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Varicose veins of the lower limbs

Post-pregnancy varicose veins on the leg. Female.

Introduction

Varicose veins of the lower limbscommonly known as varicose veins of the legs, is the most common and also the most spectacular symptom of venous insufficiency of the lower limbs. It is important to remember that varicose veins are only a symptom of a disease and not a disease in themselves. They affect both women and men. For women, the percentage of ladies with varicose veins is about three times higher than for women. The problem increases with age and women are more likely to develop varicose veins than men. Varicose veins are not just an aesthetic defect - they are a symptom of a chronic venous insufficiency (CVF), a serious condition that can lead to a number of skin and vascular complications.

Symptoms of venous insufficiency include a feeling of heaviness in the legs, pain, swelling, as well as calf cramps, itchy skin and even restless legs syndrome. In advanced cases, vascular spider veins, discolouration and even hard-to-heal ulcers appear on the skin. It is important not to underestimate the first symptoms and to consult a phlebologist for a diagnosis and appropriate treatment.

Description of the condition

Varicose veins of the lower limbs are dilated and twisted veins that become visible beneath the surface of the skin. Their formation is related to the abnormal function of the venous valveswhich, in healthy veins, prevent blood backflow. As a result of damage or weakness valves, blood starts to pool in the veins, causing them to dilate and constrict. This mechanism is driven by the excess pressure prevailing in the venous vascular bed. Varicose veins are classified into CEAP scale as clinical class C2. Untreated venous insufficiency gradually progresses, and varicose veins may enlarge and appear in more places. It is therefore important to start treatment early to help stop the progression of the disease and prevent complications.

In order to make a diagnosis, it is necessary to examine Doppler ultrasound of the venous system. This examination, performed by an experienced ultrasonographer, allows an accurate assessment of blood flow in the veins and the identification of abnormalities in the structure and function of the valves. In the Phlebology Clinic, a comprehensive Doppler examination is performed as required, including an assessment of the veins of the lower limbs, small pelvis and abdominal cavity with evaluation of the pelvic floor and perineum. This allows the causes and severity of venous insufficiency to be accurately determined, which is key to choosing an effective treatment method.

Chronic venous insufficiency. What does class C2 mean?

Modern phlebology, which deals with the diagnosis and treatment of diseases of the venous system, uses a structured classification of chronic venous disease. Its aim is to accurately determine the severity of the disease and to assess the risk of complications, such as irreversible changes in the structure and function of the venous vessels, which can lead to chronic venous stasis, venous ulcers and other complications.

The most popular and widely used classification is CEAP (Clinical, Etiology, Anatomy, Pathophysiology). It was developed to standardise nomenclature and facilitate communication between doctors from different centres.

CEAP classification consists of 4 main categories:

  • C - Clinical class: describes symptoms and changes visible on the skin, such as vascular spider veins, varicose veins, oedema or venous ulcers of the shin;
  • E - Etiology: identifies the cause of venous insufficiency, e.g. primary valvular insufficiency, thrombosis, post-thrombotic syndrome;
  • A - Anatomy: indicates which veins are affected, e.g. the saphenous vein, the saphenous vein or the perforating veins (commonly known as perforators);
  • P - Pathophysiology: describes the mechanisms of the disease, e.g. venous reflux, venous obstruction.
Patient with lower limb venous insufficiency (recurrent varicose veins, trophic changes, healed shin ulceration.

Thanks to CEAP classification we are able to create a picture of the venous disease, which allows us to choose the optimal treatment method. Depending on the severity of the disease and its causes, the doctor may suggest conservative treatment (e.g. compression therapy), minimally invasive treatment (e.g. sclerotherapy) or surgical treatment. It is worth noting that a simplified version of the CEAP classification, focusing on category C (clinical grade), is often used in clinical practice. The full version of the CEAP classification is used primarily in research studies. Thus, for example, CEAP grade C2 indicates visible varicose veins on the legs. Simply put, these are those dilated, twisted veins that the patient can see with the naked eye under the skin on the legs. According to the current 2020 CEAP classification, varicose veins (C2) are dilated and insufflated veins ≥ 3 mm in diameter (the diameter of the venous vessel should be measured by ultrasound in the standing position).

