__NOTOC__
{{Varicose veins}}
{{CMG}}

==Overview==

Varicose veins are a common disease. Its reported prevalence all over the world varies between 10% to 30%<ref name="pmid8156326">{{cite journal| author=Callam MJ| title=Epidemiology of varicose veins. | journal=Br J Surg | year= 1994 | volume= 81 | issue= 2 | pages= 167-73 | pmid=8156326 | doi=10.1002/bjs.1800810204 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8156326 }} </ref><ref name="pmid10396491">{{cite journal| author=Evans CJ, Fowkes FG, Ruckley CV, Lee AJ| title=Prevalence of varicose veins and chronic venous insufficiency in men and women in the general population: Edinburgh Vein Study. | journal=J Epidemiol Community Health | year= 1999 | volume= 53 | issue= 3 | pages= 149-53 | pmid=10396491 | doi=10.1136/jech.53.3.149 | pmc=1756838 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10396491 }} </ref>. The majority of the cases are reported in developed and industrialised countries. The prevalence of varicose veins in the USA is estimated to be 23% of the adult population. It is more common in women than in men. The prevalence increases with age. [[Heredity]] seems to play a major role in development of Varicose veins. 50% of the patients have a [[family history]] of the disease. The children with two affected parents are at almost 90% risk<ref>https://www.chicagoveininstitute.com/varicose-vein-statistics/</ref>.

==Epidemiology and Demographics==

'''Prevalence:''' Worldwide the [[prevalence]] varies between 10-30% of the population. In the USA, the [[prevalence]] is around 4500/100,000 <ref>https://www.rightdiagnosis.com/v/varicose_veins/stats-country.htm</ref>. It affects around 22 million women and 11 million men<ref name="pmid23268520">{{cite journal| author=Hamdan A| title=Management of varicose veins and venous insufficiency. | journal=JAMA | year= 2012 | volume= 308 | issue= 24 | pages= 2612-21 | pmid=23268520 | doi=10.1001/jama.2012.111352 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23268520 }} </ref>.

'''Region''': [[Varicose veins|Varicose Veins]] are more common in [[Developed countries|western]] and industrialized countries compared to the [[Developing countries|developing]] countries<ref name="pmid15723761">{{cite journal| author=Beebe-Dimmer JL, Pfeifer JR, Engle JS, Schottenfeld D| title=The epidemiology of chronic venous insufficiency and varicose veins. | journal=Ann Epidemiol | year= 2005 | volume= 15 | issue= 3 | pages= 175-84 | pmid=15723761 | doi=10.1016/j.annepidem.2004.05.015 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15723761 }} </ref>. The paper noted that the [[Prevalence rate|prevalence rates]] between Egypt and England was upwards of five-fold after standardization for age.

'''Case fatality:''' Varicose veins is not a fatal disease.

'''Age:''' The prevalence increases with age. The most affected age group is 40-80 years old.

'''Gender:''' [[Female]]<nowiki/>s are twice as likely to be affected by varicose veins as compared to males. Although, [[Males|male]]<nowiki/>s are nearly twice as likely to have visible disease<ref name="pmid15723761">{{cite journal| author=Beebe-Dimmer JL, Pfeifer JR, Engle JS, Schottenfeld D| title=The epidemiology of chronic venous insufficiency and varicose veins. | journal=Ann Epidemiol | year= 2005 | volume= 15 | issue= 3 | pages= 175-84 | pmid=15723761 | doi=10.1016/j.annepidem.2004.05.015 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15723761 }} </ref>.

'''Race:''' The San Diego Population Study, a first of its kind multi-ethnic study of Chronic venous disease noted that the prevalence of visible varicose veins was significantly higher in Hispanics; while it was lowest in Asians<ref name="pmid15723761">{{cite journal| author=Beebe-Dimmer JL, Pfeifer JR, Engle JS, Schottenfeld D| title=The epidemiology of chronic venous insufficiency and varicose veins. | journal=Ann Epidemiol | year= 2005 | volume= 15 | issue= 3 | pages= 175-84 | pmid=15723761 | doi=10.1016/j.annepidem.2004.05.015 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15723761 }} </ref>.

