Sunday December 2, 2007
Vein trouble!
AGE WELL BY Dr LIEW NGOH CHIN
When the veins in your legs cause you problems ...
THE “economy class syndrome” was coined in 1977 by Symington and Stack when they reported on eight patients with venous thromboembolism occurring shortly after travelling in economy class.
The term is a misnomer as deep vein thrombosis (DVT) is neither restricted to passengers in economy class nor to air travel and could occur in patients travelling in cars, buses or trains. A more appropriate terminology is “travel thrombosis”.
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Superficial thrombophlebitis (inflammation of the vein that occurs when a blood clot forms) is often misdiagnosed as cellulitis and treated unsuccessfully with courses of antibiotics. |
The fear of travel thrombosis has resulted in more patients seeking medical attention on their varicose veins.
Definition
Varicose veins are dilated tortuous veins occurring in the lower extremity. Some patients with venous problems have no visible veins, or may present with telangiectasias (chronic dilation of groups of capillaries causing elevated dark red blotches on the skin) or ulcers.
A more encompassing term used to define these varied disorders is “chronic venous disease”. It is defined as a spectrum of disease caused by venous hypertension secondary to reflux, or obstruction or both of the superficial or deep venous system.
Types
Varicosities are of three types: truncal, reticular and telangiectasia. Truncal varices are in the line of the great or lesser saphenous vein and their major branches.
Reticular veins are smaller veins outside of the trunk or major branches and telangiectasias are tiny intradermal venules, which may be purple or pink in colour.
Classification
In order to standardise the reporting and treatment of the diverse manifestation of this disease, a comprehensive classification (CEAP) has been used to allow uniformity in diagnosis. The clinical classification is as follows:
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Varicose ulcers on both legs. The X mark on the left leg denotes site of incompetent perforators of the veins. |
Class 1 – Telangiectasias or reticular veins
Class 2 – Varicose veins
Class 3 – Varicose veins with oedema
Class 4 – Skin changes ascribed to venous disease
Class 5 – Healed ulceration
Class 6 – Active ulceration
Prevalence
Varicose vein is a very common disorder in the Western population. The estimated prevalence rate in Europe and America is between 5% and 30% of the adult population. The male to female ratio is 1:3.
A study in London of the adult population between 35- and 70-years-old showed the prevalence of 17% in men and 35% in women.
In a meta-analysis by Callam in 1994, clinical evidence of chronic venous insufficiency was found in 50% of the population, with visible varicose veins in 10 to 15% and varicose ulcer of 0.5 to 1%.
With a paucity of scientific publication on varicose veins, the incidence and prevalence of this disease in Asia is largely unknown.
There is however no reason to doubt that the figures are any lower. The apparently lower incidence could be due to ethnicity, skin colour, culture and religion. Exposure of the lower extremity in public is deemed impolite in many parts of Asia and the venous problem remained unexposed until late in its course.
In our own series of 434 patients presenting with varicose veins in 520 limbs over a period of six years, published in International Angiology 2007, more than half of the patients have the problem for years and seek medical attention only when complications like bleeding, eczema and ulceration ensued.
Pathophysisology
Dennis P Burkitt wrote an interesting article in The Lancet in 1975. He noted that while serving in India and Africa, the number of patients with varicose veins he and his colleagues saw was exceedingly low, unlike that in Europe.
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Varicose veins that were stripped from the thigh using a stripper. |
It is now believed that varicose veins are secondary to failure of valves in the superficial veins, leading to venous reflux and vein dilatation.
Perhaps in people with varicose veins, there is inherent weakness in the venous wall leading to dilatation of the vein, separation of valve cusps and valve failure. Whether the weakness in the vein wall lead to valve failure or vice versa is a “chicken and egg” controversy.
Reflux occurs at natural points where the superficial vein drains into the deep vein. The common sites are at the sapheno-femoral junction; which is at the groin, sapheno-popliteal junction, which is behind the knee; and uncommonly from some perforators in the leg.
Consequent to the reflux, the venous hypertension leads to extravasation (leakage to the surrounding tissues) of plasma and red blood cells into the tissue around the ankle causing black pigmentation and oedema. There is migration of white blood cells into the tissue and these cells initiate release of inflammatory mediators leading to eczema and ulceration.
Risk factors for varicose veins include increasing age, childbirth and occupations that require a lot of standing. There is a familial predisposition and obese women are at higher risk of developing varicose veins.
Symptoms
The symptoms are varied and include heaviness of the legs or cramping pains, especially aggravated by prolonged standing or walking. Some may have itchiness or a feeling of tension in the legs.
Occasionally, easy fatiguability of the leg is a prominent symptom. Some patients have pain over the varices and this is aggravated by menstrual flow.
Complications
These include bleeding, oedema (swelling) of the feet, skin pigmentation, thrombophlebitis (inflammation of the vein that occurs when a blood clot forms) and eczema.
Management
Duplex scan is the investigation of choice for varicose veins. It is able to delineate the functional and anatomical abnormality of the venous system. Rarely, ascending or descending venogram is required to further clarify the anatomical abnormality.
With the widely varied presentation, management option is diverse. It includes conservative therapy, which is basically non-interventional, and interventional therapy, which includes sclerotherapy, surgery, endovenous laser therapy and radiofrequency ablation.
