Introduction

If you suffer from problems related to varicose and spider veins, you are not alone. It is estimated that more than 8 million Canadians and 80 million Americans suffer from some form of venous disorder.
While some people seek treatment for cosmetic improvement, many seek relief from pain. Help is available.
Understanding Venous Problems
To understand venous problems, you need to know a little about the anatomy of the venous system and also some about venous physiology (how the veins and the venous pump work). You will learn about deep veins, superficial veins, connecting or perforating veins, the venous pump, and the importance of venous valves. If you will read the next short section and take a look at the vein diagram, you will know more about venous disease than most physicians in Canada.

Venous Anatomy & Physiology

What is the difference between an artery and a vein?
Arteries are thick walled vessels which carry blood from the heart to the periphery.
Veins are thin walled vessels which carry blood from the periphery back to the heart.
There is a third kind of vessel, called lymphatic vessels which are tiny, extremely delicate vessels that carry proteins and lymphatic fluid from the periphery back to the heart.

What are the important veins of the legs?
There are three different kinds of veins in the legs.
The deep veins run down the center of the leg ( dark blue in the picture ). In the calf there are three pairs of deep veins.
The superficial veins are closer to the skin. Two have names: the long (or greater) saphenous vein, and the short (or lesser) saphenous vein.
There are short connecting veins between the superficial and deep veins. These are called perforaters because they penetrate the fascia of the leg
There are numerous other veins which are quite variable in their distribution.

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The heart.

The heart pumps oxygenated blood returning from the lung out to the periphery of the body.

How does blood get back from the periphery to the heart?
The muscles of the foot and the calf constitute the "venous pump." When you walk using your calf muscles and compressing the veins in your feet, the blood is propelled upward toward the heart. If you sit motionless for a long period of time, such as riding in a car or plane, blood accumulates in your feet, ankles and lower legs causing swelling.

A one way street

As you walk blood is pumped up the veins by the calf muscles. As you prepare to take the next step, gravity intervenes and tries to pull the blood back down.
Venous valves are located throughout the veins of your legs to prevent the backward or downward flow of blood (reflux ). If these valves are damaged or defective, reflux occurs; that means that the blood flows the wrong way down the vein. This is the cause of venous hypertension (high blood pressure in the veins) and the fundamental cause of all the problems associated with varicose veins or chronic venous insufficiency.

Veins & Valves of the Legs

 The dark blue are the deep veins.

 The light blue are the superficial veins.

 See if you can find a connecting (or perforating) vein* between the  superficial and deep veins. (Although the artist did not show all of them,  normally there are several in the thigh and more in the calf.)

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 Hint: Look half-way between the words femoral and popliteal on the right  side  of the diagram. The perforating vein is at right angles to the greater  saphenous vein and is dark blue.

Normal Blood Flow

After the blood has been replenished with oxygen in the lungs, it is  pumped to  the body by the heart. Blood that is pumped to the lower  extremities is  pumped back to the heart partially by the action of the calf  muscle pump.  The blood returning from the lower extremities in the deep  and superficial  veins goes past a series of one-way valves. These valves  stop the blood from  flowing backwards in the veins.
 
Reflux

The valves in the veins close just as blood begins to flow backwards. If the valves do not close properly, the blood falls backwards through the poorly closing or leaking valves. The veins downstream that are now unprotected by valves further upstream are exposed to the weight of an increasingly high column of blood. These downstream veins cannot endure the pressure of the column of blood and expand becoming snake-like in appearance. This causes the veins to bulge through the skin surface and become varicose veins.

What Are Varicose Veins and Why do they Occur?
Veins, which have one-way valves, channel the deoxygenated blood back to the heart. The one-way valves prevent blood from flowing backward (reflux). If they fail to close properly, blood will leak through the valves and result in pooling. Over time, this pooling will force the vein wall outward resulting in enlargement and bulging of the vein. These enlarged veins are varicose veins. Varicose veins can protrude from the skin surface resulting in a rope-like appearance.


About Varicose Veins

Varicose veins are usually enlarged and unsightly and are often associated with symptoms of discomfort. We take a careful history designed to elicit any of a number of symptoms commonly associated with varicose veins and perform a careful examination to identify any signs of advanced venous pathology.

Common symptoms associated with varicose veins include:

• Aching
• Heaviness
• Tiredness
• Cramping
• Swelling
• Burning
• Itching

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Less common signs or symptoms include:

• Restless legs at night
• Leg cramps at night
• Superficial blood clotting (thrombophlebitis)
• Bleeding from a superficial vein after minor trauma
• Unusual rashes or areas of dermatitis

If the condition progresses , you may notice:

• Discoloration of the skin above your ankle (hyperpigmentation)
• Hardening of the tissues above your ankle (dermatofibrosclerosis)
• Skin ulceration

What Causes Varicose Veins

Heredity is the number one contributing factor causing varicose and spider veins. Women are more likely to suffer from abnormal leg veins. Up to 50% of Canadian women may be affected. Hormonal factors including puberty, pregnancy, menopause, the use of birth control pills, estrogen, and progesterone affect the disease. It is very common for pregnant women to develop varicose veins during the first trimester. Pregnancy causes increases in hormone levels and blood volume which in turn cause veins to enlarge. In addition, the enlarged uterus causes increased pressure on the veins. Varicose veins due to pregnancy often improve within 3 months after delivery. However, with successive pregnancies, abnormal veins are more likely to remain. Other predisposing factors include aging, standing occupations, obesity and leg injury.

