Varicose Veins

What are varicose veins?

Varicose veins are enlarged, superficial veins that no longer function to effectively bring blood back to the heart. Healthy veins have one-way valves that prevent blood from flowing in the wrong direction. When these valves stop functioning, back-flow can occur, and blood pressure increases in the veins. Increased blood pressure stretches vein walls and further damages the veins’ valves. As the cycle repeats, varicose veins tend to worsen.

Varicose veins often appear bulging, twisted or simply more visible through the skin. However, some varicose veins are not visible, and as many as one third of people with symptoms of varicose veins or venous insufficiency may have no visible signs. People with venous insufficiency but no visible varicose veins may experience leg swelling, tiredness, restless legs, skin changes, or even sores (ulcers) near the ankle that fail to heal. These can be clues that someone’s veins are not functioning well. Often people with underlying varicose veins only experience one or two of these signs or symptoms.

Chronic venous disease is very common with approximately half of the American populated affected to some degree. Statistics vary, but approximately 50% of women and 45% of men will develop vein problems at some point in their lives. Except in in a few settings such as pregnancy or reversible weight gain, vein disease does not tend to heal itself or fade away on its own. Actually, vein disease tends to worsen over time until malfunctioning veins are treated.

An accurate diagnosis and understanding of an individual’s vein disease is best obtained through a duplex (lower extremity) ultrasound, as problems in one area of a person’s leg might actually be caused by an obstruction or valve deficiency in another area of the leg. Using an ultrasound and compression maneuvers, an ultrasonographer can create a map of an individual’s veins detailing problem areas and allowing for a physician to craft a rational, patient-specific treatment plan.

What are the signs and symptoms of varicose veins?

Varicose veins may not present with pain. Common non-painful signs of varicose veins include bulging and twisted blue or purple veins just under the skin on the legs.  However, painful signs and symptoms do occur. Symptoms are sometimes absent in the morning and can increase as the day goes on. Such signs and symptoms that accompany varicose veins include:

• Burning or throbbing leg muscles
• Muscle cramping in the legs
• Swelling of the legs
• Aching or heavy feeling legs
• Itching near the bulging portions of the veins
• Increased pain after prolonged sitting or standing
• Discolored skin
• Restless legs
• Tingling or numb legs
• Non healing leg wounds

Painful signs and symptoms often decrease with increased activity such as walking or when the legs are raised. Do not ignore the symptoms of varicose veins. If you present with any of the above mentioned symptoms, see a board certified physician whose certification includes phlebology or venous medicine. The gold standard is certification by the American Board of Venous and Lymphatic Medicine. If left untreated, varicose veins can lead to more serious symptoms and complications.

Varicose Vein Complications

• Skin ulcers
  • Dermatitis is often the first skin sign of venous insufficiency. Dermatitis is an itchy rash, sometimes misdiagnosed as dry skin or non-specific eczema. Those with varicose veins often experience dermatitis in the lower leg or ankle. Fluid from the leaking vessels builds up in the ankles. This fluid can lead to skin being so fragile that sores called venous ulcers can form. The development of ulcers usually begins with a discolored/darker spot on the skin, most often on the ankles. Venous ulcers are typically painful unless a patient has neuropathy (nerve damage).
  • Venous ulcers rarely heal permanently without treatment – patients sometimes succeed in an ulcer healing temporarily only to have the ulcer form again. Addressing the underlying problem of venous insufficiency and varicose veins can help alleviate your symptoms and eventually heal the painful ulcers permanently.
• Thrombophlebitis (blood clots)
  • Varicose veins and venous insufficiency can also lead to blood clots within a vein. The venous system in the legs is divided into two types of veins – superficial and deep.
  • If clots occur in the superficial venous system, they can be very painful but are rarely a threat to a patient’s life. They are often managed with over-the-counter medicines such as NSAIDs.
  • If clots occur in the deep veins, then they require urgent medical evaluation and treatment. Signs of a blood clot in a deep vein, referred to as deep vein thrombosis (DVT) include swelling, pain, tenderness and warmth in the leg. A DVT sometimes moves into the lungs causing a life threatening blockage know as a pulmonary embolism (PE). Signs that you may be experiencing a pulmonary embolism include shortness of breath, dry cough, chest pain and dizziness or light headedness.
  • DVTs can also lead to a multi-year or lifelong painful condition known as post-thrombotic syndrome. Clots within the deep venous system can severely damage the deep veins and their valves such that these veins can no longer effectively bring blood back to the heart. Blood backing up (venous reflux) can cause pain, skin changes, swelling and risk of additional DVT and future PE’s.