'''Developed countries:''' The [[prevalence]] in developed countries tends to be more in developed countries when compared to developing countries.

==References==
{{Reflist|2}}

[[Category:Vascular surgery]]
[[Category:Medical conditions related to obesity]]
[[Category:Surgery]]
[[Category:Primary care]]
[[Category:Needs content]]

{{WH}}
{{WS}}

Varicose veins medical therapy

2020-07-24T12:51:51Z

Lovepreet Randhawa:

__NOTOC__
{{Varicose veins}}

{{CMG}}

==Overview==
Non-surgical treatments include [[sclerotherapy]], elastic stockings, elevating the legs, and exercise. The traditional surgical treatment has been [[vein stripping]] to remove the affected veins. Newer surgical treatments are less invasive (see [[radiofrequency ablation]]) and are slowly replacing traditional surgical treatments<ref name="pmid24868066">{{cite journal| author=O'Flynn N, Vaughan M, Kelley K| title=Diagnosis and management of varicose veins in the legs: NICE guideline. | journal=Br J Gen Pract | year= 2014 | volume= 64 | issue= 623 | pages= 314-5 | pmid=24868066 | doi=10.3399/bjgp14X680329 | pmc=4032011 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24868066 }}</ref>. Since most of the blood in the legs is returned by the deep veins, and the superficial veins only return about 10%, they can be removed or ablated without serious harm.<ref>Merck Manual Home Edition, 2nd ed.[http://www.merck.com/mmhe/sec03/ch036/ch036d.html] </ref>

==Medical Therapy==
===Conservative treatment===
The symptoms of varicose veins can be controlled to an extent with the following:
*Elevating the legs often provides temporary symptomatic relief.
*"Advice about regular exercise sounds sensible but is not supported by any evidence."<ref>BMJ 2006;333:287-292 (5 August), Varicose veins and their management, Bruce Campbell [http://www.bmj.com/cgi/content/full/333/7562/287(subscription)]</ref>
*The wearing of graduated [[compression stockings]] with a pressure of 30–40 mmHg has been shown to correct the swelling, nutritional exchange, and improve the microcirculation in legs affected by varicose veins.<ref>Curri SB et al. Changes of cutaneous microcirculation from elasto-compression in chronic venous insufficiency. In Davy A and Stemmer R, editors: Phlebology '89, Montrouge, France, 1989, John Libbey Eurotext.</ref> They also often provide relief from the discomfort associated with this disease. Caution should be exercised in their use in patients with concurrent arterial disease.
The symptoms of varicose veins can be controlled to an extent with either of the following:
*Anti-inflammatory medication such as [[ibuprofen]] or [[aspirin]] can be used as part of treatment for superficial thrombophlebitis along with graduated compression hosiery – but there is a risk of intestinal bleeding. In extensive superficial thrombophlebitis, consideration should be given to anti-coagulation, thrombectomy or sclerotherapy of the involved vein.
*[[Diosmin 95]] is a dietary supplement distributed in the U.S. by Nutratech, Inc. The U.S. Food and Drug Administration does not approve dietary supplements, and concluded that there was an "inadequate basis for reasonable expectation of safety." <ref>New Dietary Ingredients in Dietary Supplements, U. S. Food and Drug Administration
Center for Food Safety and Applied Nutrition
Office of Nutritional Products, Labeling, and Dietary Supplements
February 2001 (Updated September 10, 2001), http://www.cfsan.fda.gov/~dms/ds-ingrd.html</ref> <ref>Memorandum
[http://www.fda.gov/ohrms/dockets/dockets/95s0316/rpt0083_01.pdf]</ref>

<div align="left">
<gallery heights="175" widths="175">
Image:Dornst_venengym.jpg|Vein gymnastics.
</gallery>
</div>