Risk factors for varicose veins

  • genetic predispositione - family history of varicose veins; congenital weakness of vessel walls, congenital anomalies of the venous system.
  • female gender - women are more likely to develop varicose veins, especially over the age of 35.
  • number of pregnancies and births in women - hormonal changes and the increasing prevalence of pelvic venous insufficiency appear to have the greatest impact on the occurrence of extensive varicose veins.
  • age and gender - female gender is a significant risk factor - the number of pregnancies and births is the most statistically significant in generating pelvic varicose veins and leg varicose veins; venous disease is up to four times more common in women; further factors are age over 35 and entering the menopausal period.
  • lifestyle - prolonged standing or sitting, lack of regular physical activity, intense strength training such as crossfit, deadlifts or barbell squats.
  • hormone replacement therapy and oral contraception - may increase the risk of vascular problems, including the incidence of varicose veins.
  • obesity - excessive body weight resulting in changes in the thickness and stiffness of the subcutaneous tissue lead to expansion and failure of the subcutaneous circulation.
Strength exercises such as crossfit or deadlifts are one of the more common causes of venous insufficiency.
Crossfit, deadlifts or barbell squats are currently the most common strength activities leading to pelvic venous insufficiency and secondarily varicose veins on the legs.

Mechanism of varicose vein formation

Varicose veins are dilated venous vessels with a tortuous course that are not always visible under the skin. The main feature of varicose veins is the abnormal flow of blood - it flows in the opposite direction than it should. Blood in a varicose vein can additionally become trapped and backed up, leading to an increased risk of venous thrombosis. It is estimated that the risk of venous thrombosis in patients with varicose veins is up to five times higher.

Varicose veins arise as a mechanism of local disorders (e.g. post-inflammatory or post-exertional stretching of part of the venous bed) or, more commonly, as a result of systemic and generalised causes, such as congenital anatomical abnormalities, pregnancies or inappropriate lifestyle habits. Varicose veins are not a disease in themselves, but the most common symptom of venous insufficiency. They are a form of natural adaptive mechanism that relieves the increased pressure in the veins. If you want to know the most common myths about the formation and treatment of varicose veins, be sure to watch our video.

Varicose veins on the legs - what do you need to know about them?

Types of lower limb varicose veins

In everyday practice, phlebologists use certain terms to classify types of varicose veins and facilitate mutual communication. At the Phlebology Clinic, we use our own proprietary divisions that make it easier for patients to understand phlebology.

We distinguish the following types of venous dilatation:

1. Reticular (reticular) varices: Venous dilatations originating from reticular veins (small green subcutaneous vessels) are usually 1 to 3 mm in diameter. They are most common in the popliteal fossa and on the lateral surfaces of the thighs and lower legs. These types of vessels give rise to various types of vascular spider veins. Among the most common are spider veins from excessive inflow, particularly prominent in ladies during pregnancy.

2. Varicose veins of the main venous trunks: are derived from insufficiency of the main venous trunks, such as the saphenous, saphenous, accessory anterior or posterior saphenous veins. By definition, their diameter exceeds 3 mm. The assessment should always be made by ultrasound in the patient in a standing position. This type of lesion always arises where the strength of the inferior segment of the vascular trunk is greater (it has more robust venous valves) than that of the branch flowing down to the insufflated part of the main venous trunk. Varicose veins of the main venous trunks become very tortuous over time and quite significantly interfere with the aesthetics of the leg. Within them, thrombophlebitis is quite common.

3. Varicose veins of accessory trunks and venous branches: this group includes varicose veins developing in the so-called vessels connecting the main venous trunks or within the venous branches forming the so-called atypical varicose veins. The phenomenon of insufficiency transfer from the pelvic venous vessels and the so-called local venous creep phenomenon are very often responsible for the formation of this type of varicose veins. Finding the cause of the occurrence of this type of varicose veins always causes the greatest difficulty for vein doctors. This is why a comprehensive evaluation of the abdominal, pelvic, pelvic floor and lower limb venous system is so important.

