Venous Insufficiency and Varicosities

Chronic venous insufficiency is a common clinical problem whose presentation ranges from mildly unsightly venous dilation to recurrent cellulitis and ulceration requiring frequent hospitalizations. An estimated 20% of the US adult population has some degree of varicose veins, and up to 5% have advanced chronic venous insufficiency and venous ulceration.

The venous system of the lower extremities is composed of deep veins that lie within the muscle fascia—within or between the muscles, with the latter more implicated in chronic venous insufficiency—and superficial veins that lie outside the deep fascia and muscles.[1] Although the underlying etiology is not fully understood (genetic, hormonal, and environmental factors have been postulated), these disorders result from chronic venous hypertension, which can be caused by incompetence of the venous valves, venous thrombosis or obstruction, and/or failure of the muscular “venous pump” (the pumping effect that occurs upon contraction of leg muscles during walking and other activities).

Telangiectasias and reticular veins are dilated intradermal and subdermal veins, respectively. They are present in about 50-66% of individuals, with women being more commonly affected than men.[2],[3]

Varicose veins are dilated, tortuous, subcutaneous veins usually greater than 3 mm in diameter. They are present in 10-30% of the general population and are particularly frequent in older individuals and women.[4],[5] Most are asymptomatic. However, clinical symptoms may include swelling, aching, tension, leg fatigue, burning, and pruritus, which may be relieved with recumbency or leg elevation.

Chronic venous insufficiency is determined by the presence of edema, skin changes, or ulceration, which, if left untreated, can be limb- or life-threatening. Six to seven million people in the US are affected. Its prevalence increases with age. Overall, it is twice as common in women as men, however, the rate of severe disease may be higher in men.[6]

Risk Factors

Family history. There is as much as a 90% risk of developing varicose veins if both parents have varicose veins, but less than a 20% risk if neither parent is affected.[2],[7]

Female gender. Venous insufficiency and varicosities occur up to twice as often in women as men.

Tall height. The association with height is thought to be due to the effect of gravity and pooling of blood in the lower extremities.

Advanced age.

Previous venous damage. History of leg injury, phlebitis, deep vein thrombosis, venous wall degeneration (e.g. aneurysms), arteriovenous shunts, or non-thrombotic iliac vein obstruction raises the risk for venous insufficiency.[8],[9]

Lifestyle factors. Prolonged standing, sedentary lifestyle, smoking, and pregnancy are suspected risk factors for the development of varicose veins, and obesity raises risk for venous disorders.[10] Physical inactivity is associated with risk for chronic venous insufficiency and varicose veins in some, although not all studies.[7],[11],[12]

High estrogen states and pregnancy also contribute to increased risk for developing venous insufficiency.

Klippel-Trenaunay-Weber syndrome. This rare congenital condition occurs due to an abnormal or absent deep venous system and results in a triad of extensive unilateral varicose veins, limb hypertrophy, and one or more port-wine stains.

Diagnosis

Diagnosis typically rests on symptomatology (i.e., leg pain, heaviness, sores) with confirmation of venous reflux by Doppler ultrasound. Additional testing is generally reserved for severe cases or when intervention is planned.

Doppler venous ultrasound gives information about the anatomy and flow patterns of the venous system. It accurately maps the veins of the leg and identifies the location and severity of valvular incompetence. In addition, it evaluates for deep vein thrombosis, which is fairly common in these patients. Ankle-brachial index (ankle-to-brachial blood pressure ratio) is calculated in conjunction with Doppler ultrasound to assess the presence of concurrent arterial disease, which is common in patients with venous disease.

Venography is an invasive method for evaluating the venous system. It is rarely used due to the safety and accuracy of Doppler ultrasound. However, venography is useful in some patients, particularly those who will undergo vascular surgery.

Treatment

Initial conservative management is recommended for most patients. Bed rest, leg elevation, and compression stockings or bandages improve blood flow, reduce inflammation and edema, and compress dilated veins.

