Overview and Risk Factors
Chronic venous insufficiency is a common clinical problem, whose presentation ranges from mildly unsightly veins to recurrent cellulitis and ulceration requiring frequent hospitalizations. An estimated 25% of the U.S. 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 muscular compartments and superficial veins that lie outside the deep fascia and muscles. Venous insufficiency is a disorder of the deep veins, whereas varicose veins, the most common manifestation of chronic venous disease, are a disorder of the superficial veins.
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, obstruction to venous flow, and/or failure of the muscular “venous pump” (the pumping effect that occurs upon contraction of leg muscles during walking and other activities).
Most cases of varicose veins are asymptomatic. However, clinical symptoms may include swelling, aching, tension, leg fatigue, burning, and pruritis, which are relieved with recumbency or leg elevation. As venous insufficiency progresses, skin pigmentation and induration occur. In severe cases, recurrent cellulitis and ulceration can develop, which may be life–threatening.
Risk Factors
The following factors are associated with increased risk of venous disorders:
- 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.
- Female gender. Varicose veins occur up to twice as often in women.
- Increasing height.
- Increasing age.
- History of leg injury.
- History of phlebitis or deep venous thrombosis.
- Lifestyle factors. Obesity, prolonged standing, sedentary lifestyle, and pregnancy are suspected risk factors for the development of varicose veins. Physical inactivity is associated with risk for chronic venous insufficiency and varicose veins in some,1,2 although not all,3 studies. Occupations that require prolonged standing are associated with greater risk.4
- Klippel–Trenaunay–Weber syndrome. This condition occurs due to an abnormal or absent deep venous system and results in a triad of extensive unilateral varicose veins, limb hypertrophy, and a port–wine stain.
Diagnosis and Treatment
Diagnosis
A thorough history and physical examination are usually sufficient for diagnosis. 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 venous 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
Bed rest, leg elevation, and compression stockings or bandages are the initial therapy in most patients. Compression stockings act by decreasing venous pressure and reflux. They should be able to exert 20 to 30 mmHg 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 DVT prevention, which exert less than 10 mmHg).
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. Aspirin and oral antibiotics may be used to accelerate the healing of venous ulcers.
Venous ablation by injection sclerotherapy is useful in many patients with varicose veins for whom conservative therapies have failed.
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.5
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, resulting in constipation–induced straining during defecation.6 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.4,6
Although this hypothesis has not been proven,7 epidemiological evidence supports a relationship between a lack of fiber and the prevalence of varicose veins. The presence of varicose veins in some developing regions is associated both with increases in refined (fiber–poor) carbohydrate and decreases in stool weight.8 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.9 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.10 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,11,12 indicating their possible utility in this condition.
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.13 Obesity prevention appears to be more effective than obesity treatment. Obesity surgery was not effective for improvement of venous insufficiency.14 See Obesity for details on dietary contributors to and treatments.
Botanical Treatments
Certain botanical treatments have demonstrated some promise for treating chronic venous insufficiency in limited clinical trials. These include the following:
Horse chestnut seed. Systematic reviews have concluded that extracts of horse chestnut seed (Aesculus hippocastanum, 50 mg twice a day) reduce leg pain, leg volume, edema, and itching.15,16 The active ingredient (aescin) appears to inhibit elastase and hyaluronidase, slowing the degradation of the capillary endothelium and extravascular matrix and normalizing capillary permeability.4
Diosmin–hesperidin combination. 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.4,17 A recent 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.18
Butcher’s Broom. Extracts of Ruscus aculeatus (150 mg 2 to 3 times/day) improve venous insufficiency through inhibition of the permeability–inducing effect of histamine, bradykinin, and leukotriene B4.4 It is particularly effective when combined with another flavonoid (hesperidin) and vitamin C.19 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.4,19,20
Orders
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. Jawien A. The influence of environmental factors in chronic venous insufficiency. Angiology. 2003;54(suppl 1):S19–S31.
2. Brand FN, Dannenberg AL, Abbott RD, et al. The epidemiology of varicose veins: the Framingham Study. Am J Prev Med. 1988;4:96–101.
3. Lee AJ, Evans CJ, Allan PL, Ruckley CV, Fowkes FG. Lifestyle factors and the risk of varicose veins: Edinburgh Vein Study. J Clin Epidemiol. 2003;56:171–179.
4. MacKay D. Hemorrhoids and varicose veins: a review of treatment options. Altern Med Rev. 2001;6:126–140.
5. Miller AL. Botanical influences on cardiovascular disease. Altern Med Rev. 1998;3:422–431.
6. Burkitt DP. The protective properties of dietary fiber. N C Med J. 1981;42:467–471.
7. Fowkes FG, Lee AJ, Evans CJ, Allan PL, Bradbury AW, Ruckley CV. Lifestyle risk factors for lower limb venous reflux in the general population: Edinburgh Vein Study. Int J Epidemiol. 2001;30:846–852.
8. Richardson JB, Dixon M. Varicose veins in tropical Africa. Lancet. 1977;1:791–792.
9. Lee AJ, Evans CJ, Hau CM, Fowkes FG. Fiber intake, constipation, and risk of varicose veins in the general population: Edinburgh Vein Study. J Clin Epidemiol. 2001;54:423–429.
10. Lee AJ, Lowe GD, Rumley A, Ruckley CV, Fowkes FG. Haemostatic factors and risk of varicose veins and chronic venous insufficiency: Edinburgh Vein Study. Blood Coagul Fibrinolysis. 2000;11:775–781.
11. 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;246:105–112.
12. Marckmann P, Sandstrom 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;59:935–939.
13. Beebe–Dimmer JL, Pfeifer JR, Engle JS, Schottenfeld D. The epidemiology of chronic venous insufficiency and varicose veins. Ann Epidemiol. 2005;15:175–184.
14. Raftopoulos I, Ercole J, Udekwu AO, Luketich JD, Courcoulas AP. 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;9:44–52.
15. Pittler MH, Ernst E. Horse chestnut seed extract for chronic venous insufficiency. Cochrane Database Syst Rev. 2006;(1):CD003230.
16. Siebert U, Brach M, Sroczynski G, Berla K. Efficacy, routine effectiveness, and safety of horse chestnut seed extract in the treatment of chronic venous insufficiency. A meta–analysis of randomized controlled trials and large observational studies. Int Angiol. 2002;21:305–315.
17. Lyseng–Williamson KA, Perry CM. Micronised purified flavonoid fraction: a review of its use in chronic venous insufficiency, venous ulcers, and hemorrhoids. Drugs. 2003;63:71–100.
18. Smith PC. Daflon 500 mg and venous leg ulcer: new results from a meta–analysis. Angiology. 2005;56(suppl 1):S33–S39.
19. 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;22:250–262.
20. 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;52:243–250.