Examples of Varicose Veins

Spider Veins

Spider veins are small red, purple or blue veins located just below the surface of the skin. They can have a web-like appearance, hence, the term spider vein. Most spider veins have an unattractive cosmetic appearance and, in some cases, may give rise to symptoms of itching, burning, or throbbing of your legs. Another type of vein is the reticular vein, which is bluish, deeper than spider veins, and often "feed" the spider vein. A commonly seen reticular vein is the (lateral) Vein of Albanese. These veins need to be treated or else the spider veins cannot be reliably eliminated.

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Example of Spider Veins

Facial Veins

The Vein center associates also offers safe and effective treatment of facial veins. All patients will start with a personal consultation with our physician. The doctor will then outline the best treatment option for your particular problem. Our physician will then work closely with you as well as the technologist to ensure optimal results are achieved.

Example of Facial Veins

What is Compression Scierotherapy?

Both spider and varicose veins can be treated with injection Scierotherapy. By injecting a solution directly into a vein, the inner wall of the vein is irritated and subsequently scars down to collapse. When varicose veins are injected, the blood is re-routed through healthier veins. Compression bandages are subsequently applied to facilitate vein obliteration. Varicosities and spider veins usually require repeated injections for resolution. You will not notice an immediate improvement. Clearance usually occurs over a 2 week period and in some cases it may take up to 6 weeks. Varicosities and spider veins usually require repeated injections for resolution.

Medium to Deep Leg Veins
Spider Veins
Varicose and Spider Veins

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What Side Affects Can I Expect?

Immediate:
• Pin prick and burning for 15 to 20 minutes.
• Occasional dull ache for one to two days.

Short Term:
• Bruising, which disappears in one to four weeks.
• Occasional tender, red, hard lumps after treatment of large veins. These may be uncomfortable but they are not dangerous and should be treated with cool wet compresses for symptomatic relief.

Rarely:
• Discolouration of the skin. Most areas will fade gradually, but some spots may be permanent.
• After injection of large veins, spider veins may appear over the injected areas. These can also be treated by injections.
• Allergic reactions to the drug or the tape. This rages from tingling/itching of the skin to more severe reactions.
• Ulceration of the skin from sclerosing solution leaking outside the vein.

Are there Special Instructions?

Compression bandages will be applied over the injection sites. Patient: with varicose veins should wear their support hose over these bandages. You will be instructed to remove theses bandages in one to four days, but keep them dry during this time. At times there can be residual adhesive from the compression bandages. We can recommend products to aid in its removal if it is an issue for you. We suggest that you:

• Do not put oil or cream on your legs the day of the treatment, as it keeps the tape from sticking to your legs.
• Do not suntan for 2 days after treatment because your skin may burn where the tapes were placed.
• Resume normal activities.

Will I Need Surgery?
Only patients with large varicose veins may need surgery. This occurs primarily when the long saphenous vein is extensively involved. Surgery may include ligation ("tying off") or striping. Both procedures are Day Stay surgery. Another non surgical option is endovenous laser ablation. It is less invasive, with less post procedure recovery compared to surgery. It is however not covered by OHIP, hence a cost to the patient.

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Prevention of varicose veins

Varicose veins and spider veins are a progressive process. They may return or new varicosities develop.
To impede their progression we suggest:
• Remain physically active.
• Wear a prescription graduated compression hose or knee high. Our trained staff will recommend a strength and style to suit   your health requirements.
• Avoid non prescription knee highs.
• Avoid standing for prolonged periods of time and excessive heat exposure.
• Maintain healthy weight.
We recommend intermittent follow-up for maintenance of healthier legs.

Therapeutic Compression Stockings

We recommend therapeutic compression stockings for everyone. They achieve a number of.
1. Relieve tired, achy legs
2. Augment the efficiency of our vein treatment
3. Help delay and even prevent recurrences of varicose veins and then sequelae

Gradient compression delivers a squeezing to the leg that is tightest at the ankle. The degree of squeezing or compression gradually decreases up the leg. This compression, generally expressed in mmHg (millimeters of mercury) provides two main benefits. A complete understanding of precisely how compression works remains unknown. Two actions are generally accepted. Probably the most beneficial effects of compression are its effects on the capillaries and tissue spaces. Compression is believed to increase the pressure in the tissues beneath the skin thus reducing excess leakage of fluid from the capillaries and increasing absorption of tissue fluid by the capillaries and lymphatic vessels. Compression therefore reduces and helps prevent swelling.
The physical presence of the stocking also helps control the size (diameter) of superficial veins beneath the stocking. The stocking does not allow these superficial veins to over expand with blood. This action helps prevent "pooling". The venous blood then flows more quickly up the leg towards the heart.

