Patient & Consumer
What is phlebology?
Phlebology is the study of the anatomy, physiology, and disease of veins. The root of this word is phleb, Latin for “to flow”. Blood returns from the body to the heart through veins. All veins can become diseased but the veins of the legs are most susceptible to disease by a variety of stressors. Much of the practice of phlebology is focused on treatment of varicose veins in the legs. Varicose vein disease encompasses spider veins to visible large tortuous veins on the legs, and to chronic leg swelling and ulcers. Other diseases covered by phlebology include congenital venous malformations and venous thromboembolism.
Phlebology has seen some great advances in the last decade with the now routine use of duplex ultrasound to accurately diagnose the source and extent of venous disease. There has also been significant progress in the treatment of varicose veins with the use of laser, radiofrequency and other minimally invasive devices that can replace the need for traditional surgical ligation and stripping of varicose veins. Furthermore, sclerotherapy (the practice of injecting varicose veins with medication to close the vein) has become more predictable and safe with the use of foamed sclerosants injected into the veins under ultrasound guidance.
What causes varicose veins?
Almost all veins in the body have valves that allow one-way flow of blood from the body to the heart. Without these valves, blood would flow in whatever direction dictated by gravity. In the case of the legs, blood would all pool in the ankles. Varicose veins develop when the valves do not function properly causing the blood to pool in the diseased area. This pooling causes the vein wall to become distended and also causes valves further down the vein and other connected veins to become damaged. This is the reason that people that have untreated varicose veins see gradual enlargement of the diseased veins and more veins becoming affected in a “road map” fashion.
What are the risk factors for varicose veins?
- Pregnancy – The pregnant uterus puts a lot of pressure on the leg veins and varicose vein disease tends to get worse with every pregnancy.
- Family history – about half the people with varicose veins have a family member who has them as well.
- Hormones – females are more likely to develop varicose veins partially due to hormonal changes during pregnancy, premenstruation or menopause. Female hormones, naturally or in the form of birth control pills or hormone replacement therapy, can relax vein walls leading to an increased risk of varicose veins.
- Increasing age – valves and vein walls can weaken with wear and tear.
- Trauma – direct damage to veins and valves can occur with leg injuries.
- History of blood clots – superficial or deep venous blood clots can damage valves.
- Obesity – the extra weight can add pressure to the leg veins.
- Inactivity – the calf muscle pump that is activated with walking is the main force driving blood up against gravity towards the heart. Standing or sitting still for long periods of time can cause blood to pool in the legs, putting pressure on the valves of the leg veins.
What are the symptoms of varicose vein disease?
Varicose veins disease may cause dull aching in the affected leg, itchiness, warmth, swelling, restless legs and night cramps. Some people with large varicose veins may not have any symptoms while people with small spider veins do – the size of diseased veins does not always correlate with symptoms. Varicose vein disease of long duration can also cause dry, scaly skin on the lower legs as well as leg ulcers.
What treatments are available for varicose veins?
Varicose vein treatment must be individualized and treatment options are based on a careful physical exam including the use of duplex ultrasound imaging. All treatments discussed here are aimed at destroying or removing the affected vein or veins. People are often worried about where blood will go if veins are destroyed. It must be understood that there are many superficial veins in our legs and destroying diseased veins will actually improve the circulation. Blood will travel in normal veins towards the heart instead of pooling in diseased veins.
A short description of each treatment option is discussed below:
Unfortunately, once a vein becomes varicose, it stays varicose and eventually becomes worse with time. However, there are ways to improve symptoms including:
- Leg elevation when possible to help relieve pooling of blood in the legs.
- Regular exercise to activate the calf muscle pump, which also helps relieve pooling of blood.
- Wear medical strength compression stockings as much as possible – knee high stockings are sufficient for symptomatic improvement.
- There are some over the counter natural products that may help with symptoms including Diosmin, Butcher’s Broom extract, Horse chestnut, Hesperidine and Rutin.
This treatment involves the injection of medication into the diseased veins that will cause the vein to shut down and no longer function. The body absorbs the vein over time. All veins from large to the smallest spider vein can be treated with sclerotherapy. For larger veins, the injection is usually done with ultrasound visualization. In the last ten years, the use of foamed sclerosant has enabled the closure of very large veins. Liquid sclerosant is most often used for spider veins.
The most common complications of sclerotherapy are bruising, darkening or hyperpigmentation of the skin overlying the vein, the development of small spider veins called matting, and superficial phlebitis, an inflammation of the vein caused by the medication. All of these complications usually resolve over time or with further treatment. More serious complications of sclerotherapy are possible but rare.
Until recently, surgical high ligation and stripping has been the main treatment for removing the main collecting veins of the superficial venous system, the so called “truncal veins”, including the great and the small (short) saphenous veins. This method, while effective for removing varicose veins, is associated with risks related to general, spinal or epidural anesthesia, the possibility of scarring, damage to other vessels or nerves. There is generally more pain and downtime associated with this treatment as opposed to newer, less invasive methods of destroying the disease truncal veins. This modality tends to result in a fairly high recurrence rate of varicose veins.
If the truncal veins are not involved, ambulatory phlebectomy is an effective way under local anesthesia to remove large visible varicose veins. Using tiny incisions, a phlebectomy hook is used to pull the diseased vein out through the skin. There is usually little visible scarring after the procedure and bruising clears with time.
The use of lasers and radiofrequency devices to deliver heat directly to the affected vein, from inside the vein under local anesthetic has revolutionized the treatment of diseased truncal veins. This modality has in many cases replaced traditional surgical stripping and is associated with a much shorter recovery period and much less pain compared to surgery. It is associated with a very high success rate and a low rate of recurrence of varicose veins.
Complications are uncommon, but can include superficial phlebitis and numbness and tingling of the skin after treatment which both usually resolve with time. As with any procedure involving the veins, deep vein clots can occur but not more commonly than what is seen with sclerotherapy or surgical stripping.
What can be done to prevent varicose veins?
It is important to understand that your doctor can only treat the veins that are diseased at the time of presentation. If a person is prone to the disease due to genetics, age or gender, more will develop with time. There are ways, however, to delay the development of varicose veins or keep them from progressing:
- Regular walking or any activity that uses the calf muscle pump will keep blood from pooling in the legs.
- Wear medical strength compression stockings as much as possible, or at least when standing or sitting for prolonged periods of time. This is available by prescription.
- Try to achieve a normal weight for height.
- Follow-up yearly or as suggested by your phlebologist. Catching and treating varicose veins in an earlier stage will protect surrounding veins from becoming diseased and can prevent progression to higher stages of varicose vein disease.