Chronic Venous Insufficiency / Varicose Veins of Lower Limbs
International studies indicate that about 20 to 33% of women and 10 to 20% of men will present some degree of the disease throughout their life. Because it is a chronic and evolutionary disease, about 3 to 11% of people with varicose veins can reach more advanced stages of the disease where irreversible changes occur in the skin of the affected region. Such changes range from darkening, peeling and dryness of the skin, usually accompanied by worsening of symptoms such as pain, burning and swelling, and it may be the opening of wounds in the legs that can take years to heal. At the other extreme we have the small dermal vessels called telangectasias (or simply vases) that have a primarily aesthetic appeal, at least at the beginning, but over time may generate some symptoms such as local pain and discomfort.
What causes the disease?
Although there are several theories about it, and the subject is thoroughly studied, there is still no consensus on the exact origin of varicose veins. On the other hand, we know that there are some risk factors for development and worsening of the disease that can be easily identified. Some of these factors are modifiable and some are not. Among the most common are:
Family tendency: a history of close relatives such as grandparents, parents and siblings with varicose veins indicates a greater risk of presenting the problem. There is thus a clear genetic and hereditary correlation so that, in at least 70% of cases, we find this correlation quite easily.
Obesity: Excessive weight overloads the venous system, particularly the legs, facilitating the appearance of venous dilatation.
Sedentarism: Muscle movement, particularly the calf (leg potato), is an important mechanism that assists in the circulation of the legs. Lack of exercise worsens this circulation and increases the chance of venous problems.
Multiple pregnancies: each pregnancy leads to hormonal changes and return of leg blood, either by the increase in weight inherent to gestation or by uterine enlargement. In pregnant women, this leads to a higher occurrence of varicose veins. (Table 1). An interesting fact. Although an increase in veins almost always occurs during the gestational period, it is common for a large proportion of these varicose veins to decrease spontaneously, without any procedure, in the weeks following delivery.
Table 1: Number of pregnancies and prevalence of varicose disease.Contraceptive use: It is believed that the hormones present in most contraceptives, in particular oral ones, have as a side effect a weakening of the venous wall thus allowing their dilatation. This trend does not appear to be uniform among women, with some being more susceptible than others.
Standing work: professions that impose long standing journeys are related to a higher incidence of varicose veins.
Gender: Women have a greater chance of developing varicose veins, even though they have higher exposure to other risk factors.
Age: Although we may identify very early venous changes in certain patients who already have a genetic predisposition, as other risk factors add up, particularly over the years, it is in the most advanced ages that we witness the highest incidence of IVC.
Smoking: the role of the cigarette is not established at the origin of the IVC. However, its serious implications for the circulatory system are publicly known and, at a minimum, its use implies a greater risk for practically any treatment that may be proposed.
Wearing high-heeled shoes: The very high-heeled shoe decreases the mobility of the hind leg muscle known as the calf (popularly the leg potato), an important mechanism involved in the circulation and return of blood from the leg to the heart. Although there is no scientific evidence in this regard, it is advisable, especially in case of standing too much, to avoid using too high a heel. If the daily activity is more in a sitting position, the impact of high heels is lower, but in general we suggest the use of lower heels in day to day work. The use of high heels sporadically, for example in a celebration or an eventual social event, does not seem to influence the development of varicose veins.
Venous thrombosis: Thrombosis of large veins in the lower limbs makes it difficult to return blood temporarily or permanently. In addition, such veins may undergo a process of degeneration of the valves contained therein. Altering these valves overloads the veins further down, which increases the chance of developing varicose veins in the short term and IVC in the long run.
Venous Compression: External compression by other structures over some point of the venous system causes an overload in the veins below this site, increasing the chance of varices and IVC.
How can I identify the problem?
Varicose veins are usually easily identifiable by simple visual examination. In most cases the patient himself makes his diagnosis. The doctor must confirm this diagnosis, grade the disease (something that will influence the treatment decision), and indicate the pertinent complementary tests that will help to discover the origin of the problem that will guide the decisions about the type of treatment. A family history of varicose veins, or personal history of pregnancy, previous thrombosis, use of contraceptives, and lifestyle habits help define the origin of varicose veins. The physical examination allows to join data such as obesity and atypical distribution of varices, which may suggest a compression in a certain venous territory.
Which exams are important?
Currently the most used test is the Doppler ultrasound of the lower limb venous system. It is an examination that does not use contrast or radiation, being painless and simple to perform with good results in the hands enabled. It can provide fundamental data such as the caliber of the veins (varicose veins are permanently dilated), its flow or reflux, the presence of recent or old thrombosis, as well as the existence of compression points. It is usually the exam of choice and sufficient for surgical planning. In cases of exception, more complex, expensive and invasive examinations such as computed tomography, nuclear magnetic resonance, endovascular ultrasound and phlebography may be necessary to complement the diagnosis, to define strategies and to plan the treatment. We suggest that a vascular surgeon be consulted both for the request of these examinations and for their analysis. This may prevent unnecessary and possibly dangerous examinations.
