Tuesday, October 30, 2007

Spider Veins

Just in time for Halloween--those "scary-looking" spider veins. (photo credit)

It is estimated that up to 50% of women by age 50 will have telangiectatic (spider veins) leg veins. It has been estimated that 10-20% of adults in the United States and Western Europe have varicose veins. The difference between varicose and spider veins is one of size. The tortuous veins greater than 4-5 mm in diameter are referred to as varicose. The veins between 1-4 mm in diameter are referred to as reticular, and the veins less than 1 mm in diameter are referred to as telangiectatia (spider veins). All three are the visible surface manifestations of an underlying venous insufficiency syndrome. Venous insufficiency syndromes allow venous blood to escape from a normal flow path and flow in a retrograde direction into an already congested leg.

"The most common scenario-- a single venous valve fails and creates a high-pressure leak between the deep and superficial systems. High pressure within the superficial system causes local dilatation, which leads to sequential failure (through over-stretching) of other nearby valves in the superficial veins. After a series of valves have failed, the involved veins are no longer capable of directing blood upward and inward. Without functioning valves, venous blood flows in the direction of the pressure gradient: outward and downward into an already congested leg. As increasing numbers of valves fail under the strain, high pressure is communicated into a widening network of dilated superficial veins in a recruitment phenomenon. Over time, large numbers of incompetent superficial veins acquire the typical dilated and tortuous appearance of varicosities. " (photo credit)

Common predisposing factors

  • Family history
  • Standing for long periods of time
  • Pregnancy
  • Age

History

    • Common symptoms that should be elicited include leg heaviness, exercise intolerance, pain or tenderness along the course of a vein, pruritus, burning sensations, restless legs, night cramps, edema, skin changes, and paresthesias.
    • Common symptoms of telangiectasia include burning, swelling, throbbing, cramping, and leg fatigue. Pain associated with larger varicose veins usually is a dull ache that is worse after prolonged standing
        • Pain caused by venous insufficiency is often improved by walking or by elevating the legs in contrast to the pain of arterial insufficiency, which is worse with ambulation and elevation.

Physical:

Veins and their connections become gradually better defined through inspection, palpation, percussion, and hand-held Doppler examination to form a venous map that later guides treatment. The courses of all the dilated veins that are identified may be marked along the leg with a pen and later transcribed into the medical record as a map of all known areas of superficial reflux.

  • The Perthes maneuver is a traditional technique intended to distinguish antegrade flow from retrograde flow in superficial varices. Antegrade flow in a variceal system indicates that the system is a bypass pathway around deep venous obstruction. This is critically important because, if deep veins are not patent, superficial varices are an important pathway for venous return and must not be sclerosed or surgically removed.
  • The Trendelenburg test can often be used to distinguish patients with superficial venous reflux from those with incompetent deep venous valves.
  • Doppler examination is an adjunct to the physical examination that can directly show whether flow in a suspect vein is antegrade, retrograde, or to-and-fro.

TREATMENT

SCLEROTHERAPY
Sclerotherapy is the introduction of a foreign substance into the lumen of the vein to cause thrombosis and subsequent fibrosis.

Chemical Irritants produce direct destruction of the endothelial cells.

  • Glycerin--for use in veins less than 1 mm in diameter
  • Polyiodinated Iodine

Hypertonic solutions produce dehydration of endothelial cells through osmosis, resulting in endothelial destruction.

  • Hypertonic-saline 11.7% --for use in veins less than 1 mm in diameter
  • Hypertonic-glucose

Detergent sclerosants produce endothelial damage through interference with the cell's surface lipids.

  • Sodium morrhuate
  • Sodium tetradecyl sulfate, 0.25% used in veins less than 1 mm in diameter; 0.25-0.5% used in 1-4 mm veins; and 1-3% used in veins 4-10 mm in diameter
  • Ethanolamine oleate
  • Polidocanol foam, 0.5 % used in veins less than 1 mm; 0.5-1% used in veins 1-4 mm; and 2-5% used in veins 4-10 mm in diameter

Postsclerosis compression is important for multiple reasons, one of which is to support the untreated vessels while the sclerosed vessels heal/scar. (photo credit)

MINIPHLEBECTOMY
Miniphlebectomy or ambulatory phlebectomy allows removal of short segments of varicose and reticular veins through tiny incisions using special hooks developed for the purpose. This procedure is extremely useful for the treatment of residual clusters after saphenectomy and for removal of nontruncal tributaries when the saphenous vein is competent.

TRANSCULTANEOUS LASER AND INTERMITTANT PULSED LIGHT (IPL) have proven effective for the tiniest surface vessels (eg, those found on the face), but this modality is not generally useful as primary therapy for treatment of spider veins of the lower extremity. For most patients, the laser pulses are significantly more painful than the 30-gauge needles used for microsclerotherapy. Most spider veins of the legs have associated feeding vessels that must be treated by some other means before the tiny surface vessels are amenable to laser or IPL treatment.

LASE (Laser assisted Saphenous Endoablation)
The procedure was pioneered in 1999 by Dr. Robert Min and Dr. Luis Navarro in conjunction with Diomed. The technique continues to be refined and enhanced today reflecting Diomed’s ongoing commitment to the science and practice of vein management. EVLT® is a minimally invasive, clinically proven alternative to surgical vein stripping that effectively and safely treats varicose veins using a diode laser fiber to occlude the vein. (photo credit)

LIGATION
Some problems, such as large varicose veins, may call for ligation, a procedure in which the connections between the damaged veins and the normal vein systems are interrupted. Saphenectomy with saphenofemoral ligation is a traditional approach that is most often performed using an internal stripping tool and an invagination technique.

Complications:

  • Complications of varicose disease include venous ulcers, variceal bleeding, and venous thromboembolism.
  • Potential complications of treatment include anaphylaxis, changes of pigmentation, ulcerations, paresthesias, arterial injury, and venous thromboembolism.

PREVENTION --Activity is a strong protective factor against venous stasis. So I would encourage all of you to move--walk, dance, fidget. Be active.

  • Pregnant patients and those with a strong family history of varicose disease may prevent, delay, or ameliorate the problem by wearing 30-40 mm Hg gradient compression hose whenever standing.
  • Constant use of compression hose can prevent the worsening of existing varicose disease that cannot be treated immediately

References

Varicose Veins and Spider Veins--Women's Health.gov

Varicose Veins and Spider Veins by Craig Feied, MD--eMedicine Article

No More "Spider Veins" by Michel P Goldman, MD--Plastic Surgery Products Newsletter, October 2007

Varicose Veins--Mayo Clinic

Spider Veins (Sclerotherapy),Diminishing Unsightly 'Spider Veins'--American Society of Plastic Surgeons

Minimally Invasive Venous Intervention Procedure (OR-Live)--Morristown Memorial Hospital (requires media player, 1 hour program)

Treatment of Varicose Veins through Laser Surgery (OR-Live)--Nebraska Medical Center (requires media player, 1 hour program)

Site with good before and after photos--Veintec Varicose Vein Clinic

1 comment:

make mine trauma said...

Nice post. I am going to forward this to my sister. She has horrible tortuous varicose veins. I keep offering to help pay for treatment but she keeps refusing. Perhaps the before and after photos will give her the incentive she needs.