Pay attention if your veins are enlarged, swollen, lumpy, twisted, blueish or dark purple – they are probably varicosed and need medical attention.
Patients seldom consult a doctor as the initial symptoms may be mild and do not always lead to major health complications.
These unsightly veins can appear anywhere in the body, but most of the time, they show up in the legs because standing and walking increases the pressure in the veins of the lower body.
Our circulatory system is made up of blood vessels that carry blood from and towards the heart.
Arteries are blood vessels responsible for carrying oxygen-rich blood from the heart to the body.
Veins are blood vessels that carry blood low in oxygen from the body back to the heart (and to the lungs) for reoxygenation.
There are tiny one-way valves inside our veins that open to let the blood through, and then close to prevent it from flowing backwards.
If the walls of our veins become stretched and lose their elasticity, it causes the valves to weaken.
When the valves malfunction, the blood then leaks and flows backwards in a condition called venous reflux or chronic venous insufficiency (CVI).
This results in blood pooling in the veins.
For blood to return from the legs to the heart, the veins in the leg must work against gravity and as they are unable to do so, they become swollen or enlarged.
Other CVI symptoms include restless or heavy legs, fatigue, leg or ankle swelling, pain, aching, cramping, burning or itching skin, and ulcers.
CVI is two times more common than coronary artery disease and five times more common than peripheral arterial disease, yet there is poor awareness among Malaysians of the possible complications resulting from untreated varicose veins.
From cosmetic to pain
There are six stages of varicose veins:
- Stage 0: No visible or palpable (detectable by touch) sign of venous disease.
- Stage 1: Telangiectasis (also known as spider veins) or reticular veins, which are both visible, but not palpable signs of venous disease.
- Stage 2: Varicose vein.
- Stage 3: Oedema (swelling due to fluid accumulation).
- Stage 4a: Pigmentation of the skin or eczema.
- Stage 4b: Lipodermatosclerosis (inflammation of the layer of fat under the skin).
- Stage 5: Healed venous ulcer.
- Stage 6: Active venous ulcer.
As the disease progresses, the skin above the affected vein becomes pigmented, hardened and itchy, and eventually develops non-healing ulcers.
Occasionally, veins close to the skin’s surface can also burst and cause bleeding.
Varicose veins may start off as light spider veins (telangiectasis).
For many, this presents a simple cosmetic concern until pain and discomfort sets in.
Consultant vascular and endovascular surgeon Dr Tan Kia Lean says: “A lot of people live with varicose veins and think it is nothing because it doesn’t cause much pain in the early stages.
“I won’t say this is the wrong attitude as people are scared of operations and being cut up, but modern treatment is different.
“When it gets to the last stage (ulcer), varicose veins become very difficult to treat and may take months or years to heal.
“One of my patients had a non-healing ulcer for 20 years!
“Even with treatment, he was only able to go back to stage 5 and that’s why early treatment is vital.”
While in stage 3, the symptoms can still be reversed, but at stage 4 when there is skin damage, the symptoms cannot be completely reversed.
Dr Tan explains: “The pigmentation around the ankle area is like rusted iron.
“Our red blood cells carry iron and this iron has oxygen-binding capacity.
“But in varicose veins, when the vein is dilated and turns tortuous (i.e. twisted), the red blood cells cannot pass through and remain outside the veins.
“The iron within those cells will be oxidised and this oxidisation gradually leads to stage 4b, changing the colour of the skin and damaging it.
“The drying and hardening of the skin results in it stretching, and causes micro-oxidisation that cannot be seen with our eyes.
“But we can feel it because when it is exposed to air, it turns itchy; when we scratch, it gets infected and inflamed.”
Women more prone
This is due to the presence of oestrogen and progesterone in their bodies.
Dr Tan says: “These hormones make the vein walls more relaxed, especially during pregnancy, so the neck area of the vein gets dilated easily.
“In addition, the enlarging uterus in the pelvic cavity compresses the venous system and speeds up the formation of varicose veins.”