Although ultrasound is an important examination, not all patients are candidates. There are patients who may have established the indication of treatment based only on clinical examination and consultation with the physician.How can I treat varicose veins?
The presence of varicose veins is detected, the only way to eliminate them is through interventions such as surgery and sclerotherapy (chemical ablation or simply drying the veins). The choice of treatment depends on the type of vein, the clinical condition of the patient, the location and extent of the problem in the vein, as well as the expectation regarding this treatment.
Conservative treatment methods, without surgery or sclerotherapy, do not cure or prevent problems in the veins. However, they often help relieve symptoms such as pain, swelling, itching and weight in the legs while awaiting the time of definitive treatment, even after or in the impossibility of it. As conservative methods may be indicated the use of elastic stockings and / or the use of phlebotonic drugs, but always with medical guidance.
In the most current view on the management of venous disease, the various modalities of treatment are combined to obtain the best results, both aesthetic and for relief of symptoms.
It is common to find miraculous methods that promise treatments for varicose veins through creams, ointments, natural medicines, teas, etc., etc., etc.
After the appearance of varicose veins, the only way to eliminate them, as has been said, is through interventions, be it surgery or sclerotherapy (drying).
There is no scientific evidence about effective creams or ointments, much less miracle drugs that make the varicose veins go away.
As for the effective treatments we can mention the main techniques:
Conventional surgery: it is the most practiced method in Brazil and there is more time. Brazilian vascular surgeons have probably accumulated one of the world's largest experiments in this method, obtaining very good results on average. In surgery, diseased veins are removed through small incisions in the skin. The procedure is performed in a surgical center, usually under blockage with spinal anesthesia, and the usual hospital stay is one day. Complete recovery depends on the extent of the disease and the degree of sensitivity of the patient and it takes from a few days to a few weeks depending on the case. A minor variation of this technique, known as varice microsurgery, uses local anesthesia and can be done outpatient or in the office, which provides infrastructure for the procedure.
Thermoablation or Venous Endovascular Treatment: it is a recent method in Brazil, but widely used in countries such as USA, Canada and Europe in general. In this method an Endolaser fiber (or a radiofrequency catheter) is introduced into the diseased vein through ultrasound monitoring, and a controlled amount of energy is drawn that occludes the vein in question. Eventually it allows for local anesthesia, but can be done with spinal anesthesia, and the recovery time is usually a little lower.
Chemical ablation or sclerotherapy: also known as drying, is the injection of a liquid or foam-like substance into the diseased vessel or vein. This substance causes the vessel to clear and does not promote further symptoms or dilatation in other veins. It is now possible to treat vessels of virtually any size or caliber with this method. It is the simplest method, requiring hospitalization and usually also anesthesia, but it is also the one with the highest rates of relapse over time.
Will not the vases and varicose veins be removed?
No, quite the opposite. The well-indicated and well-performed treatment eliminates diseased veins, which no longer fulfill their normal function. Such vessels do not lack any, and there are other normal veins and vessels that are supplying the circulation in the place.Do you have varicose veins?
Frequently patients are in doubt about the reappearance of varicose veins.
The varicose formation process is continuous and mainly related to the genetics and risk factors previously mentioned. Thus, it is common for new varicose veins to appear in the course of time, even after successful treatment. It is recommended that an evaluation be made from time to time and that the treatment be as early as possible, reducing complications and also to obtain a better aesthetic result. The treatment of varicose veins should be continuous, as well as trying to avoid modifiable risk factors such as sedentary lifestyle, obesity, etc.
What are the results of varicose vein treatment?
As for the results, they are generally quite satisfactory, but factors such as disease evolution time, varice extension, patient expectation, skill and experience of the medical team and patient healing can influence to a better or worse result, both aesthetic and functional. Complications and surprises can and will happen, statistically, with any medical procedure, however well it has been performed. The best way to achieve good results and avoid problems is to find a qualified and trained professional in the diagnosis and treatment of the disease that is intended to treat, in this case the venous disease.
Final considerations:
Each treatment method has its advantages and limitations. There are practically infinite presentations of the venous disease, so there is a modality of treatment that may be more or less adequate for each case. The only specialist who has mastered all these techniques, and so may indicate the best treatment, is the vascular surgeon. If you have any degree of venous disease, take care! Venous disease is progressive. If nothing is done, there is very likely to be a worsening of the picture. Seek an SBACV-SP specialist for guidance.
"Of course, each individual in developing chronic venous insufficiency / varicose veins of the lower limbs carries personal characteristics with innumerable possibilities of clinical presentation, anatomical changes and different associated diseases. Therefore, the decision of which or which appropriate treatment modalities / techniques to be adopted, after evaluation of their advantages and disadvantages, should be established by the physician who assists the patient.
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