Wikipedia:Osmosis/Varicose veins



Author: Tanner Marshall, MS

Editor: Rishi Desai, MD, MPH, Tanner Marshall, MS

Varicose veins are veins that have become enlarged and twisted, and this most commonly happens in the veins of the leg.

How do they form? Well - the arterial circulation, going away from the heart, is a high pressure system, meaning the movement of blood is dependent on high pressures that essentially push it through the arteries, on the order of 120 mmHg. The venous circulation going back to the heart, on the other hand, is a low-pressure system with a central venous pressure around 5mm Hg.

This means that the movement of blood has to rely heavily on what’s called the skeletal muscle pump, which is just a way of saying that it relies on the contraction of surrounding skeletal muscles, which compresses the vein and propels blood through the vessels.

But let’s think about the veins in the legs when you’re standing, now to get to the heart the blood has to go up, right, which is working against gravity. So if your calf muscles contract and squeeze the blood inside, some blood gets propelled downward, while some gets propelled upward, but then gravity pushes that upward-moving blood back down, and it doesn’t seem like much gets accomplished...and it wouldn’t, but that’s not the whole story—most veins also have one-way valves. These valves only let blood move in one direction, toward the heart. So now, as the skeletal muscles contract, it squeezes the veins, and this lower valve stays closed to prevent blood from going downward, while the upper valve lets blood through, but even though gravity wants to push it back down, that blood isn’t allowed to fall back down through the upper valve, right?

For some people, the downward gravitational pull on blood causes the walls of the leg veins to stretch apart over time, which tends to also pull apart those valves. If these valves fail to close properly, they can allow blood to leak backward and pool in the veins, which can lead to more valves stretching out and failing. The veins have now become varicose veins, and from this additional blood, they start becoming tortuous, or twisted.

This most commonly affects the superficial veins on the surface of legs, since they see high pressures when standing, rather than the deep veins buried inside the muscles. Oftentimes, though, collateral veins are used instead, which is where other veins can take the blood as an alternate pathway so it doesn’t stagnate in the varicose vein, and these tend to actually be the deep veins in the legs.

Other than the legs, in men it can also occur in the scrotum (usually on the left side) where it is called a varicocele. This develops because the left testicular vein brings blood back to the left renal vein at about a 90-degree angle, while the right testicular vein drains directly into the inferior vena cava.

Getting blood back up through a tight 90 degree turn isn’t easy, and so blood backs up, and the back up of venous blood around the testicle causes the testicular vein to enlarge and get tortuous where it starts to loop back and forth on itself - and it makes the scrotum look like a bag of worms which gets larger with standing and smaller when lying flat. Also all this warm stagnant venous blood can cause the testicular temperature to rise, and over time this can result in testicular atrophy or wasting away, as well as poorer quality sperm and infertility. Generally, embolization or surgery can be used to get rid of this problematic vein, and the testicles then drain through smaller collateral veins.

Alright, back to the legs, so now the deep veins are acting as collateral veins and taking blood back, right? Over time those deep veins though can be affected as well, resulting in even more pooling of blood in the gravity dependent parts of the body. If this happens for prolonged periods of time, it progresses to what we call chronic venous insufficiency or CVI. With CVI the stagnant blood in the lower extremities starts to cause an inflammatory reaction in the vessels and the surrounding tissue, which leads to fibrosis, and potentially even ulcers, called venous stasis ulcers. Other symptoms of CVI include hyperpigmentation or darkening of the skin, as well as pruritus or itchiness, and pain. There can also be a lot of edema as some of this fluid starts to leak out of the veins and into the surrounding tissues of the ankles and lower legs.

Although there are probably a lot of factors that play into the development of varicose veins in the legs and resulting CVI, women tend to be more at risk than men, people that stand or cross their knees for long periods of time, as well as those who are obese. Treatment options for varicose veins and CVI might involve manual compression to help increase blood flow, as well as compressive bandages and stockings, and frequent periods of elevating the legs above the heart. Besides these more conservative options, the gold-standards of treatment are now minimally-invasive endovenous techniques such as radiofrequency ablation, laser ablation, and sclerotherapy. A more novel technique is VenaSeal™ developed by Medtronic. The VenaSeal™ system delivers a small amount of a specially formulated medical adhesive to seal — or close — the diseased vein, rerouting blood to nearby healthy veins, which provides symptom relief. Endovenous techniques have replaced prior more open-surgical techniques such as stripping and valve repair. While technology has improved drastically and veins are no longer treated within the operating room with ‘vein stripping’, these procedures still require expertise. It is important to remember that while new, minimally invasive techniques such as ablation and sclerotherapy are preferred, not all patients will benefit from one method alone.