Varicose Veins in the Legs

Varicose Veins in the Legs – Symptoms and Treatment

Varicose veins, or vein dilation in the legs, represent a primary alteration of superficial veins in the legs, characterized by the appearance of “spots” or “nodules” on the legs. In the International Classification of Diseases, 10th Revision (ICD-10), this condition is coded as “I83” and falls under the category of chronic venous diseases. This category includes:

  • Varicose veins
  • Post-thrombotic syndrome
  • Various vein deformities (vein enlargement)
  • Spider veins” and reticular veins (capillary dilation and expansion)

Varicose veins are prevalent worldwide, with a prevalence rate reaching up to 60% among adult populations depending on the country. It’s worth noting that populations in Africa, Asia, and the Pacific region experience varicose veins less frequently than those in European countries and the United States.

The precise causes of varicose veins remain unclear to date. However, the high prevalence rates suggest a significant role of genetics in its nature. Genetic studies conducted in recent years have revealed mutations in genes responsible for the formation of vein walls and valves. Abnormal function of these genes leads to “weakness” in the vein wall, gradually causing its dilation and increased diameter. This process is accompanied by valve failure, resulting in the backward flow of blood in the veins (reflux) under the influence of gravity. Year after year, the veins descend lower, “eating away” at new veins, leading to the formation of varicose veins (from the Latin “varix” – swelling or nodule), hence the name of the disease – varicose veins.

Symptoms of Varicose Veins in the Legs:
In most cases, varicose veins can be identified even without specialized medical examination. The clear and objective sign of the disease is the appearance of “spots” or “nodules” on the legs, where the skin covering them does not differ from any natural color. The bluish veins are often not considered a disease per se, although they frequently cause aesthetic discomfort, especially among women.

However, in advanced cases, vein dilation may be accompanied by a change in skin color due to venous inflammation, which manifests as various skin eruptions (blisters, nodules) and redness. These signs, along with persistent leg swelling during nighttime rest, indicate the development of chronic venous insufficiency.

Regarding the personal symptoms of varicose veins, their nonspecific nature should be noted. Complaints may indicate the disease or may be a sign of increased pressure on the leg venous system. Patients often experience heaviness, swelling, and diffuse pain in the legs. Sometimes complaints arise regarding pain in the area of the dilated vein and leg fatigue.

Although these symptoms may vary greatly among patients, some characteristics should be considered. Exacerbation of symptoms typically occurs during periods of inactivity, such as prolonged sitting or standing, as well as at the end of the day. During physical activity, especially while walking, complaints decrease. Resting in a lying position or wearing compression garments can also provide relief. Personal symptom severity often appears periodically: vessel symptoms are more pronounced in summer or during the menstrual period for women.

Classification and Stages of Varicose Veins in the Legs:

The International Classification of Chronic Venous Diseases (CEAP), which includes varicose veins, was adopted in 2003. Previously, in our country, a staging classification was used, with stages I, II, and III indicating the worsening of the condition. It is important to note that the stage represents a non-reversible stage in the progression of the disease process. With the emergence of modern approaches in the treatment of chronic venous diseases, there has been a gradual transition away from such classification toward a classification that considers clinical characteristics, etiology, anatomy, and disease pathways.

Currently, vascular specialists do not discuss stages of vein dilation in the legs, although in some cases, the national health reality necessitates a return to the old classification. The internationally recognized classification is the CEAP classification (an abbreviation for four words: C — clinic, E — etiology, A — anatomy, P — pathogenesis).

Its main component is the clinical category (the letter “C”), which describes the most common sign of chronic venous diseases:

  • Category 0 (C0): No signs of the disease.
  • Category 1 (C1): Presence of telangiectasia and reticular veins (“spider veins” and “star marks”).
  • Category 2 (C2): Characterized by dilated subcutaneous veins resembling varicose veins.
  • Category 3 (C3): Venous insufficiency begins, first detected through leg swelling.
  • Category 4 (C4): Trophic skin changes appear: C4a — hyperpigmentation and/or vein inflammation; C4b — lipodermatosclerosis.
  • Category 5 (C5): Healing venous ulcers.
  • Category 6 (C6): Open venous ulcers.

Complications of Varicose Veins in the Legs:

Trophic Disorders:

  • Due to disease progression without treatment, trophic disorders develop, and this process continues over years and decades.
  • These disorders begin with signs on the skin such as increased pigmentation (brown spots), vein inflammation, and lipodermatosclerosis (skin hardening).
  • The primary area for these changes is the leg, although vein inflammation can be seen in any area containing varicose veins, including the thigh.
  • As a result of the different nutritional supply to soft tissues, venous ulcers form at the site of previous changes.
Venous ulcer

Vein Inflammation (Thrombophlebitis):

  • Superficial vein inflammation should not be confused with deep vein thrombosis, as the latter is more severe.
  • When thrombosis affects the dilated veins, a painful thrombus forms, characterized by redness and local temperature elevation, and in some cases, thrombosis restricts limb movement.
  • The clinical presentation resembles that of venous ulcer or a larger perforation.

Bleeding from Dilated Veins:

  • Bleeding from dilated veins appears frightening due to increased vein pressure, where the blood force is strong enough.
  • In rare cases, this may lead to significant blood loss.