===Non-surgical treatment===
====Sclerotherapy====

A commonly performed non-surgical treatment for varicose and "spider" leg veins is [[sclerotherapy]]. It has been used in the treatment of varicose veins for over 150 years.<ref>Goldman M, Sclerotherapy Treatment of varicose and telangiectatic leg vein, Hardcover Text, 2nd Ed, 1995</ref> Sclerotherapy is often used for telangiectasias (spider veins) and varicose veins that persist or recur after vein stripping.<ref>"Veins & Lymphatics," L. K. Pak et al, ''in'' Lange's Current Surgical Diagnosis & Treatment, 11th ed., McGraw-Hill, </ref><ref>Tisi PV, Beverley C, Rees A. Injection sclerotherapy for varicose veins. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD001732.</ref>

Sclerotherapy can also be performed using microfoam sclerosants under ultrasound guidance to treat larger varicose veins, including the greater and short saphenous veins.<ref>Paul Thibault, Sclerotherapy and Ultrasound-Guided Sclerotherapy, The Vein Book / editor, John J. Bergan, 2007.</ref><ref>Padbury A, Benveniste G L, Foam echosclerotherapy of the small saphenous vein, Australian and New Zealand Journal of Phlebology Vol 8, Number 1 (December 2004)</ref> A study by Kanter and Thibault in 1996 reported a 76% success rate at 24 months in treating saphenofemoral junction and great saphenous vein incompetence with STS 3% solution.<ref>Kanter A, Thibault P. Saphenofemoral junction incompetence treated by ultrasound-guided sclerotherapy, Dermatol Surg. 1996. 22: 648-652.</ref> A Cochrane Collaboration review<ref>http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD001732/abstract.html</ref> concluded sclerotherapy was better than surgery in the short term (1 year) for its treatment success, complication rate and cost, but surgery was better after 5 years, although the research is weak.<ref>Rigby KA, Palfreyman SJ, Beverley C, Michaels JA. Surgery versus sclerotherapy for the treatment of varicose veins. Cochrane Database of Systematic Reviews 2004, Issue 4. Art. No.: CD004980. [http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD004980/abstract.html]</ref>

A Health Technology Assessment found that sclerotherapy provided less benefit than surgery, but is likely to provide a small benefit in varicose veins without reflux.<ref>Michaels JA, Campbell WB, Brazier JE, MacIntyre JB, Palfreyman SJ, Ratcliffe J, et al. Randomized clinical trial, observational study and assessment of cost-effectiveness of the treatment of varicose veins (REACTIV trial). Health Technol Assess 2006;10(13). [http://www.hta.ac.uk/fullmono/mon1013.pdf] This Health Technology Assessment monograph includes reviews of the epidemiology, assessment, and treatment of varicose veins, as well as a study on clinical and cost effectiveness of surgery and sclerotherapy</ref> Complications of sclerotherapy are rare but can include blood clots and ulceration. [[Anaphylaxis|Anaphylactic]] reactions are "extraordinarily rare but can be life-threatening," and doctors should have resuscitation equipment ready.<ref>William R. Finkelmeier, Sclerotherapy, Ch. 12, ACS Surgery: Principles & Practice, 2004, WebMD (hardcover book)</ref> There has been one reported case of stroke after ultrasound guided sclerotherapy when an unusually large dose of sclerosant foam was injected.

====Endovenous laser and radiofrequency ablation====
The Australian Medical Services Advisory Committee (MSAC) in 2008 has determined that endovenous laser treatment for varicose veins "appears to be more effective in the short term, and at least as effective overall, as the comparative procedure of junction ligation and vein stripping for the treatment of varicose veins."<ref>Medical Services Advisory Committee, Endovenous laser therapy (ELT) for varicose veins. MSAC application 1113, Dept of Health and Ageing, Commonwealth of Australia, 2008. http://www.msac.gov.au/internet/msac/publishing.nsf/Content/2E0BACBB8704139ACA25745E001C2F21/$File/1113report.pdf</ref> It also found in its assessment of available literature, that "occurrence rates of more severe complications such as DVT, nerve injury and paresthesia, post-operative infections and hematomas, appears to be greater after ligation and stripping than after EVLT". Complications for endovenous laser treatment include minor skin burns (0.4%)<ref name="Elmore"> Elmore FA and Lackey D, Effectiveness of laser treatment in eliminating superficial venous reflux, Phlebology 2008 :23 :21-31</ref> and temporary paresthesia (2.1%).<ref name="Elmore" /> The longest study of endovenous laser ablation is 39 months.