4. Varicose veins in locations other than the lower limbs: venous dilatations forming within the organ and cutaneous venous branches can of course occur in other locations. The identification of the name 'varicose vein' with the legs comes from the fact that this is an area that is easy for the patient to assess. Varicose veins are equally common (and usually precede those of the extremities) in the small pelvic veins, perineum, vulva or scrotal sac. For more on this topic, see: pelvic venous insufficiency in women and pelvic venous insufficiency in men.

5. Varicose vein-like lesions: Within this group we distinguish venous dilatations that originate from dysplastic veins, and are therefore most often a component of a venous malformation and occur superficially enough under the skin to be visible. They should not be equated with typical varicose veins, as they have a slightly different vascular wall structure and background. A typical example is the so-called 'varicose vein'. marginal vein (marginal vein) in Klippel-Trenaunay syndrome, running along the lateral aspect of the lower limb up to the level of the hip or buttock. For more on this topic, see VENOUS MALFORMATIONS.

Recognition and diagnosis of venous disease

The modern diagnosis of venous disease and accompanying symptoms such as spider veins, dilated reticular veins ("reticular varicose veins"), extremity varicose veins, venous oedema or venous ulcers of the shin, is based on taking a medical history (including pregnancy history in women giving birth), a physical examination and a thorough clinical assessment by a doctor of phlebology. In the initial assessment, the most important is always the ultrasound evaluation in the overall Doppler ultrasound examination of the veins and good mapping of venous dilatations, determining their distribution and mechanisms of formation. Once the cause of venous insufficiency has been treated, the phlebologist (in addition to an ultrasound assessment of the venous capacity of the abdominal, pelvic and lower limb veins) should always assess the overall distribution of varicose and spider veins on the legs before planning treatment for leg veins.

Treatment methods for varicose veins of the lower limbs

Contemporary phlebology has a wide range of treatments for venous insufficiency of the lower limbs, including varicose veins of the lower limbs. Any Patient wishing to cure venous disease should start by reducing risk factors and changing lifestyle habits. The key to success, however, is the Patient's active participation in the treatment process. Anyone struggling with venous disease should first focus on lifestyle modification and elimination of risk factors.

What is worth changing when embarking on the battle against varicose veins?

Physical activity:

  • introduce regular, moderate exercise;
  • choose activities that are friendly to your veins; these include swimming, Nordic walking or cycling;
  • avoid prolonged standing and sitting;
  • avoiding strength sports such as crossfit or deadlifts;
  • while working, it's a good idea to take breaks for short walks or to stretch!

Weight control:

  • aiming to maintain a healthy body weight;
  • eating a balanced diet rich in fibre (avoiding constipation);

Fashion style modification:

  • limiting tight clothing that compresses the legs and lower abdomen;
  • use of comfortable and flat footwear;
  • use of travel, sports and medical compression therapy as recommended;

Changing daily habits:

  • avoiding hot baths, saunas and solariums;
  • avoiding putting one's leg over the other;
  • Rest with legs raised.

In situations where lifestyle changes alone do not alleviate symptoms, the following can help compression therapy, or compression treatment. It is the simplest and most effective form of conservative treatment and prevention of venous disease. Socks, stockings or compression tights, professionally selected and individually tailored to the patient's legs, bring significant relief by supporting the muscle and joint pump, deep and superficial veins in our legs.

As an adjunct to the treatment of venous disease, the following are also used phlebotropic drugs (veno-active), which, however, are only an adjunct to compression therapy and treatment. Veno-active preparations administered orally (e.g. diosmin, hesperidin, rutoside, escin or rhuscus spinosus extract), although they have the potential to increase the tension of the venous wall, improve lymph drainage, reduce capillary permeability or reduce inflammation, are unable to affect the patient's anatomy and the most common causes of venous insufficiency.

