Since the discovery of the relationship between varicose veins and superficial vein thrombosis in the early 1980s, standard belief has dictated that varicose veins (C2+Europaische Befundklassifikation) are a chronic condition of the superficial veins and have little relevance to the pathophysiology of DVT, which occurs in the deep veins. This states that chronic venous disease (CVD) and its more severe sequelae, including ulceration, result from ambulatory venous hypertension, which is caused by venous valve reflux secondary to valvular incompetence in the superficial veins. Conversely, the development of DVT is classically described as occurring in the deep veins, secondary to venous stasis, vascular trauma, increased coagulability, or a combination of these factors (Virchow’s triad). This occurs commonly in patients with serious illness or recent surgery and, in addition to the acute deep venous obstructive symptoms (phlegmasia cerulea dolens), can lead to the post-thrombotic syndrome (PTS), which has been widely considered the analogue of CVD in the deep venous system.
Causes and Risk Factors
Any condition or activity that puts increased pressure on the veins in the legs can cause varicose veins. Common causes are pregnancy, obesity, and older age. Varicose veins are common in pregnancy. This is because there is a higher volume of blood during pregnancy, and this causes veins to enlarge. In addition, hormonal changes in pregnancy cause the vein walls to relax. Varicose vein that occur during pregnancy generally improve within three months after delivery. However, with successive pregnancies, the varicose veins are more likely to stay. High body weight puts extra pressure on the veins. Varicose veins are a common problem in older people, and this is because the veins lose their elasticity as people age. This causes the valves to weaken and be more likely to allow blood to flow back into the vein. This pooling is the cause of the vein enlargement.
The cause of primary varicose veins is not well understood. There seems to be a hereditary predisposition to this condition, and primary varicose veins are related to weakness in the vein wall. Each vein has a set of one-way valves that control blood flow. In primary varicose veins, the valves don’t function properly. In this way, increased pressure from standing or walking is transmitted to the vein wall, and this pressure is the reason for the vein enlargement. The increased pressure can also cause the legs to ache, fatigue easily, or swell, particularly after prolonged standing. This is because of the effect of increased pressure on the small blood vessels in the skin.
Symptoms and Complications
The good news is that DVT and PE are not common outcomes from varicose veins, and most people with varicose veins will never develop a deep vein clot.
Deep vein thrombosis (DVT) does have the potential to be a dangerous and life-threatening illness. The clot, a solid mass made of blood, must be large enough to cause a partial or complete blockage of blood flow in a vein for an extended period of time. This prevents the inflammatory response from being effective in the removal of the thrombus, and so it remains present in the vein. If the thrombus dislodges from the vein, it can travel to the heart and into the pulmonary artery, where it becomes a pulmonary embolism (PE). A PE can be fatal if the clot is large. It is possible to have a PE without any major symptoms, and the clot can resolve itself. If the clot prevents the pulmonary valve from opening, the embolism will cause sudden heart failure within one to two hours of onset. Generally, a PE is accompanied by a sudden onset of chest pain and a fast heart rate. Symptoms such as collapse and sudden shortness of breath can be life-threatening and require immediate medical attention.
Varicose veins have often been considered a cosmetic concern, and certainly this is the main purpose. People want to get rid of veins which bulge or cause discoloration of the skin. In this vein, the formation of skin damage is very obviously an undesirable effect. Lipodermatosclerosis causes the skin of the ankle and lower calf to become shiny and taut, and the area about the ankle may contract and become, or its blood flow may be so disturbed, so as to cause an ulcer. These can be very difficult to heal and are best treated by curing the underlying veins.
Treatment and Prevention
Recent Cochrane systematic reviews of the effectiveness of treatment for varicose veins and prevention of venous ulcers have shown much about the various treatments that are used. One important thing to highlight is that the review identified the need for more research into the effects of the treatments on quality of life and the long-term management of the conditions. From our discussion, the prevention of DVT is very important for the general population and also hospitalized patients. It is a necessary measure for public health in the reduction of deaths due to DVT, which are mostly associated with hospital care. With the growing awareness of risks and a recent increase in lawsuits for negligence, this is an area that is likely to receive much focus and ultimately will provide better outcomes for patients.
The current invasive treatments of varicose veins and DVT are effective in treating the particular conditions and the prevention of associated problems. However, they are not completely effective in preventing recurrence of the treated condition. Furthermore, many methods are invasive and require patients to take periods of time off work and stop exercise, so the methods of treatment often go against modern principles of medicine. Patients will be pleased to hear that advancements in medical and surgical research mean that now there is a strong focus on methods of management and treatment that allow patients to live a normal lifestyle. In time, it is expected that treatments involving stem cells and gene therapy will be available. The long-term aims of this research are to have treatments that are highly effective and permanent.
Invasive treatment of varicose veins is indicated in the presence of symptoms of pain, heaviness, or swelling that do not respond to more conservative management. It may also be indicated for recurrent phlebitis, skin ulceration, or in the presence of skin changes or inflammation of the veins (superficial thrombophlebitis). Surgery is one of the conventional approaches to treating varicose veins, but there are many other methods available, including injection of a sclerosant (which damages the affected veins), diathermy, and laser treatment. Surgery can range from drastic stripping and ligation of the affected veins to more conservative and modern techniques, such as ambulatory phlebectomy and endoscopic vein surgery. Deep vein thrombosis is treated using anticoagulant and thrombolytic therapy. The prevention of DVT is approached in patients who have risk factors through prophylactic anticoagulant therapy and/or mechanical methods designed to prevent stasis of blood in the legs.