Diagnosis of Varicose Veins in the Legs:

Diagnosing vein dilation in the legs usually does not pose particular difficulties. The main feature of the disease is the presence of “clusters” or “nodules” in the veins. Although they may be difficult to see if there is excessive development of fatty tissue under the skin in the legs.

To further confirm the diagnosis, various diagnostic methods are used, with duplex ultrasonography being the most commonly used. This examination can help quickly, accurately, and safely identify the source of vein dilation, as well as assess vessel size, structure, valve function, reflux range, and detect the presence of clots. Both deep and superficial veins are examined simultaneously. The examination is performed in a standing position or, if the patient’s condition does not allow, in a sitting position with the feet dropped downward. Conducting the examination while standing is preferred to avoid errors in estimating blood reflux and clots.

Complementary tests are used to assess valve function and blood reflux, including:

  • Compression bandage test with pressure on various parts of the legs.
  • Valsalva test (strain test).
  • Walking simulation.
  • Parana test – a mild attempt to unbalance the patient to stimulate leg muscle tension.
  • The examination results should be documented linearly and with the formation of a “vein map.” The examination results are highly useful in planning subsequent treatment. However, these results should only be considered if they come with clinical data, as a change in appearance without clear symptoms (varicose veins) was associated with functions (i.e., unrelated to venous diseases). It should also be noted that ultrasound examination may not be necessary if the diagnosis is clear and if the patient does not plan to undergo surgical treatment for varicose veins.

There are also additional diagnostic methods:

  • Doppler ultrasound examination (do not confuse with duplex).
  • Thermography.
  • Phlebography.
  • Crystal vein imaging (phlebography).
  • Radiographic imaging (radiographic phlebography).
  • Computed tomography (CT) imaging.
  • Magnetic resonance imaging (MRI).
  • Thermography.
  • Intravascular ultrasound (IVUS) search – a new method.

Treatment of Varicose Veins:

The goal of treating vein dilation in the legs is to remove all veins that are functioning improperly. This can only be achieved through targeted surgical intervention, which distinguishes between three approaches:

  1. Stripping – excision of the common vein, short stripping, small vein excision, and perforator vein dissection.
  2. “Gluing” – sclerosis, mechanical closure, cyanoacrylate closure.
  3. “Sealing” – laser closure or radiofrequency closure of the veins.

The treatment goal is achieved by fulfilling two tasks: removing the source of vein dilation (known as the vertical reflex) and removing the dilated veins. For a long time, combined phlebectomy was the most commonly used method. It includes two stages:

  1. Ligation of the branching source – the location where the large superficial vein connects to the comprehensive thigh vein (also known as the “reticulation cut” or the Trivano-Trendelenburg procedure).
  2. Removal of the superficial vein by a pen.

This operation is characterized by radical intervention and carries several inherent drawbacks shared with any surgical procedure, such as the frequent need for anesthesia, tearing and invasions, tangible recovery period, and increased risk of disability compared to other methods.

Revolution in Venous Science:

However, about twenty years ago, there was a “revolution in venous science.” This was thanks to the expanded use of comprehensive ultrasound scanning and the emergence of advanced techniques such as endothermal ablation. The significance of this technique lies in the effect of high temperatures on the vein wall from the inside, which can be achieved through laser radiation (EVLO) or radiofrequency effect (RF) that “seals” the vein lumen.

The vein in this context immediately ceases to function, after which it is gradually absorbed. This method allows for the rapid removal of the vertical reflex without tearing, effectively, safely, and aesthetically without the need for sustained recovery. As a prominent method in “office surgery,” endothermal ablation is considered one of the most effective ways to treat venous disease worldwide.

Additionally, sclerosing (fixing the affected vein with a special substance) has found wide usage in removing dilated veins. However, achieving the desired results requires careful patient selection due to the increased risk of disease recurrence.

Traditional treatment methods include preventive measures, including compression therapy, vein-enhancing medications, and local formulations (gel, ointments), but they are primarily supportive, focusing on alleviating symptoms of vein dilation without removing its source.

Sources and references:
  1. Ilyukhin, E. A. Varicose, Thrombosis, Lymphostasis, and Other Diseases of Veins That Can and Should Be Treated. Moscow: EKSMO, 2019. 256 p.
  2. Vasiliev, A. Yu., Postnova, N. A., Dibirov, M. D., Shimanko, A. I. Handbook of Ultrasonic Phlebology. Moscow: MIA, 2007. 80 p.
  3. Clinical Phlebology. Ed. by Yu. L. Shevchenko, Yu. M. Stoyko. Moscow: DPK Press, 2016. 256 p.
  4. Saveliev, V. S., Kirienko, A. I., Zolotukhin, I. A., Seliverstov, S. E. Prospective Observational Study SPECTR: Registry of Patients with Chronic Diseases of the Veins of the Lower Extremities. Phlebology. 2012; (1): 4-9.
  5. Vascular Surgery. National Guide. Short edition. Ed. by V. S. Saveliev, A. I. Kirienko. Moscow: GEOTAR-Media, 2014. 464 p.