Varicose veins of the lower limbs - treatment methods used.

In cases where venous insufficiency has already occurred and varicose veins have formed on the legs, more advanced, surgical treatment is needed. It is important that the treatment is as causal as possible, taking place after a thorough diagnosis of the problem, according to the principles of haemodynamics (blood circulation). We should remember that the treatment of varicose veins, the most common symptom of venous insufficiency, cannot be limited to just closing or removing them. Such a strategy always leads to a recurrence of venous disease.

The following are among the products we use treatments for varicose veins on their feet belong:

  • non-thermal methods (chemical) treatments such as microsclerotherapy, sclerotherapy or mechano-chemical obliteration (Flebogrif system) and vein bonding using tissue adhesives administered intravascularly (VenaSeal, VariClose, VenaBlock, VeinOff);
  • thermal methods - among which the most effective techniques are laser venous ablation with birefringent fibres using 1470 nm laser light (1940 nm gives comparable results; however, recanalisation of veins after their use is slightly more frequent); slightly less effective are thermal ablation methods using radiofrequency (EVRF) or, rarely used due to the high risk of complications, steam (SVS);
  • minimally invasive treatments and operations surgical (microflebectomy, miniflebectomy, surgery to remove the venous trunk - now going out of use);
  • hybrid approach, involving the combination of several methods at the same time.

Each method has its own specific indications, and the choice of the appropriate surgical technique should be made by an experienced phlebologist on the basis of a thorough Doppler ultrasound examination and the extended diagnostics performed, such as MR venography or CT venography.

Treatment methods for recurrent varicose veins

The treatment of venous insufficiency of the lower limbs, including its most common symptom - limb varicose veins - should take into account all possible causes of venous disease, i.e. pathologies of the pelvic and abdominal venous system and effects resulting from vascular insufficiency in the legs. The modern approach to treatment is based on the most minimally invasive management possible using endovascular techniques.

Despite the knowledge we have had for many years, the treatment of venous disease is still a challenge for us. There are patients who, despite a full initial and pre-surgical diagnosis and causal treatment, return several years later with a recurrence of venous disease and recurrent varicose veins. Although the results of today's treatment (recurrence rate of more than 5 years at 10-12%) differ significantly from what patients faced many years ago (recurrence rate of more than 50%), we are still looking for better and more effective therapeutic methods by optimising both the treatment strategy and individual treatment techniques.

Contemporary treatment of recurrent varicose veins.

Can varicose veins on the legs return after previous treatment? Unfortunately, yes. But we have effective ways to deal with it! Discover modern treatments for recurrent varicose veins.

Mostly
questions asked

  • Although we cannot completely exclude the development of varicose veins (especially when there is a genetic predisposition and certain anatomical disadvantages), we can significantly reduce the risk of their development and the severity of venous disease by:

    Regular application compression therapy, including sport, in particular:

    • during long journeys (more than 4-6 hours in a plane)
    • during physical activity
    • when working standing or sitting

    Modification lifestyles:

    • avoidance of prolonged standing or sitting
    • regular, moderate physical activity
    • maintaining a healthy body weight
    • avoiding too intensive strength training

    Appropriate selection sports activities:

    • preference for walking, swimming, cycling
    • limiting sports that increase intra-abdominal pressure (crossfit, deadlifts or barbell squats).

  • Yes, varicose veins in the lower limbs significantly increase the risk of developing deep vein thrombosis (DVT). In healthy veins, the blood flows smoothly; in varicose veins, there is constant venous stasis and slowed blood flow. It is in areas of venous stasis that blood clots most easily form. This is why it is so important to have regular phlebological checks with Doppler ultrasound assessment of the veins of the lower limbs, and to wear compression devices in situations of increased risk of thrombosis (long flights, car rides, immobilisation of the limb or periods of pregnancy and childbirth). Appropriate thromboprophylaxis before planned operations should also be remembered.