What are the causes and risk factors for varicose veins?

Progressive in nature, varicose veins tend to increase in number, size and visibility with time.

Some of the risk factors for venous insufficiency include:

• Age – As we age, veins tend to lose elasticity and the valves within our veins may weaken. Veins return blood from the rest of the body to the heart using valves as doors preventing backflow and muscle contractions within your legs as pumps to push blood upwards towards your heart. Older veins often exhibit some degree of valve leakage, and venous insufficiency results.
• Family history – Genetics is the biggest risk factor for the development of varicose veins. Risk for the development of varicose veins for someone whose parents are both free of varicose veins is roughly 20%. Astonishingly, that risk jumps to 90% for the development of varicose veins for a person if both of their parents were affected by varicose veins.
• Pregnancy – Pregnancy, especially multiple pregnancies, is one of the most common factors accelerating the symptoms and prevalence of varicose veins.
• Fluctuations of female hormones – Varicose veins (as well as spider veins) increase during times of hormonal fluctuations such as puberty, pregnancy and menopause. Both estrogen and progesterone are responsible for vessel dilation, causing veins to become more visible through the skin. Furthermore, estrogen and progesterone can loosen vessel walls, causing the valves within the veins to become ineffective and blood to pool in the lower extremities instead of returning to the heart for recirculation.
• Extended periods of sitting or standing – Decreased activity such as extended sitting or standing does not allow for the muscle contractions that accompany walking/activity to help move blood upward towards the heart, thus causing blood to pool in the lower extremities. Gravity and inactivity combine to worsen veins. The most famous example of this is the blood clot that results after a long flight on an airplane. The prolonged sitting and inactivity of air travel can be dangerous. Travelers with risk factors for blood clots may even want to consider anticoagulants (anti-blood clotting medicines) before long flights.
• Injury or trauma such as a sports injury – Direct trauma such as a fall or a sports injury can cause damage to superficial veins lying just underneath the skin
• Obesity – Additional body weight adds undo pressure on your veins which affects the veins ability to shuttle blood back towards the heart for recirculation. Unfortunately, added weight often makes varicose veins less noticeable, as the swollen veins are not as visible underneath a thicker layer of adipose tissue (fat). Also, many of the signs and symptoms of varicose veins are often attributed to the weight problem itself and not the possibility of varicose veins. Other factors associated with obesity such as high blood pressure can affect blood flow in the lower extremities and lead to advanced skin changes such as skin ulcers. Because vein problems are often hidden from plain view in obese patients, it is critical that a lower extremity ultrasound scan (duplex scan) be performed in obese patients with symptoms of venous insufficiency, even when no varicose veins are visible.
• History of blood clots
• Birth control pills
• Liver disease
• Diet – Venous disease is more prevalent in Western cultures than in cultures whose diet is predominantly high fiber, low fat diets. Fiber helps to decrease pressure on the colon and the pressure needed to evacuate the colon.
• Leg crossing – Although debated, leg crossing, in theory, decreasing the return of blood flow from the lower extremities to the heart by physically compressing veins in the legs.
• Abdominal straining – Along with pressure on the colon due to straining during bowel movements, those who experience regular abdominal straining such as constant heavy lifting often experience increased varicose veins.
• Steroid use

How are varicose veins diagnosed?

Varicose veins are best diagnosed with a physical exam and a duplex lower extremity ultrasound. Dr. Taylor will examine your legs while standing to check for leg swelling and bulging veins. He will ask you to describe any signs and symptoms you may be having including any pain or aching in your legs. Then a registered vascular technician will perform a doppler ultrasound on your legs to check the blood flow and identify any malfunctioning valves. The leg ultrasound is a simple, non-invasive procedure in which a transducer is guided over your leg and transmits images of blood flow through your venous system onto a monitor using sound waves.

Am I a candidate for varicose veins treatment?

If you have any of the above symptoms or are bothered by the cosmetic appearance of your veins, vein treatment is worth considering. Modern treatments are very safe and easy to tolerate. There are few settings when someone would not be a candidate for varicose veins treatment.

Varicose vein prevention:

• Maintain a healthy weight
• Wear compression stockings/socks if you will be sitting or standing for long periods
• Try to interrupt long periods of sitting or standing with breaks to get up, walk and stretch
• Maintain a regular exercise regimen
• Avoid crossing your legs
• Talk with a doctor about managing risk factors such as genetic tendencies to clot
• Treat existing varicose veins to prevent worsening disease

What are my spider and varicose veins treatment options?