Leg elevation above the level of the heart for 30 minutes three or four times per day increases blood flow velocity, thus improving cutaneous microcirculation, and reduces edema in patients with chronic venous disease.[13]

Exercise, such as daily walking and progressive resistance exercise up to three times per week, contributes to improvement in hemodynamic parameters and function. When combined with usual care such as compression, exercise has been shown to improve venous leg ulcer healing at 12 weeks.[14],[15],[16],[17]

Compression stockings act by decreasing venous pressure and reflux. They should be able to exert 20 30 mm Hg at the ankle with a decreasing pressure gradient toward the knee (note that compression stockings are different from the “antiembolism” stockings used in hospitals for deep venous thrombosis prevention, which exert less than 10 mm Hg).

Intermittent pneumatic compression pumps can be used for several hours daily and may be more effective than compression stockings or bandages.

Several drug therapies have been used. Diuretics may be used in patients with severe edema resulting from medical conditions that exacerbate lower extremity symptoms. Aspirin and oral antibiotics may be used to accelerate the healing of venous ulcers.

Venous ablation by injection sclerotherapy is useful in some patients with varicose veins for whom conservative therapies have failed. Laser therapy is the only option for treatment of telangiectasias that are too small for injection.

Several surgical options are available and have high success rates. These include venous ligation with or without stripping, endovenous catheter ablation, and valvular reconstruction.

Nutritional Considerations

Chronic venous insufficiency and varicose veins appear to be related to an obesity-promoting Western lifestyle poor in dietary fiber and low in physical activity. Evidence suggests that avoidance of these risk factors may reduce the incidence of venous disorders. In persons with established venous insufficiency and varicose veins, the therapeutic applications of flavonoid-containing botanicals may strengthen blood vessels by increasing collagen cross-linking in the vascular endothelium.

In observational studies, the following factors are associated with reduced risk of venous disorders:

High-Fiber Diets

Denis Burkitt, known for the identification and treatment of Burkitt’s lymphoma, hypothesized that varicose veins result from a fiber-poor diet that leads to constipation-induced straining during defecation.[18] This straining may raise intra-abdominal pressure, causing transmission of pressure to the major venous trunks draining the leg veins. (Dr. Burkitt hypothesized a similar mechanism for the pathogenesis of hemorrhoids.) The resulting retrograde blood flow to these veins may in turn result in a dilation of the proximal segment of the veins and failure of the valves in a sequential manner. Further abdominal straining and the presence of unsupported blood in the veins cause a deterioration in vascular integrity.[10],[18]

Although this hypothesis has not been proven, epidemiological evidence supports a relationship between a lack of fiber and the prevalence of varicose veins.[19] The presence of varicose veins in some developing regions is associated both with increases in refined (fiber-poor) carbohydrate and decreases in stool weight.[20] Straining during defecation resulted in an almost 3-fold higher risk for the prevalence of both mild and severe trunk varices, but this was observed in men only.[21] Subjects with trunk varicose veins and those with chronic venous insufficiency had higher levels of haemostatic factors (fibrinogen, tissue plasminogen activator [tPA], and von Willebrand factor) compared with those without trunk varices or chronic venous insufficiency.[22] Although additional studies are needed to investigate the role of a high-fiber diet in varicose vein prevention, low-fat, high-fiber diet interventions have reduced tPA and increased fibrinolysis, indicating their usefulness in the prevention of varicosities.[23],[24]

Avoidance of Overweight

Obesity has not been consistently associated with chronic venous insufficiency. However, most studies have shown that overweight and obese women are more likely to develop varicose veins. Women who are moderately overweight (BMI = 25.0-29.9 kg/m2) have a 1.5-fold increased risk of varicose veins, compared with nonoverweight women. Women with a BMI ≥ 30 have a 3-fold greater risk.[25] Obesity prevention appears to be more effective than obesity treatment. Obesity surgery was not effective for improvement of venous insufficiency.[26] For details on dietary contributors to and treatments for obesity, see the Obesity chapter.