Conservative therapy
Compression therapy – This is an effective modality leading to decrease in the superficial vein diameter and reduces reflux. It also improves blood flow through the microcirculation leading to decrease in tissue oedema.
Compression is only effective when it is applied and does little to alter the underlying pathology.
In tropical countries like Malaysia, wearing of compressive stocking is cumbersome due to sweating which causes itchiness and irritation. To be effective, appropriate compressive stocking must be chosen. There are two types of stockings available: one is to prevent DVT and the other to treat varicose veins.
Compressive stockings for the prevention of DVT have a pressure range of 10 to 15mmHg whereas those for varicose veins treatment must have a pressure range of 20 to 25mmHg. This is labelled as class 1 to class 3 compression depending on whether it is British, other European or American based products; not unlike the shoe sizes.
Compressive stocking must be applied when waking up from bed, before oedema sets in. After a period of mobilisation, the leg would swell – putting on the stocking then would be difficult as it would be tight.
Medication – The symptoms of varicose veins like itching, cramps and sweating can be treated with medications. Venoactive drugs include naturally occurring products like flavonoids, coumarines, saponins and other plants extracts.
Commonly available medications in Malaysia include diosmin and ginkgo biloba.
Lifestyle modification – Patients have often been advised to elevate the legs and sleep with legs supported on pillows. There is little evidence that these work. With standing or walking, the reflux of blood occurs almost instantaneously and it negates the hours of elevation. On lying down, the legs are level with the heart and further elevation does little to decrease the reflux.
Contrary to belief, exercise like walking is good as it improves the tone in the calf muscles and helps venous return. To prevent further reflux, compressive stocking must be worn during the exercise.
In general, there is much to recommend on losing weight, smoking cessation and exercise. This would indirectly help in reducing venous symptoms.
Interventional therapy
Injection sclerotherapy – Injection sclerotherapy has been reserved in the past for telangiectasias, reticular veins and residual varices after surgery.
Using sclerotherapy to treat patients with truncal varices results in a high recurrence rate, like 70% in two years.
The procedure was largely abandoned until recently when newer foam sclerosants (an injectable irritant that causes inflammation and subsequent fibrosis, thus obliterating the lumen of the vein) emerged. These sclerosants are injected into the incompetent veins and perforators. The foams could be accurately directed to the incompetent valve junction under duplex scan guidance and effectively closes off the vein.
Until data on longer term follow up emerges, foam sclerotherapy on the truncal veins remain experimental. It however, has the potential to be the simplest, cheapest and an effective modality of treatment of varicose veins.
Surgery – Removal of the varicose veins with ligation of the sapheno-femoral junction or sapheno-popliteal junction is considered the standard operation for people with truncal varicosities. Concomitantly, the perforators in the thigh or legs may be ligated.
This procedure is in practice for half a century and is durable and effective. The technique has been refined over the years and various newer procedures like Subfascial Endoscopic Perforator Surgery (SEPS) have been added to the surgical armamentarium.
Endovenous Laser Therapy (EVLT) and Radiofrequency ablation (RFA) – The use of thermal energy in the form of laser or radiofrequency to obliterate the great saphenous vein is a great advancement in venous disease management.
Thermal energy destroys the venous wall, leading to thrombosis and eventual fibrosis. It is applied through a tiny puncture on the great or lesser saphenous vein under local anaesthesia. It obviates the need for any regional or general anaesthesia and the patient could be treated as an outpatient.
The result of EVLT and RA is excellent, with successful obliteration rates of 85 to 95% over a period of two years. More studies have recently emerged attesting to the efficacy and durability of this procedure and it has been approved for use by the FDA.
The advantage of this procedure is the convenience of outpatient therapy, superior cosmetic result and an early return to work.
The down side is the reported DVT incidence of 1%, which resolves with anticoagulation (a substance that prevents the clotting of blood).
EVLT, like other minimally invasive therapy, will in due course, replace open surgery as the therapy of choice in the management of truncal varicosities.
Summary
Varicose veins and chronic venous diseases are common diseases that are gaining recognition as an important morbidity in developing countries.
While it is usually not fatal, it is prevalent and consumes a substantial amount of the healthcare budget.
Newer modality of therapies like endovenous laser therapy, radiofrequency ablation and foam sclerotherapy will in due course replace surgery as the primary mode of treatment.
The members of the panel include: Datuk Prof Dr Tan Hui Meng, consultant urologist; Dr Yap Piang Kian, consultant endocrinologist; Datuk Dr Azhari Rosman, consultant cardiologist; A/Prof Dr Philip Poi, consultant geriatrician; Dr Hew Fen Lee, consultant endocrinologist; Prof Dr Low Wah Yun, psychologist; Datuk Dr Nor Ashikin Mokhtar, consultant obstetrician and gynaecologist; Dr Lee Moon Keen, consultant neurologist; Dr Ting Hoon Chin, consultant dermatologist; Assoc Prof Khoo Ee Ming, primary care physician; Dr Ng Soo Chin, consultant haematologist. For more information, e-mail starhealth@thestar.com.my
The Star Health & Ageing Advisory Panel provides this information for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care.
The Star Health & Ageing Advisory Panel disclaims any and all liability for injury or other damages that could result from use of the information obtained from this article.
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