  • Definitely not. Varicose veins are a symptom of venous insufficiency, which is a serious circulatory condition that leads to numerous health complications over time. In dilated and uncooperative veins, blood flows abnormally and can stop, increasing the risk of thrombotic complications. In addition, untreated varicose veins can lead to swelling, skin lesions and, in advanced cases, even venous ulcers of the shin. This is why it is important to treat them as a medical problem requiring diagnosis and appropriate treatment. It is worth having a phlebologist you trust!

  • Varicose pearls are small - bubbly or beaded - venous dilatations visible just under the thinning skin. They are often seen in Patients with long-standing varicose veins, following a history of thrombophlebitis. Quite often they cause distress in Patients due to the increased risk of bleeding. Even a minor trauma can lead to damage to the wall of the affected vessel, causing quite profuse bleeding from the varicose vein.

  • Atypical varices on the lower limbs arise in the flow of veins other than those originating from the main vascular trunk system, such as the saphenous vein or the saphenous vein.

    For men, there is a high correlation between venous compression syndromes, varicose veins of the scrotal sacand atypical varicose veins of the lower limbs. This problem often already affects young men with varicose veins of the spermatic cord. In the Department of Phlebology, this topic is dealt with by a team of interventional radiologists and phlebologists.
    In the female population, by far the most common source of atypical varicose veins on the legs is venous leakage from the pelvic area, as a consequence of secondary compression syndromes, ovarian vein insufficiency or insufficiency of one of the tributaries of the internal iliac veins.

    Atypical varicose veins in men and women are diagnosed at the Phlebology Clinic using all methods depending on clinical needs. Our doctors perform specialised diagnostic imaging using Doppler ultrasound (with assessment of the veins of the lower limbs, the veins of the small pelvis, abdominal cavity, perineal area and scrotal sac), and using CT or MR venography, as well as modern digital phlebography techniques.

  • Recurrent varicose veins is, by definition, a reoccurrence of varicose vein disease in a patient who has previously undergone surgery or an intravenous procedure. The occurrence of recurrent varicose veins is most often due to improperly performed Doppler ultrasound of the veins in a patient qualified for the first treatment.

    A poorly performed Doppler examination often leads to the selection of an inappropriate treatment method, as well as to an incorrectly performed procedure to eliminate the venous reflux and varicose veins.

    From our daily practice, the most common causes of recurrent varicose veins include:

    • inadequately defined venous anatomy on initial Doppler ultrasound examination
    • incorrect choice of treatment method (so-called non-causal treatment)
    • poorly performed procedure due to "difficult" venous anatomy
    • incorrect identification of the source(s) of reflux, in particular failure to take into account reflux from the pelvis (known as 'pelvic reflux'). pelvic venous insufficiency)
    • failure to recognise post-thrombotic syndrome

  • The sciatic nerve vein is an atrophic venous vessel surviving from fetal life. It runs parallel to the sciatic nerve in its canal along the posterior surface of the thigh. Usually, the sciatic nerve vein joins the inferior gluteal vein, but this is not the 100% course. Varicose veins of the persistent sciatic nerve vein are most common in patients with complex venous malformations and in women who have given birth more than 2-3 times. Excessive dilatation of this vein, stasis forming in it and sometimes inflammation, can cause symptoms similar to those resulting from a typical attack of so-called sciatica.

  • Venous insufficiency of the lower limbs combined with the presence of typical varicose veins on the legs (C2 according to CEAP) is characterised by a wide spectrum of symptoms.
    The most common limbic symptoms include:
    - discomfort in the shin area
    - a feeling of heaviness and tension in the muscles of the lower limbs, particularly after prolonged standing or sitting, disappearing after rest, especially in an elevated position
    - troublesome calf cramps (especially at night)
    - itching of the skin
    - "restless legs syndrome"
    - pain along the dilated vein.

Related issues

Laser varicose vein removal with the ELVeS 1470 system. phlebology clinic

Modern vein treatment

We offer treatment both on an outpatient basis and in day ward admissions. The stay is of short duration. The patient spends between 1 and 5 hours in the Clinic.

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