Botanical Treatments

Certain botanical treatments have demonstrated promise for treating chronic venous insufficiency in limited clinical trials. These include the following:

Horse chestnut seed (Aescin). A systematic review of the use of horse chestnut seed (Aesculus hippocastanum) for chronic venous insufficiency concludes that it probably reduces lower leg volume and may reduce ankle and calf swelling.[27] The active component (aescin) appears to promote blood circulation and may strengthen the elasticity of veins. The common dosage of horse chestnut is 300 mg twice daily, containing 50 mg of Aescin in each dose.

Diosmin-hesperidin combination (Micronized Purified Flavonoid Fraction). Long-term controlled clinical trials have revealed that this combination (Daflon 500 mg twice daily) of flavonoids increases venous tone, improves lymphatic drainage, and reduces capillary hyperpermeability, with resultant changes in chronic venous insufficiency and associated venous conditions. These improvements included significant decreases in ankle and calf circumferences, functional discomfort (nocturnal cramps and sensations of leg heaviness, swelling, or heat), and plethysmographic parameters, such as venous capacitance, distensibility, and emptying.[10],[28]A meta-analysis of controlled clinical trials indicated that adding Daflon 500 mg twice daily increased the likelihood of healing venous leg ulcers by 32%, compared with conventional therapy alone.[29] Furthermore, the diosmin-hesperidin combination may reduce edema to a greater extent, compared with other venoactive drugs, as shown in a meta-analysis of 10 trials which demonstrated reduction of mean ankle circumference by 0.80 cm for the combination but 0.58 cm and 0.20 cm for hydroxyethylrutoside and diosmin alone, respectively.[30]

Butcher’s broom. Extracts of Ruscus aculeatus (150 mg 2 3 times/day) improve venous insufficiency through inhibition of the permeability-inducing effect of histamine, bradykinin, and leukotriene B4.[10] Butcher’s broom is particularly effective when combined with another flavonoid (hesperidin) and vitamin C.[31] Benefits include improved venous emptying; decreased capillary filtration rate; reduction of pain severity, cramps, heaviness, paresthesia, venous capacity, and severity of edema; and decreases in calf and ankle circumference.[10],[32]

Pycnogenol (Maritime Pine Bark). Studies have demonstrated that pycnogenol may improve symptoms of chronic venous insufficiency, promote healing of venous ulcers, reduce leg edema and the risk of blood clots, especially during long flights, due to its anti-inflammatory compound called procyanidins.[33],[34]

Supplemental therapy with pycnogenol has been shown to reduce oxidative-stress and may slow progression of varicose veins to chronic venous insufficiency.[35] In one study comparing pycnogenol with grape leaf extract and use of stockings for chronic venous insufficiency, use of pycnogenol at 100 mg/day for 8 weeks reduced venous leg edema by 40%.[36] In another trial that compared pycnogenol with diosmin-hesperidin, use of pycnogenol (150 mg per day for 8 weeks) was shown to reduce a combination of symptoms, including edema, pain, restless limbs, skin changes, and redness associated with venous insufficiency, and was more effective than diosmin-hesperidin.[37] The recommended dose is 45-360 mg of a standardized maritime pine bark extract taken daily in up to three divided doses for 3-12 weeks.

Orders

See Basic Diet Orders chapter.

Exercise prescription.

What to Tell the Family

Some evidence suggests that venous insufficiency and varicose veins may be, in part, preventable through a high-fiber, low-fat diet; regular exercise; and maintenance of normal body weight. Medical, surgical, and botanical approaches are available for treatment.

