varicose veins

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Varicose Veins

 

Definition

Varicose veins are dilated, tortuous, elongated superficial veins that are usually seen in the legs.

Description

Varicose veins, also called varicosities, are seen most often in the legs, although they can be found in other parts of the body. Most often, they appear as lumpy, winding vessels just below the surface of the skin. There are three types of veins, superficial veins that are just beneath the surface of the skin, deep veins that are large blood vessels found deep inside muscles, and perforator veins that connect the superficial veins to the deep veins. The superficial veins are the blood vessels most often affected by varicose veins and are the veins seen by eye when the varicose condition has developed.
The inside wall of veins have valves that open and close in response to the blood flow. When the left ventricle of the heart pushes blood out into the aorta, it produces the high pressure pulse of the heartbeat and pushes blood throughout the body. Between heartbeats, there is a period of low blood pressure. During the low pressure period, blood in the veins is affected by gravity and wants to flow downward. The valves in the veins prevent this from happening. Varicose veins start when one or more valves fail to close. The blood pressure in that section of vein increases, causing additional valves to fail. This allows blood to pool and stretch the veins, further weakening the walls of the veins. The walls of the affected veins lose their elasticity in response to increased blood pressure. As the vessels weaken, more and more valves are unable to close properly. The veins become larger and wider over time and begin to appear as lumpy, winding chains underneath the skin. Varicose veins can develop in the deep veins also. Varicose veins in the superficial veins are called primary varicosities, while varicose veins in the deep veins are called secondary varicosities.

Causes and symptoms

The predisposing causes of varicose veins are multiple, and lifestyle and hormonal factors play a role. Some families seem to have a higher incidence of varicose veins, indicating that there may be a genetic component to this disease. Varicose veins are progressive; as one section of the veins weakens, it causes increased pressure on adjacent sections of veins. These sections often develop varicosities. Varicose veins can appear following pregnancy, thrombophlebitis, congenital blood vessel weakness, or obesity, but is not limited to these conditions. Edema of the surrounding tissue, ankles, and calves, is not usually a complication of primary (superficial) varicose veins and, when seen, usually indicates that the deep veins may have varicosities or clots.
Varicose veins are a common problem; approximately 15% of the adult population in the United States have varicose veins. Women have a much higher incidence of this disease than men. The symptoms can include aching, pain, itchiness, or burning sensations, especially when standing. In some cases, with chronically bad veins, there may be a brownish discoloration of the skin or ulcers (open sores) near the ankles. A condition that is frequently associated with varicose veins is spider-burst veins. Spider-burst veins are very small veins that are enlarged. They may be caused by back-pressure from varicose veins, but can be caused by other factors. They are frequently associated with pregnancy and there may be hormonal factors associated with their development. They are primarily of cosmetic concern and do not present any medical concerns.

Key terms

Congenital — Existing at or before birth; a condition that developed while the fetus was in utero or as a consequence of the birth process.
Edema — Swelling caused by a collection of fluid in a tissue or body cavity.
Hemorrhage — Bleeding from blood vessels.
Palpation — The process of examining a patient by touch.

Diagnosis

Varicose veins can usually be seen. In cases where varicose veins are suspected, but can not be seen, a physician may frequently detect them by palpation (pressing with the fingers). X rays or ultrasound tests can detect varicose veins in the deep and perforator veins and rule out blood clots in the deep veins.
Varicose veins may be surgically removed from the body when they are causing pain and when hemorrhaging or recurrent thrombosis appear. Surgery involves making an incision through the skin at both ends of the section of vein being removed (figure B). A flexible wire is inserted through one end and extended to the other. The wire is then withdrawn, pulling the vein out with it (figure C).
Varicose veins may be surgically removed from the body when they are causing pain and when hemorrhaging or recurrent thrombosis appear. Surgery involves making an incision through the skin at both ends of the section of vein being removed (figure B). A flexible wire is inserted through one end and extended to the other. The wire is then withdrawn, pulling the vein out with it (figure C).
(Illustration by Electronic Illustrators Group.)