<div align="left">
<gallery heights="175" widths="175">
Image:000 1486.jpg|Varicose veins after [[EVLT]]
</gallery>
</div>

Two prospective randomized trials found speedier recovery and fewer complications after radiofrequency obliteration (AKA radiofrequency ablation) compared to open surgery.<ref>Rautio, T, et al., Endovenous oblitration versus conventional stripping operation in the treatment of primary varicose veins, J Vasc Surg 2002:35:958-65</ref><ref>Lurie F, et al., Prospective randomized study of endovenous radiofrequency oblitration (closure) versus ligation and vein stripping (EVOLVeS: two-year follow-up. Eur J Vasc Endovasc Surg 2005;29:67-73</ref> Myers<ref>Kenneth Myers, An opinion —surgery for small saphenous reflux is obsolete!" Australian and New Zealand Journal of Phlebology, Vol 8, Number 1 (December 2004)</ref> wrote that open surgery for [[small saphenous vein]] reflux is obsolete. Myers said these veins should be treated with endovenous techniques, citing high recurrence rates after surgical management, and risk of nerve damage up to 15%. In comparison, radiofrequency ablation has been shown to control 80% of cases of small saphenous vein reflux at 4 years, said Myers. Complications for radiofrequency ablation include burns, [[paresthesia]], clinical phlebitis, and slightly higher rates of deep vein thrombosis (0.57%) and pulmonary embolism (0.17%). One 3-year study compared radiofrequency, with a recurrence rate of 33%, to open surgery, which had a recurrence rate of 23%.

Endovenous laser and radiofrequency ablation require specialized training for doctors and expensive equipment. Endovenous laser treatment is performed as an outpatient procedure and does not require the use of an operating theater, nor does the patient need a general anesthetic. Doctors must use ultrasound during the procedure to see what they are doing. Some practitioners also perform phlebectomy or ultrasound guided sclerotherapy at the time of endovenous treatment. Follow-up treatment to smaller branch varicose veins is often needed in the weeks after the initial procedure.

==References==
{{Reflist|2}}

[[Category:Vascular surgery]]
[[Category:Medical conditions related to obesity]]
[[Category:Surgery]]
[[Category:Primary care]]

{{WH}}
{{WS}}

Varicose veins natural history, complications and prognosis

2020-07-24T12:31:51Z

Lovepreet Randhawa:

__NOTOC__

{{Varicose veins}}
{{CMG}}

==Overview==
The progression of chronic venous insufficiency over time is not well understood. The progression follows quite a variable path. Some patients might initially have varicose veins but not have any clinical symptoms; others might develop clinical symptoms(such as heaviness,eczema, etc.) without any clinically visible disease. Without treatment most patients will show worsening of the condition over time<ref name="pmid15768012">{{cite journal| author=Labropoulos N, Leon L, Kwon S, Tassiopoulos A, Gonzalez-Fajardo JA, Kang SS | display-authors=etal| title=Study of the venous reflux progression. | journal=J Vasc Surg | year= 2005 | volume= 41 | issue= 2 | pages= 291-5 | pmid=15768012 | doi=10.1016/j.jvs.2004.11.014 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15768012 }} </ref>.

Serious complications are rare but severe varicosities can lead to major complications, due to the poor circulation through the affected limb.