References

  1. Tretbar LL. Deep veins. Dermatol Surg. 1995;21(1):47-51.  [PMID:7600018]
  2. Criqui MH, Jamosmos M, Fronek A, et al. Chronic venous disease in an ethnically diverse population: the San Diego Population Study. Am J Epidemiol. 2003;158(5):448-56.  [PMID:12936900]
  3. Chiesa R, Marone EM, Limoni C, et al. Chronic venous disorders: correlation between visible signs, symptoms, and presence of functional disease. J Vasc Surg. 2007;46(2):322-30.  [PMID:17600668]
  4. Callam MJ. Epidemiology of varicose veins. Br J Surg. 1994;81(2):167-73.  [PMID:8156326]
  5. Evans CJ, Fowkes FG, Ruckley CV, et al. Prevalence of varicose veins and chronic venous insufficiency in men and women in the general population: Edinburgh Vein Study. J Epidemiol Community Health. 1999;53(3):149-53.  [PMID:10396491]
  6. Criqui MH, Denenberg JO, Bergan J, et al. Risk factors for chronic venous disease: the San Diego Population Study. J Vasc Surg. 2007;46(2):331-7.  [PMID:17600666]
  7. Lee AJ, Evans CJ, Allan PL, et al. Lifestyle factors and the risk of varicose veins: Edinburgh Vein Study. J Clin Epidemiol. 2003;56(2):171-9.  [PMID:12654412]
  8. Browse NL. The etiology of venous ulceration. World J Surg. 1986;10(6):938-43.  [PMID:3798942]
  9. Browse NL, Burnand KG. The cause of venous ulceration. Lancet. 1982;2(8292):243-5.  [PMID:6124673]
  10. MacKay D. Hemorrhoids and varicose veins: a review of treatment options. Altern Med Rev. 2001;6(2):126-40.  [PMID:11302778]
  11. Jawien A. The influence of environmental factors in chronic venous insufficiency. Angiology. 2003;54 Suppl 1:S19-31.  [PMID:12934754]
  12. Brand FN, Dannenberg AL, Abbott RD, et al. The epidemiology of varicose veins: the Framingham Study. Am J Prev Med. 1988;4(2):96-101.  [PMID:3395496]
  13. Myers MB, Cherry G, Heimburger S, et al. The effect of edema and external pressure on wound healing. Arch Surg. 1967;94(2):218-22.  [PMID:6016270]
  14. Klonizakis M, Tew GA, Gumber A, et al. Supervised exercise training as an adjunct therapy for venous leg ulcers: a randomized controlled feasibility trial. Br J Dermatol. 2018;178(5):1072-1082.  [PMID:29077990]
  15. Mutlak O, Aslam M, Standfield N. The influence of exercise on ulcer healing in patients with chronic venous insufficiency. Int Angiol. 2018;37(2):160-168.  [PMID:29368880]
  16. Jull A, Slark J, Parsons J. Prescribed Exercise With Compression vs Compression Alone in Treating Patients With Venous Leg Ulcers: A Systematic Review and Meta-analysis. JAMA Dermatol. 2018;154(11):1304-1311.  [PMID:30285080]
  17. O'Brien J, Finlayson K, Kerr G, et al. Evaluating the effectiveness of a self-management exercise intervention on wound healing, functional ability and health-related quality of life outcomes in adults with venous leg ulcers: a randomised controlled trial. Int Wound J. 2017;14(1):130-137.  [PMID:26817648]
  18. Burkitt DP. The protective properties of dietary fiber. N C Med J. 1981;42(7):467-71.  [PMID:6265811]
  19. Fowkes FG, Lee AJ, Evans CJ, et al. Lifestyle risk factors for lower limb venous reflux in the general population: Edinburgh Vein Study. Int J Epidemiol. 2001;30(4):846-52.  [PMID:11511615]
  20. Richardson JB, Dixon M. Varicose veins in tropical Africa. Lancet. 1977;1(8015):791-2.  [PMID:66583]
