent of vein changes occur without an identifiable cause. Doctors also refer to this type of varicose veins as primary or congenital varicosis. This contrasts with secondary varicosis, which has another disease as its cause (for example, venous thrombosis).

The following factors increase the risk of developing primary varicose veins (varicosis):

• Heredity: connective tissue weaknesses and thus also varicose veins are hereditary in up to 50 percent of cases.
• Hormones: Female hormones (oestrogens) can be responsible for the slackening of the connective tissue. This is also the reason why varicose veins occur more frequently among women. One in three women develops varicose veins during pregnancy, but they disappear again after birth.
• Lack of exercise: If you mainly perform standing or sitting activities, the muscle pump can become slack. In addition, sitting causes the veins in the back of the knees to bend, which further increases the impeded blood flow.
• Factors such as age, overweight and smoking are also not insignificant.

Spider veins:

These fine varicose veins, located in the upper layers of the skin, usually pose no danger. They do not cause any discomfort and are purely an aesthetic problem.

Trunk or side branch varicosis:

The first characteristic of varicose veins is a feeling of heaviness, tiredness and tension in the legs. These complaints improve when the patient is lying down and when he or she moves. Sometimes there may also be itching or cramps in the feet and wastes at night. In general, an increase of the symptoms can be noticed in warm weather.

If the blood congestion persists over a longer period of time, the vessels become more and more permeable, whereby fluid, protein and blood pigments (haemosiderin) are pressed into the tissue. This results initially in evening and later in constant water retention in the legs (oedema), which occurs mainly in the ankle area. At a later stage, skin discoloration (stasis dermatitis, stasis eczema) may also occur.

Older people also suffer from thinning skin as a result of chronic damage ("parchment skin"). As a result, it tends to bleed minimally even in the case of minor injuries.

As a result of the blood congestion, the tissue is supplied with less oxygen, which ultimately leads to the development of "open" legs (ulcus cruris). Varicose veins also often lead to superficial phlebitis. If a blood clot (thrombus) also develops, this is called thrombophlebitis. In rare cases, this blood clot can break loose and be transported with the bloodstream to the lungs, where it blocks a vessel (pulmonary embolism). Depending on the symptoms of the vein changes, a distinction is made between four stages of varicose veins:

• Stage I: no complaints
• Stage II: feeling of congestion, calf cramps at night, tired or heavy legs
• Stage III: water retention in the legs (oedema), skin changes, healed ulcers
• Stage IV: Open leg ulcers (Ulcus cruris)

Based on the medical history and the physical examination, the doctor can already obtain initial indications of varicose veins (varicose veins). By means of various tests, information can be obtained about functional disorders of the venous valves and involvement of the deep venous system. Depending on the location, different forms of varicose veins can be distinguished:

• Truncal vein varicose veins and lateral branch varicose veins: these are varicose veins of the large and medium-sized veins. This type of varicose veins is the most common and occurs mainly on the inner side of the upper and lower legs.
• Perforating varices: varicose veins in the veins connecting the superficial and deep veins.
• Reticular varicose veins: Varicose veins of the small veins, which have a diameter of two to four millimetres. They occur mainly on the backs of the knees and outer sides of the upper and lower legs.
• Spider veins- Varicose veins: Varicose veins of the superficial, fine veins that have a diameter of less than one millimetre. They often occur on the back of the thighs.

With the help of a special ultrasound examination (Doppler/duplex sonography), the doctor can see whether the deep veins are permeable and whether the venous valves can do their job. In addition, it is possible to see in which direction the blood is flowing. In rare cases, duplex sonography may not be available and an X-ray contrast image of the veins (phlebography) must be taken.

The therapy aims to maintain the blood flow in the veins and to prevent blood stasis. As a result, edema should be minimized, tissue supply improved, and ulceration prevented.

General measures:

• It is advisable to keep moving. Prolonged standing or sitting puts a strain on the veins. Even while working, try to alternate between sitting, standing and walking as often as possible.
• When sitting, it can be helpful to keep your legs elevated. Circular foot movements can also stimulate blood circulation while sitting.
• At night, the legs can be elevated slightly, which improves blood return.
• Cold leg casts during showers lead to better blood circulation.
• Extreme heat, such as in the sun or sauna, should be avoided.

Support stockings:

If there are mild to moderate complaints (for example, water retention), these can be treated with the help of support bandages or stockings (compression stockings). However, this method only reduces the discomfort, whereas the varicose veins remain. Nevertheless, this therapy is considered the first choice.

