Varicose vein disease has a spectrum of presentations and complications. People with venous disease may present with:
- Abnormal veins - spider veins, reticular veins, varicose veins
- Abnormal veins and symptoms, such as swelling in the leg or venous ulcers (breakdown in skin around the lower leg or ankle region)
- Symptoms alone, with no visible abnormal veins
Abnormal veins can range from small thread-like veins called "spider veins" or "telangiectasia", to slightly larger "blue veins" or "reticular veins", to large and bulging "varicose veins". Varicose veins can in turn affect any part of the leg or pelvic area.
Varicose veins are large, dilated, tortuous veins that bulge above the skin surface. They no longer serve one of the primary functions of normal veins, which is to transport blood into the deep veins and then up towards the heart. Varicose veins can occur alone or with many of the physical manifestations of Chronic Venous Disease, and many patients do not realise they have a complication of venous disease until they see a phlebologist.
It is important to note that varicose veins serve NO useful function to the body's circulation - the body develops alternative pathways to bypass them. When a phlebologist closes down a varicose vein, the circulatory system actually improves, as do many of the symptoms.
It is also important to understand that varicose veins can be a progressive condition and that new veins can develop with time; ongoing maintenance treatment is likely for most patients.
Pelvic and Vulval Varicose Veins
Pregnancy-related varicose veins often appear extending from the vulval or gluteal area into the inner thigh. They are caused by varicose veins within the pelvis (around the ovaries, uterus and vagina), and occur predominantly as a result of Ovarian Vein Incompetence, often after multiple pregnancies. These pelvic varicose veins can extend through the vulva and into the thigh and lower leg.
Pelvic Congestion Syndrome can occur in women who have had 2 or more pregnancies. It presents with the presence of pelvic varicose veins as described above in conjunction with several debilitating symptoms - patients usually complain of heaviness and aching in the pelvis after intercourse, with periods, and just before periods. Occasionally, patients may describe urinary symptoms such as incontinence or frequency of urination and bowel symptoms such as bloating and constipation.
Pelvic varicose veins can occur in 2-7% of pregnancies and affect up to 80% of women who have had at least 2 pregnancies. It is extremely important to diagnose this condition as it can lead to recurrence following any vein treatment. Ultrasound Guided Sclerotherapy is used to treat vulval veins.
Spider veins are extremely common - they are the tiny red or blue vessels that can appear anywhere on the body, but more commonly on the legs, face, chest or even abdomen. They may be visible as short, seemingly unconnected lines each about the size of a large hair or they may resemble a spider web or tree with branches. In medical terms spider veins are called "telangiectasias", and usually occur in association with larger dilated blood vessels (often blue / green in colour) called "reticular veins". Often dilated blood vessels cause aching especially with prolonged standing.
Although dilated blood vessels do carry blood they are not very efficient and are often not necessary to the circulatory system. The body will have already established an alternative route for the blood to travel back more efficiently to the heart - thus, they can be treated without damaging the circulation, and treatment actually improves venous circulation.
There is an approximately 80% chance for a greatly improved appearance with Sclerotherapy, depending on the severity of the problem. Treatment will also usually relieve any symptoms caused by the veins. Where necessary, Sclerotherapy of these veins is gold standard treatment.
It is often human nature to allow things to progress to an advanced state before seeking medical attention.
This is the case with this particular patient. Illustrated are many of the signs of chronic venous disease including thickening of the skin and soft tissue in the lower leg and ankle (lipodermatosclerosis), a healed ulcer, discolouration (known as hyperpigmentation), swelling of the lower limb (known as oedema), and of course, large and tortuous varicose veins.
COMPLICATIONS OF SEVERE VARICOSE VEINS (VENOUS DISEASE)
If left untreated (which is usually the case in the majority of patients), patients will progressively develop worsening symptoms in the lower legs, which ultimately culminate in the development of a VENOUS ULCER. A venous ulcer is a breakdown in the skin that is affected by venous disease. They typically occur in the inside part of the ankle (known as 'gaiter's area').
Ulcer treatment can be quite complex and must be managed correctly with a combination of conservative and medical interventions.
One of the stages of skin change prior to ulceration is referred to as "lipodermatosclerosis" or "chronic panniculitis" - this refers to a thickening of the skin and soft tissue in the lower leg and ankle primarily in association with chronic venous disease and varicose veins.
This patient has lipodermatosclerosis and if you look more closely, several small ulcers.
One of the early dermatological signs of varicose veins is what phlebologists refer to as "venous dermatitis" or "venous eczema".
If blood pools in a vein, the overlying skin can become quite irritated and start to itch. Many patients will complain of itchiness over varicose veins and a large percentage of these patients will develop dermatitis in an area affected by venous disease.
This picture illustrates 2 larger areas of venous dermatitis.
Prior to ulceration, small lesions know as "atrophe blanche" can appear in an area affected by varicose vein disease.
Atrophe blanche are necrotic, porcelain scars which occur quite frequently in advanced venous disease.