While committing to a daily exercise program, losing weight, wearing compression stockings and elevating your legs may help to prevent future varicose veins, these measures almost never eliminate existing varicose veins. Fortunately, Premier Dermatology offers several minimally invasive treatment options that will effectively treat varicose veins and their uncomfortable symptoms without the need for general anesthesia and with minimal to no downtime.

At Premier Dermatology, we carefully select from a combination of endovenous laser ablation (EVLA), ultrasound-guided foam sclerotherapy, phlebectomy, and liquid sclerotherapy to treat venous insufficiency, varicose veins, and spider veins.

• Endovenous laser ablation (EVLA) – Endovenous laser ablation is a minimally invasive procedure in which a vein is sealed from the inside. It is performed for large, relatively straight poorly functioning veins. The vein to be treated is identified by ultrasound. A small area of skin is numbed with lidocaine, and a small nick in the skin is made. A hollow needle is inserted into the vein. This access point is used to allow a laser fiber to be gently glided inside the vein. The fiber is capable of carrying laser light. The area around the vein is numbed with anesthetic, and the laser is turned on. The light travels to the tip of the laser fiber where the light exits and heats up the inside of the vein sealing it shut. The fiber is slowly withdrawn, with the light continuing to seal the entire vein as the fiber is withdrawn. The fiber is removed and a small bandage placed on the access point. This is an in-office procedure that generally takes an hour to perform, does not require a hospital stay and has minimal downtime. With the vein closed, the body will reroute blood to neighboring healthy veins for dispersal. Success rates for closing a vein with EVLA are approximately 99%.
• Ultrasound guided foam sclerotherapy – Foam sclerotherapy, performed under the guidance of an ultrasound is used to treat large varicose veins that are generally too tortuous (twisty) to allow easy passage of a laser fiber. Sclerosing agents are medications that can irritate the interior lining of a vein and cause it to close and seal shut. Most sclerosing agents come as a liquid. Air can be passed through some sclerosing agents allowing for the creation of a foam. Compared with liquid sclerosants, foams are more effective at closing large varicose veins. Ultrasound guided foam sclerotherapy is a non-surgical, minimally invasive technique that allows the physician to close varicose veins using injected foamed sclerosants. Ultrasound guidance allows the physician to ensure that the foamed sclerosant only affects the area that is intended and increase safety. This technique offers quick relief of symptoms, minimal risk and long lasting results.
• Phlebectomy – For most veins, a minimally invasive approach such as endovenous laser ablation or foam sclerotherapy is the preferred treatment. However, some veins are too shallow or are located over bony prominences such as the ankle bone. For these veins, phlebectomy remains a valuable tool. During phlebectomy, a vein is accessed by means of a tiny incision. The vein is often tied off (ligated), and the affected varicose vein is removed. Note: modern phlebectomy is not the same as “vein stripping.”
• Liquid sclerotherapy – Liquid sclerotherapy is highly effective for treating small spider veins. If a patient has underlying venous insufficiency and larger varicose veins, those veins should be treated first with a combination of the above measures. Spider veins are treated by sterilizing an area of skin and injecting a small amount of sclerosing agent through a tiny needle into the vein. Complications are rare. If you are interested in treating any symptomatic or cosmetically bothersome spider veins, schedule an appointment with Premier Dermatology today.

Why should I choose Premier Dermatology for my vein care?

Premier Dermatology provides comprehensive venous evaluations and advanced venous insufficiency treatments. Unlike many vein care clinics, Premier Dermatology provides a comprehensive array of vein care treatment options by a board certified dermatologist who is fellowship-trained and certified by the American Board of Venous and Lymphatic Medicine.

Dr. Brent Taylor is both a board certified dermatologist and certified by The American Board of Venous and Lymphatic Medicine in phlebology. His extensive fellowship training in both dermatology and phlebology allow him to provide comprehensive patient education and superior treatment to his patients. If you are concerned about your veins or are experiencing leg symptoms such as swelling or discomfort, contact Premier Dermatology and Mohs Surgery of Atlanta in Alpharetta for a consultation today.

Premier Dermatology and Mohs Surgery of Atlanta is located off of GA 400 (Windward Parkway or Old Milton Parkway) convenient to Alpharetta, Milton, Cumming, Crabapple, Johns Creek, Roswell, Buckhead or Atlanta.