Being overweight and having jobs that require one to be on their feet for long hours also contribute to the problem, e.g. barbers or hairstylists; hawkers, cooks or chefs; teachers, etc.
“Sometimes, when you wear your shoe in the morning, it will fit well, but as the day passes on, it becomes tight as the blood is gushing down to the leg.
“With sitting, you can also get CVI, but it may not lead to varicose veins,” he adds.
Lifestyle management, leg rest and skin care are important interventions to delay disease progression.
Often, patients only consult a medical practitioner when there is pain, and when the doctor asks them when they started seeing their varicose veins, they will say since childhood!
“Varicose veins can be there for two or three decades without causing symptoms.
“When a patient turns up with symptoms, we have to find out where the problem is.
“Usually, it’s through diagnostic tests via an ultrasound as it provides real-time information on whether blood flow is one direction or bi-directional.
“Varicose veins can also reflect something in the heart – it can be quite difficult to tell what is causing the leg swelling.
“If we suspect something else, then we do a CT (computed tomography) scan,” says Dr Tan.
Evolving treatment
The earliest record of varicose veins is in the papyrus of Ebers, written 1550 BCE, where the author described them as “tortuous and solid, with many knots, as if blown up by air”, and recommended people leave their veins in place.
Later, the ancient Greek physician Hippocrates, widely touted as the father of modern medicine, suggested that people do something about their varicose veins as he noticed a correlation between veins and leg ulcers.
This marked the introduction of vein punctures, cautery (using a hot or caustic agent) and compression bandages as a treatment for varicose veins.
“Now we have compression stockings that prevent the reflux – you might have to use it for a lifetime, but it provides very good control.
“When doctors started understanding the disease better, they used the stripping method where they cut the skin near the top and bottom of the damaged vein, put a thin wire through the top (usually the groin), tie the vein over with wire and then pull it out through the cut in the lower leg,” Dr Tan explains.
Since 1990, endovenous treatment such as thermal ablation, i.e. radiofrequency ablation and laser therapy; sclerotherapy; and mechanochemical ablation; have been available.
Of late, these treatment modalities have become less invasive and less painful, without the need for general anaesthesia to carry them out.
Gluing it shut
In the last five years, cyanoacrylate glue – a special type of “super glue” – has become a popular form of treatment for varicose veins.
In this treatment, medical grade glue is placed in a catheter and inserted into the affected vein at the thigh to close it off.
Once the affected vein is glued shut, blood will immediately be rerouted through other healthy veins in the leg.
The closed vein will undergo a process of hardening (sclerosis) and will gradually be absorbed by the body.
“The therapy is quick and effective, takes around 30 minutes and is done as a daycare procedure – the patients don’t feel anything and there is no need for compression stocking afterwards either,” says Dr Tan.
There are also no pre-procedure drugs involved and patients can return to their normal activities right after the treatment.
There is no risk of skin burns or nerve damage, and immediate post-treatment pain medication is not necessary.
There are no guaranteed methods of preventing varicose veins, but the condition can be managed by getting diagnosed early, making lifestyle adjustments via diet and light to moderate physical activity, and symptom control.
The latter can consist of putting on compression stockings, taking intermittent breaks to sit if you have a job that requires long periods of standing, and resting the legs by elevating them above heart level before sleeping.
On the use of compression stockings, the surgeon says to use them only while standing, walking or exercising.
“When you lie down, there is no venous reflux, so why do you need compression stockings at night?” he notes.
“If you’re travelling, then the worry is not so much about varicose veins, but deep vein thrombosis (DVT, blood clots that form in the deep veins of the leg and travel to the lungs).
“The stockings that you wear for DVT are different from the ones used for varicose veins.
“If you’re on a long haul flight, it is good to put on a DVT stocking, but be sure to maintain hydration throughout so that your blood does not become concentrated.
“Also, walk around to get the blood circulation going,” he advises.
A common myth is that massage is good for varicose veins.
Dr Tan points out: “A massage does not prevent varicose veins from returning; in fact, it will rupture the veins.
“You can massage the legs, but not the affected vein.”
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