Treatment

There is no cure for varicose veins. Treatment falls into two classes; relief of symptoms and removal of the affected veins. Symptom relief includes such measures as wearing support stockings, which compress the veins and hold them in place. This keeps the veins from stretching and limits pain. Other measures are sitting down, using a footstool when sitting, avoiding standing for long periods of time, and raising the legs whenever possible. These measures work by reducing the blood pressure in leg veins. Prolonged standing allows the blood to collect under high pressure in the varicose veins. Exercise such as walking, biking, and swimming, is beneficial. When the legs are active, the leg muscles help pump the blood in the veins. This limits the amount of blood that collects in the varicose veins and reduces some of the symptoms. These measures reduce symptoms, but do not stop the disease.
Surgery is used to remove varicose veins from the body. It is recommended for varicose veins that are causing pain or are very unsightly, and when hemorrhaging or recurrent thrombosis appear. Surgery involves making an incision through the skin at both ends of the section of vein being removed. A flexible wire is inserted through one end and extended to the other. The wire is then withdrawn, pulling the vein out with it. This is called "stripping" and is the most common method to remove superficial varicose veins. As long as the deeper veins are still functioning properly, a person can live without some of the superficial veins. Because of this, stripped varicose veins are not replaced.
Injection therapy is an alternate therapy used to seal varicose veins. This prevents blood from entering the sealed sections of the vein. The veins remain in the body, but no longer carry blood. This procedure can be performed on an out-patient basis and does not require anesthesia. It is frequently used if people develop more varicose veins after surgery to remove the larger varicose veins and to seal spider-burst veins for people concerned about cosmetic appearance. Injection therapy is also called sclerotherapy. At one time, a method of injection therapy was used that did not have a good success rate. Veins did not seal properly and blood clots formed. Modern injection therapy is improved and has a much higher success rate.

Prognosis

Untreated varicose veins become increasingly large and more obvious with time. Surgical stripping of varicose veins is successful for most patients. Most do not develop new, large varicose veins following surgery. Surgery does not decrease a person's tendency to develop varicose veins. Varicose veins may develop in other locations after stripping.

Resources

Books

Alexander, R. W., R. C. Schlant, and V. Fuster, editors. The Heart. 9th ed. New York: McGraw-Hill, 1998.

varicose

 [var´ĭ-kōs]
1. of the nature of or pertaining to a varix.
2. unnaturally and permanently distended (said of a vein); called also variciform.
varicose veins swollen, distended, and knotted veins, usually in the subcutaneous tissues of a lower limb; they result from stagnated or sluggish flow of the blood, combined with defective valves and weakened vein walls. This occurs most often in those who must stand or sit motionless for long periods. Pregnancy is also sometimes a causative factor. It also appears that a tendency to develop varicose veins may be inherited.

Causes. Blood returning to the heart from the lower limbs must flow upward through the veins against the pull of gravity; it is “milked” upward principally by the massaging action of the muscles against the veins. To prevent the blood from flowing backward, the veins contain flaplike valves, located at frequent intervals and operating in pairs. When the blood is flowing toward the heart, these are open and the blood can move freely. If the blood should attempt to flow backward, the valves close, effectively stopping the reverse movement of the blood.



Prolonged periods of standing or sitting without movement place a heavy strain on the veins. Without the massaging action of the muscles, the blood tends to back up. The weight of blood continually pressing downward against closed venous valves causes the veins to distend, and in time they lose their natural elasticity. When a number of valves no longer function efficiently, the blood collects in the veins, which gradually become swollen and more distended. During pregnancy, more force often is necessary to push the blood through the veins because of the pregnant uterus pressing against the veins coming from the legs and preventing the free flow of blood; this increased back pressure can cause varicose veins.
Symptoms. The development of varicose veins is usually gradual. There may be feelings of fatigue in the lower limbs, with cramps at night; a continual dull ache may develop in the legs, and the ankles may swell. If the condition is untreated and allowed to spread, as it often does, the veins become thick and hard to the touch, and dull or stabbing pains may be felt in time. Because of impaired circulation, ulcers often develop on the lower legs.
Treatment. Treatment of mild cases of varicose veins includes rest periods at intervals during the day; the patient lies flat with feet raised slightly above the level of the heart. Bathing the legs in warm water helps to stimulate the flow of blood, as does exercise. The daily routine should be changed to allow movement and changes in posture; even a brief walk will stimulate circulation grown stagnant during a time of standing or sitting in one position. Stockings lightly reinforced with elastic can be worn to help support the veins in the legs. Heavy elastic stockings, however, should be fitted and worn only under medical supervision; if they do not fit correctly they may aggravate the condition by further restricting blood flow.
Injections. Certain cases of varicose veins that have developed past the stage when exercise and rest are helpful may be treated by sclerotherapy, the injection of a hardening, or sclerosing, solution into them. A few hours after this treatment, which usually can be performed in the primary care provider's office, the injected veins become hard, tender to the touch, and painful. The pain subsides within a few days, however, and in about 2 months the varicose veins atrophy while the blood is channeled into other veins. The number of injections necessary depends upon the extent of the condition. This form of treatment usually is not recommended for advanced cases because it has been found that in such cases recurrence is likely after a varying period of time following the injections.
Surgery. Varicose veins can cause much discomfort. The poor circulation involved means that any break in the skin of the leg is likely to develop into an ulcer that is painful and heals slowly and with difficulty. Therefore, chronic or well-advanced varicose conditions are best treated surgically. The operation consists of ligating (tying off) the affected vein and removing it.
Prevention. Regular leg exercises such as long walks will stimulate the flow of blood through the limbs. Those who have a predisposition to varicose veins should make such activities a part of their regular routine. If possible, they should avoid occupations that require them to stand or sit motionless for long periods, or should make it a point to walk about and exercise their leg muscles often during working hours. Tight stockings or garters should not be worn, nor should clothing that fits tightly or binds. See also chronic leg ulcer.
Comparison of normal veins and varicose veins in the leg.