Pregnancy:

Pregnancy is a special time to take care of your developing baby and yourself. While much of the focus is on your baby and bodily changes, changes are also affecting your veins. The normal hormonal changes that occur with pregnancy affect the walls of your veins causing the vein walls to relax or dilate. Relaxation of the veins occurs early in the pregnancy – during the first trimester. Total blood volume also increases in the first trimester and gradually rises with gestation. Your total blood volume may increase as much as 45% in comparison to the non-pregnant level. Relaxation of the vein walls, especially in areas of venous valves may cause the valve to become incompetent – thus allowing backward flow of the venous blood. Vein relaxation, valve incompetence, and increased blood volume all contribute to reducing venous flow from your legs. The reduced flow results in congestion. Venous congestion in turn causes swelling and leg discomfort. Ankle swelling occurs with most pregnant women.
During the later months of pregnancy (third trimester) the weight of the baby and the uterus may impede return of blood through the veins of your legs. This is often dependent on your physical position. Gradient compression stockings reduce venous congestion and support the superficial veins of your legs. This helps manage the increased blood volume and relaxed vein walls thus reducing the amount of swelling and the severity of varicose veins. We recommend full pantyhose 20-30 mm Hg Class 1 Medical Compression stockings.

Travel:

Long distance travel, whether by automobile, train, or airline can be associated with leg discomforts and risks. Lack of leg movement gives way to swelling of the feet and legs. The swelling contributes to leg fatigue, discomfort and the sensation of leg heaviness.
Activity restriction in the confined seated position results in diminished flow of venous blood from the legs back to the heart. This combined with pre-existing risk factors may lead to a more serious danger - travel-related thrombus. You may have heard this reported in the media as economy class syndrome (ECS). A travel-related thrombus is a venous thrombosis (blood clot in a vein) associated with greater than 5 hours of travel in a seated position. The venous thrombosis may be limited to a deep vein (DVT) or a fragment could flow to the lungs and lodge causing a pulmonary embolism (PE).
The likelihood of a thrombus occurring can be reduced with appropriate preventive measures suited to an individual’s risk. Risk factors for long-distance travel related venous thrombosis include: age >40, malignancy, heart failure, severe varicose veins, chronic venous insufficiency (CVI), obesity, hormonal medication, previous DVT, family history of DVT, and recent surgery.
Consult with your physician to determine your risk category and seek advice on appropriate prophylactic measures, including the amount of compression to wear.
Recommendations for any extended travel:
Drink plenty of non-alcoholic fluids, especially water
Perform ankle movements often
Stretch and exercise your legs at least once every hour
Elevate legs when possible
Avoid high-heeled footwear and restrictive clothing
Wear gradient compression hosiery
Seek medical advice if you have or are concerned about any risk factors

At Contours MD we recommend Class 1 20-30 mm Hg medical compression stockings of the knee high form.

Facts About Economy Class Syndrome (ECS) and Deep Vein Thrombosis (DVT)

•"Economy Class Syndrome" (ECS) is the term associated with a serious condition called deep vein thrombosis (DVT). Crowded,   cramped conditions and limited physical activity during extended air travel may increase the risks for DVT.

•ECS got its name from the inactivity associated with air travel, particularly in cramped coach seating.

•During prolonged periods of inactivity, the effects of gravity make it difficult for the blood in the veins of the legs to return to  the heart. Activity of the calf muscles is needed to contract and pump blood up the legs. Without this activity, blood can pool  in the legs, causing swelling and discomfort and may develop into a blood clot in a deep vein – deep vein thrombosis.

•When normal activity resumes, the blood clot can break off and form an embolism that can pass to the heart or lungs, obstruct  the pulmonary arteries, and lead to death.

•Development of thrombi during extended air travel has been documented throughout the past 40 years.

•Although DVT can strike individuals who are in good health with relatively little warning, there are people who are at greater  risk for developing the condition. Obesity, pregnancy, chronic heart disease, use of hormone medications, malignancies, history  of blood clots, varicose veins, and recent trauma or surgery may increase a person's risk for DVT. 1 Travelers should ask a  physician if they are predisposed to any risk factors for DVT.

•DVT is not only associated with long flights. This condition may also be linked with activities or occupations that involve long  periods of passive sitting.1

•To reduce the risk for DVT while traveling, physicians recommend wearing gradient compression hosiery to improve blood circulation in the legs in conjunction with foot/ankle exercises and walking.

"Not All in Vein"

For more information please arrange a complimentary consultation with
our physician to determine the best recommendation for your particular needs.

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