==Natural History==
The natural history of varicose veins is not well understood. This has been a roadblock in prioritizing patients on the basis of stage of clinical disease. For different patients, the disease progresses in different manners. The progression of the varicose veins is driven by a cycle of venous hypertension, [[inflammation]], [[capillary damage]], and [[edema]] <ref name="pmid16885552">{{cite journal| author=Bergan JJ, Schmid-Schönbein GW, Smith PD, Nicolaides AN, Boisseau MR, Eklof B| title=Chronic venous disease. | journal=N Engl J Med | year= 2006 | volume= 355 | issue= 5 | pages= 488-98 | pmid=16885552 | doi=10.1056/NEJMra055289 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16885552 }} </ref>. In a study by Lee et al<ref name="pmid26993676">{{cite journal| author=Lee AJ, Robertson LA, Boghossian SM, Allan PL, Ruckley CV, Fowkes FG | display-authors=etal| title=Progression of varicose veins and chronic venous insufficiency in the general population in the Edinburgh Vein Study. | journal=J Vasc Surg Venous Lymphat Disord | year= 2015 | volume= 3 | issue= 1 | pages= 18-26 | pmid=26993676 | doi=10.1016/j.jvsv.2014.09.008 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26993676 }} </ref>, it was found that almost half(57%) the patients who develop some level of chronic venous disease initially would show a progression of the disease when followed over time. 98% of the patients who had both varicose veins and [[chronic venous insufficiency]] at baseline showed deterioration with time. While the progression was affected by a family history of varicose veins, age, history of [[Deep vein thrombosis|DVT]], being [[overweight]]; gender did not seem to play a role in determining the rate of progression. On duplex [[ultrasonography]] scanning, venous reflux especially, superficial combined with deep vein reflux was found to be associated with higher rates of disease progression.

==Complications==
Most varicose veins are relatively benign, but severe varicosities can lead to major complications, due to the poor circulation through the affected limb <ref>https://www.clinicbarcelona.org/en/assistance/diseases/varicose-veins/evolution-of-the-disease#:~:text=Although%20varicose%20veins%20and%20venous,discomfort%2C%20complications%2C%20and%20progression.</ref>.
* Pain, heaviness, inability to walk or stand for long hours thus hindering work
* Skin conditions / [[dermatitis]] often occurs with chronic stasis of venous blood
* [[Bleeding]]: although uncommon, a life-threatening bleed can happen from injury to the varicose vein
* [[Ulcer]]: non-healing varicose [[ulcer]] could threaten limb amputation.
* Development of [[carcinoma]] or [[sarcoma]] in long-standing venous ulcers. There have been over 100 reported cases of malignant transformation and the rate is reported as 0.4% to 1%.<ref>Goldman M. Sclerotherapy, Treatment of Varicose and Telangiectatic Leg Veins. Hardcover Text, 2nd Ed, 1995</ref>
* Coagulation of blood in varicose veins cause superficial venous thrombosis, [[deep vein thrombosis|deep vein thrombosis (DVT)]], [[pulmonary embolism]] (PE) & could precipitate [[stroke]] in the rare case of predisposed individuals (that is, patients with [[patent foramen ovale]]).

==Prognosis==
Even though Varicose veins are a chronic condition, the prognosis is often benign. Most of the mortality associated with varicose veins is due to [[venous thromboembolism]]. The possibility of DVT should always be considered in patients with varicose veins. In a 14 year study conducted in Taiwan during the year 2018, the incidence of DVT was found to be 5 times higher in subjects with varicose veins as compared to without<ref name="pmid29486040">{{cite journal| author=Chang SL, Huang YL, Lee MC, Hu S, Hsiao YC, Chang SW | display-authors=etal| title=Association of Varicose Veins With Incident Venous Thromboembolism and Peripheral Artery Disease. | journal=JAMA | year= 2018 | volume= 319 | issue= 8 | pages= 807-817 | pmid=29486040 | doi=10.1001/jama.2018.0246 | pmc=5838574 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29486040 }} </ref>. This can be prevented with timely intervention.

==References==
{{Reflist|2}}

[[Category:Vascular surgery]]
[[Category:Medical conditions related to obesity]]
[[Category:Surgery]]
[[Category:Primary care]]
[[Category:Needs content]]

{{WH}}
{{WS}}