var·i·cose veins

[MIM*192200]
permanent dilation and tortuosity of veins, most commonly seen in the legs, probably as a result of congenitally incomplete valves; there is a predisposition to varicose veins among persons in occupations requiring long periods of standing, and in pregnant women.

varicose veins

Varicosis; varicosity Surgery Enlarged, twisted veins with nonfunctioning valves, resulting in IV pooling of blood and venous enlargement, most commonly in leg veins; VVs affect ±10% of the population, most commonly ♀, age 30 to 60 Etiology Congenital valve defects, thrombophlebitis, pregnancy, prolonged standing or sitting, poor posture, ↑ intraabdominal pressure. See Esophageal varices, Vein stripping. Cf Varicocele.

varicose veins

Enlarged, twisted and distorted veins, occurring in the legs, at the lower end of the gullet (see VARICES) or in the scrotum (see VARICOCOELE). Leg varicosities are due to a constitutional or acquired failure of the vein valves so that deep vein pressure is transmitted to the surface veins. They cause stagnation of blood, inadequacy in local tissue nutrition and tissue staining and breakdown to form varicose ulcers. Deep veins, if healthy, afford adequate blood drainage so varicose veins of the legs can safely be removed or obstructed by injections of sclerosing substances. Support from firm elastic hosiery is also helpful. Exercise is beneficial.

Varicose Veins

DRG Category:263
Mean LOS:6 days
Description:SURGICAL: Vein Ligation and Stripping
DRG Category:299
Mean LOS:5.8 days
Description:MEDICAL: Peripheral Vascular Disorders With Major CC

Varicose veins (varicosities) are the visible manifestations of abnormally dilated, tortuous veins. They occur most often in the lower extremities but can appear anywhere in the body. Primary varicosities are caused by incompetent valves in the superficial saphenous veins, whereas secondary varicosities are the result of impaired blood flow in the deep veins. Primary varicosities tend to occur in both legs, whereas secondary varicosities usually occur in only one leg.

In a ladderlike fashion, perforator veins connect the deep vein and the superficial vein systems, promoting drainage of the lower extremities. Blood can be shunted from one system to the other in the event of either system’s being compressed. Incompetence in one system can lead to varicosities. Varicose veins are considered a chronic disease and, along with valvular incompetence, can progress to chronic venous insufficiency (CVI).

Causes

Primary varicose veins occur because of incompetent venous valves that result in venous hypertension. They occur most commonly at the saphenofemoral junction. Several factors cause increased venous pressure and venous stasis that result in dilation and stretching of the vessel wall. Increased venous pressure results from being erect, which shifts the full weight of the venous column of blood to the legs. Prolonged standing increases venous pressure because leg muscle use is less; therefore, blood return to the heart is decreased. Secondary varicose veins result from deep venous thrombosis and its sequelae or congenital anatomical abnormalities.

Heavy lifting, genetic factors, obesity, thrombophlebitis, pregnancy, trauma, abdominal tumors, congenital or acquired arteriovenous fistulae, and congenital venous malformations are among the causes of varicose veins. Chronic liver diseases such as cirrhosis can cause varicosities in the rectum, abdomen, and esophagus.