Support stockings exert a measured pressure on the leg and thus support the damaged vein walls. As a result, there is less blood stasis in the veins, the venous valves close more efficiently and there is a reduction in water retention in the tissue. However, the effect can only unfold if those affected put on the support stockings while lying down, as 500 ml of blood has already "pooled" in both legs while standing.

Depending on the position and extent of the varicose veins, calf, knee, half-thigh or thigh stockings can be used. Support stockings must be tailored exactly to the person affected, which is why they are often made to measure. They should be changed after four to six months.

Support stockings are available in compression classes I to IV, with class I being the weakest. They are used only for mild discomfort, as well as for prevention during pregnancy.

Compression bandages:

Compression bandages lead to an increase in pressure in the tissue. As a result, water retention is flushed out, the veins become slimmer and the venous valves close better. Compression bandages are mainly used in the first days after vein surgery, as well as for acute, pronounced swelling. For permanent use, well-fitted compression stockings have proven better.

Medications:

Medications against varicose veins are not known to date. Nevertheless, there are various preparations for internal and external use. However, the effectiveness is controversial.

In order to prevent oedema, various herbal preparations can be used (oedema protectors), which are supposed to seal the vessels. According to some studies, horse chestnut extract as well as the mixture of substances isolated from it, namely aescin, troxerutin and hydroxyethylrutoside, have a positive effect on the prevention of oedema. Further well-studied herbal remedies are butcher's broom, red vine leaves and sweet clover.

Vein-strengthening drugs have the effect of increasing the tension of the vascular walls.

Diuretics cause water to be flushed out of the body, but should not be taken over a long period of time and should only be taken if the patient suffers from very severe oedema.

A variety of vein ointments, which mainly contain heparin in combination with various plant extracts, also promise to be effective. However, there is no evidence about the effectiveness of these substances and whether they penetrate the skin at all.

Sclerotherapy (sclerotherapy), laser therapy:

This method is used for superficial and thinner varicose veins (spider veins or side branch varicose veins). These can be sclerosed under local anaesthesia. For this purpose, a liquid or foam is injected into the veins to close them. This method is primarily intended to improve the cosmetic result.

Sclerotherapy cannot be performed on larger varicose veins or if the veins connecting the superficial and deep blood vessels (perforating veins) are affected, as the risk would be too high of damaging the blood outflow pathways in the depth of the leg.

Sclerotherapy of varicose veins can also be done under local anesthesia with a laser or with radio waves. The procedures are similar. The treating physician makes a small incision on the inside of the ankle or in the hollow of the knee and inserts a thin special fiber into the varicose vein. Depending on the technique, this is heated with laser light or radio waves. As a result, the inner wall of the vein is stuck together and the varicose veins are closed. The vein hardens and is broken down by the body within a few months. Both methods are still relatively new and have few reported experiences.

Surgery:

Surgery is the method most likely to provide permanent relief from varicose veins. During surgery, the doctor removes or cuts off the altered vein. Usually, the missing varicose vein is not a problem because there are many veins running in the leg. However, this operation can only be carried out if the deep veins in the leg are open.

If the affected person suffers from pronounced varicose veins that cause discomfort, surgery is the best method.

A choice can be made between the following surgical techniques:

• Vein stripping: In this method, the entire varicose vein is removed. To do this, the doctor inserts a wire into the vein on the inside of the ankle and guides it to the groin, where the varicose vein enters the deep vein system. With the help of this wire, it is possible to pull out the vein completely.
• Crossectomy: In addition to vein stripping, all vein branches are often cut off at the so-called vein star (crosse). This location in the groin represents the mouth of the superficial leg veins into the deep vein system. This technique is intended to prevent new varicose veins from developing after the operation.
• Perforator ligation: In this procedure, the doctor makes a small incision over each altered connecting vein between the superficial and deep leg veins. The varicose vein is either tied off and broken down by the body within months or pulled out immediately.

These measures lead to a relief of the veins and thus to the prevention of varicose veins or the associated complaints:

• Endurance sports such as walking, swimming or cycling prevent varicose veins.
• Extreme heat such as the sun or sauna puts a strain on the veins
• Alternating showers and cold water lead to improved blood circulation.
• In general, sitting and standing are rather bad and walking and lying down are better.
• Vessel-sealing medicines, which are to be taken early for prevention, should be regarded critically.
• Particular attention should be paid to leg veins during pregnancy. If there is evidence of varicose veins, it is advisable to wear compression stockings.