  21. Lee AJ, Evans CJ, Hau CM, et al. Fiber intake, constipation, and risk of varicose veins in the general population: Edinburgh Vein Study. J Clin Epidemiol. 2001;54(4):423-9.  [PMID:11297893]
  22. Lee AJ, Lowe GD, Rumley A, et al. Haemostatic factors and risk of varicose veins and chronic venous insufficiency: Edinburgh Vein Study. Blood Coagul Fibrinolysis. 2000;11(8):775-81.  [PMID:11132657]
  23. Lindahl B, Nilsson TK, Jansson JH, et al. Improved fibrinolysis by intense lifestyle intervention. A randomized trial in subjects with impaired glucose tolerance. J Intern Med. 1999;246(1):105-12.  [PMID:10447232]
  24. Marckmann P, Sandström B, Jespersen J. Low-fat, high-fiber diet favorably affects several independent risk markers of ischemic heart disease: observations on blood lipids, coagulation, and fibrinolysis from a trial of middle-aged Danes. Am J Clin Nutr. 1994;59(4):935-9.  [PMID:8147341]
  25. Beebe-Dimmer JL, Pfeifer JR, Engle JS, et al. The epidemiology of chronic venous insufficiency and varicose veins. Ann Epidemiol. 2005;15(3):175-84.  [PMID:15723761]
  26. Raftopoulos I, Ercole J, Udekwu AO, et al. Outcomes of Roux-en-Y gastric bypass stratified by a body mass index of 70 kg/m2: a comparative analysis of 825 procedures. J Gastrointest Surg. 2005;9(1):44-52; discussion 52-3.  [PMID:15623444]
  27. Underland V, Sæterdal I, Nilsen ES. Cochrane summary of findings: horse chestnut seed extract for chronic venous insufficiency. Global Adv Health Med . 2012;1:122-123.
  28. Lyseng-Williamson KA, Perry CM. Micronised purified flavonoid fraction: a review of its use in chronic venous insufficiency, venous ulcers and haemorrhoids. Drugs. 2003;63(1):71-100.  [PMID:12487623]
  29. Smith PC. Daflon 500 mg and venous leg ulcer: new results from a meta-analysis. Angiology. 2005;56 Suppl 1:S33-9.  [PMID:16193225]
  30. Allaert FA. Meta-analysis of the impact of the principal venoactive drugs agents on malleolar venous edema. Int Angiol. 2012;31(4):310-5.  [PMID:22801396]
  31. Boyle P, Diehm C, Robertson C. Meta-analysis of clinical trials of Cyclo 3 Fort in the treatment of chronic venous insufficiency. Int Angiol. 2003;22(3):250-62.  [PMID:14612852]
  32. Vanscheidt W, Jost V, Wolna P, et al. Efficacy and safety of a Butcher's broom preparation (Ruscus aculeatus L. extract) compared to placebo in patients suffering from chronic venous insufficiency. Arzneimittelforschung. 2002;52(4):243-50.  [PMID:12040966]
  33. Toledo RR, Santos MERC, Schnaider TB. Effect of Pycnogenol on the Healing of Venous Ulcers. Ann Vasc Surg. 2017;38:212-219.  [PMID:27521821]
  34. Gulati OP. Pycnogenol® in chronic venous insufficiency and related venous disorders. Phytother Res. 2014;28(3):348-62.  [PMID:23775628]
  35. Belcaro G, Luzzi R, Hu S, et al. Improvement in signs and symptoms in psoriasis patients with Pycnogenol® supplementation. Panminerva Med. 2014;56(1):41-8.  [PMID:24637472]
  36. Belcaro G. A Clinical Comparison of Pycnogenol, Antistax, and Stocking in Chronic Venous Insufficiency. Int J Angiol. 2015;24(4):268-74.  [PMID:26648668]
  37. Cesarone MR, Belcaro G, Rohdewald P, et al. Comparison of Pycnogenol and Daflon in treating chronic venous insufficiency: a prospective, controlled study. Clin Appl Thromb Hemost. 2006;12(2):205-12.  [PMID:16708123]
  38. Miller AL. Botanical influences on cardiovascular disease. Altern Med Rev. 1998;3(6):422-31.  [PMID:9855567]