Genetic considerations

Genetic transmission of varicose veins has been reported since the 1950s with various modes of transmission suggested. Several loci have been identified through linkage analysis (FOXC2, LIPH), and candidate genes are being further investigated. Disruption of production of the gene coding for vascular endothelial growth factor (VEGF) is one implicated mechanism. Family history accounts for an estimated 50% of the risk of disease.

Gender, ethnic/racial, and life span considerations

About 15% to 20% of all adults in the United States have varicose veins. Prevalence increases with age, peaking in the 50s and 60s and decreasing dramatically after age 70. Varicose veins are more common in women; in the population over age 30, four times as many women as men are affected. There are no known ethnic or racial considerations.

Global health considerations

Varicose veins affect an estimated one in five persons in the world. The prevalence of venous disease and varicose veins is higher in developed than in developing nations, likely due to alterations in lifestyle, nutrition, body mass index, and physical activity.

Assessment

History

Elicit a history of symptoms, paying particular attention to pain and discomfort, changes in appearance of vessels and skin, and complaints of a sensation of fullness of the lower extremities. Ask the patient to describe the amount of time each day spent standing. Take an occupational history with particular attention to those jobs that require long hours of walking or standing. Question the patient about lifetime weight changes, such as changes during pregnancy and sustained periods of being overweight. Ask the patient if there is a personal or family history of heart disease, obesity, or varicose veins.

Physical examination

Superficial veins can be inspected for distension and prominence as well as accompanying symptoms such as ulceration, swelling, blanching, and a sense of fullness of the legs. The number, severity, and type of varicosities determine the symptoms experienced by the individual. With the patient standing, examine the legs from the groin to the foot in good lighting. Inspect the ankles, measure the calves for differences, and assess for edema. Time of examination is a factor because secondary varicosities are more symptomatic earlier in the day. Palpate both legs for dilated, bulbous, or corkscrew vessels. Patients may complain of heaviness, aching, edema, muscle cramps, increased fatigue of lower leg muscles, and itching. Severity of discomfort may be difficult to assess and is unrelated to the size of the varicosity.

Psychosocial

The patient with varicose veins has usually been dealing with a progressively worsening condition. Assess the patient for any problems with body image because of the changed appearance of skin surface that is caused by varicose veins. Question the patient to determine possible lifestyle adjustments to decrease symptoms. The patient may need job counseling or occupational retraining.

Diagnostic highlights

General Comments: Incompetency of the deep and superficial veins can be diagnosed by several tests.

TestNormal ResultAbnormality With ConditionExplanation
Duplex ultrasound (most commonly used diagnostic tool)Normal Doppler venous signal with spontaneous respirations; no evidence of occlusionReversal of blood flow is noted as a result of incompetent valves in varicose veinsDetects moving red blood cells, thus demonstrating venous patency
Trendelenburg’s testVeins fill from below in about 30 sec after the tourniquet is in place and the client stands; no further blood fills the veins from above after the tourniquet is releasedAdditional blood flows into the vein from above, indicating a valve is incompetent and has allowed a backflow of bloodDetects abnormal filling time and incompetent valves; veins normally fill from below; if the vein fills from above, the incompetent valve is allowing blood to flow backward
Venous plethysmography (cuff pressure test)Patent venous system without evidence of thrombosis or occlusionVenous obstructionMeasures the volume of an extremity; rules out a deep vein thrombosis
Magnetic resonance venography and magnetic resonance imagingNormal blood flow without evidence of occlusionReversal of blood flow notedExamines blood flow in extremities
VenographyNo evidence of obstructionAbnormal venous flow seenX-ray study designed to locate thrombi in lower extremities

Other Tests: Contrast venography and color-flow duplex ultrasonography

Primary nursing diagnosis

Diagnosis

Altered tissue perfusion (peripheral) related to increased venous pressure and obstruction

Outcomes

Tissue perfusion: Peripheral

Interventions

Circulatory care; Positioning; Pain management

Planning and implementation

Collaborative

medical.
Treatment for varicose veins is aimed at improving blood flow, reducing injury, and reducing venous pressure. Pharmacologic treatment is not indicated for varicose veins. To give support and promote venous return, physicians recommend wearing elastic stockings. If the varicosities are moderately severe, the physician may recommend antiembolism stockings or elastic bandages or, in severe cases, custom-fitted heavy-weight stockings with graduated pressure. When obesity is a factor, the patient is placed on a weight-loss regimen. Experts also recommend that the patient stop smoking to prevent vasoconstriction of the vessels.

A nonsurgical treatment is the use of sclerotherapy for varicose and spider veins. Sclerotherapy is palliative, not curative, and is often done for cosmetic reasons after surgical intervention. A sclerosing agent, such as sodium tetradecyl sulfate (Sotradecol), hypertonic saline, aethoxysclerol, or hyperosmolar salt-sugar solution, is injected into the vein, followed by a compression bandage for a period of time.

surgical.
A surgical approach to varicose veins is vein ligation (tying off) or stripping (removal) of the incompetent veins. Removal of the vein is performed through multiple short incisions from the ankle to the groin. A compression dressing is applied after surgery and is maintained for 3 to 5 days. Patients are encouraged to walk immediately postoperatively. Elevate the foot of the bed 6 to 9 inches to keep the leg above the heart when the postoperative client is in bed.

Pharmacologic highlights

No medications are generally used to treat varicose veins, except for analgesics following surgery.

Independent

Nursing interventions are aimed at educating the patient to decrease venous stasis, promote venous return, and prevent tissue injury. To prevent vein distention by compression of superficial veins, teach the patient to apply elastic support stockings before standing and to avoid long periods of standing. The patient should be encouraged to engage in an exercise program of walking to strengthen leg muscles. Teach the patient to avoid crossing the legs when sitting and to elevate the legs when sitting or lying down. The patient should be taught to observe the skin when removing stockings to check for signs of irritation, edema, decreased nerve sensation, and discoloration. Preventive measures are similar to those for a patient with thrombophlebitis.

For patients who have had sclerotherapy, teaching should focus on activity restrictions. The patient should learn to avoid heavy lifting. Teach the patient to wait 24 to 48 hours after the procedure before showering and to avoid tub baths. Teach the patient to wear supportive stockings as ordered. Prepare the patient by advising him or her to expect ecchymosis and some scarring, which will fade in several weeks. Caution the patient that some residual brown staining may remain at the injection sites. Inform the patient that the sclerotherapy may need to be repeated in other areas.

Evidence-Based Practice and Health Policy

Karathanos, C., Sfyroeras, G., Drakou, A., Roussas, N., Exarchou, M., Kyriakou, D., & Giannoukas, A.D. (2012). Superficial vein thrombosis in patients with varicose veins: role of thrombophilia factors, age and body mass. European Journal of Vascular and Endovascular Surgery, 43(3), 355–358.

  • In a study among 230 patients with varicose veins, 55.7% experienced a superficial vein thrombosis (SVT).
  • Patients older than 60 were 3.56 times more likely to have experienced SVT than patients younger than 60 (95% CI, 1.9 to 6.68; p < 0.001).
  • Obese patients were 3.3 times more likely to have experienced SVT than patients of normal weight (95% CI, 1.53 to 7.22; p = 0.002).

Documentation guidelines

  • Physical assessment of both extremities: Presence of edema, pain, discoloration
  • Reaction to the medications used for sclerotherapy and pain management
  • Tolerance to activity and exercise

Discharge and home healthcare guidelines

prevention.
To prevent worsening of varicosities, teach the patient to avoid prolonged standing in one place, to avoid sitting with the legs crossed, to elevate the legs frequently during the day, to wear support stockings as ordered, and to drink 2 to 3 L of fluid daily. The patient should wear shoes that fit comfortably and are not too tight.

medications.
Teach the patient the purpose, dosage, route, and side effects of any medications ordered.

complications.
Teach the patient to recognize and observe daily for signs of thrombophlebitis, which include redness, local swelling, warmth, discoloration (not related to surgery area), and back pain on bending. Teach the patient which signs to report to the physician.

postoperative complications.
Teach the patient to report any signs of infection, such as redness at incision sites or injection sites, severe pain, purulent drainage, fever, or swelling.

varicose veins

permanent dilation and tortuosity of leg veins; characteristic of poor venous return and compromised vein valves

varicose veins,

n twisted and enlarged veins; can develop anywhere on the body, but feet and legs are most commonly affected. Although usually a cosmetic defect for some, it can be a source of discomfort and pain. Occasionally may indicate underlying circulatory problem. More prevalent in females than in males.

varicose

of the nature of or pertaining to a varix; unnaturally and permanently distended (said of a vein); variciform.

varicose scrotal tumor
benign vascular proliferation in dogs; resembles cavernous hemangioma.
varicose veins
are uncommonly found in animals except on the scrotum of old bulls, in the dorsal wall of the vagina in mares and on the prepuce in stallions. May also be associated with arteriovenous fistulae.