Chapter 214 Varicose Veins
Veins are fairly frail structures. Defects in the wall of a vein lead to dilation of the vein and damage to the valves. When the valves become damaged, the higher static pressure results in the bulging veins known as varicose veins.
Varicose veins affect nearly 50% of middle-aged adults. The subcutaneous veins of the legs are the veins most commonly affected, owing to the gravitational pressure that standing exerts on them. When an individual stands for long periods, the pressure buildup in the vein can increase up to 10 times. Hence, individuals with occupations that require long periods of standing are at greatest risk for the development of varicose veins.
Women are affected about four times as frequently as men; obese individuals have a much greater risk; and the risk rises with age owing to loss of tissue tone, loss of muscle mass, and weakening of the walls of the veins. Pregnancy, which increases venous pressure in the legs, may also lead to the development of varicose veins.
In general, varicose veins pose little risk if the involved vein is near the surface. These types of varicose veins are, however, cosmetically unappealing. Although significant symptoms are not common, the legs may feel heavy, tight, and tired. If the varicose veins are associated with significant chronic venous insufficiency, leg ulcers may form that are often difficult to resolve.
A more serious form of varicose vein involves obstruction and valve defects of the deeper veins of the leg. This type of varicose vein can lead to problems such as thrombophlebitis, pulmonary embolism, myocardial infarction, and stroke. Phlebography and Doppler ultrasonography are the most accurate methods of diagnosing deep venous involvement.
The following theories have been advanced to explain the cause of varicose veins:
• Genetic or functional weakness of the veins or venous valves.
• Excessive venous pressure due to increased straining during defecation, often caused by a low-fiber diet.
• Long periods of standing and/or heavy lifting.
• Damage to the veins or venous valves secondary to thrombophlebitis.
The major cause of varicose veins is weakness of the vascular walls due to either abnormalities in the proteoglycans of the interendothelial cement substance or excessive expression/activity/release of matrix metalloproteinases (MMPs) such as β-N-acetylglucosaminidase, β-glucuronidase, and arylsulfatase, which degrade extracellular matrix proteins and affect the structural integrity of the vein wall, leading to increased capillary permeability and loss of venous structural integrity. The MMPs also affect the endothelium and smooth muscle components of the vein wall, thereby causing changes in the properties of venous constriction/relaxation. Endothelial cell injury also triggers leukocyte infiltration, activation, and inflammation, which leads to further damage to the vein wall and thus chronic and progressive venous insufficiency and varicose vein formation.1,2
The treatment of varicose veins ranges from conservative measures to surgical interventions. Conservative therapy involves the following:
• Elevating the legs periodically.
• Wearing graduated compression stockings with variable pressure gradients, especially if standing for long periods of time is unavoidable.
• Exercise, especially walking, riding a bike, or jogging, is thought to be helpful, because contraction of the leg muscles pushes pooled blood back into circulation.
• Achieving or maintaining one’s ideal body weight.
• Maintaining adequate intake of dietary fiber to avoid increasing venous pressure consequent to straining during defecation.
• Using nutritional and botanical agents to assist in improving the structural integrity of the veins.
For severely affected veins, more aggressive treatment may be necessary. The traditional surgical treatment has been vein stripping to remove the affected veins. Newer, less invasive treatments that seal the main leaking vein at the highest point of valvular dysfunction on the thigh include ultrasound-guided foam sclerotherapy, radiofrequency ablation, and endovenous laser treatment. Because most of the blood in the legs is returned by the deep veins, the superficial veins, which return only about 10% of the total blood of the legs, can usually be removed or ablated without serious harm. Sclerotherapy with segmental phlebectomy (stripping of the vein) is also popular. In sclerotherapy with segmental phlebectomy, a sclerosing agent is injected at the highest portion of the affected vein. Only the most badly diseased segments of vein are stripped away with segmental phlebectomy.
A low-fiber diet that is high in refined foods contributes to the development of varicose veins.3,4 Individuals consuming a low-fiber diet tend to strain more during bowel movements because their smaller and harder stools are more difficult to pass. This straining raises the pressure in the abdomen, obstructing the flow of blood up the legs. Over time, this increased pressure may significantly weaken the vein walls, leading to the formation of varicose veins or hemorrhoids, or it may weaken the wall of the large intestine and produce diverticuli.5
A diet rich in vegetables, fruits, legumes, and grains promotes peristalsis, and many fiber components attract water and form a gelatinous mass, which keeps the feces soft, bulky, and easy to pass. The net effect of a high-fiber diet is significantly less straining during defecation.
Natural bulking compounds can also be used. These substances, particularly psyllium seed, pectin, and guar gum, possess a mild laxative action owing to their ability to attract water and form a gelatinous mass. This process, as previously mentioned, keeps the feces soft and promotes peristalsis, significantly reducing straining during defecation. These types of fibers are generally less irritating than wheat bran and other cellulose fiber products.
Berries, such as hawthorn berries, cherries, blueberries, and blackberries appear to be beneficial in the prevention and treatment of varicose veins. These berries are very rich sources of proanthocyanidins and anthocyanidins,6–8 flavonoids are noted for their ability to improve the integrity of ground substance and the vascular system. Extracts of several of these berries are used widely in Europe for various circulatory conditions.6–8
Another rich source of flavonoids is buckwheat, which is high in rutin. In one double-blind placebo-controlled study, 77 patients with chronic venous insufficiency were given placebo tea or Fagopyrum esculentum (buckwheat) tea for 12 weeks. The tea was standardized to contain 5% total flavonoids, yielding a daily dosage of 270 mg of rutin. A statistically significant reduction in total leg volume was seen in the treated group, along with statistically insignificant improvements in capillary permeability and symptoms. No adverse effects were noted.9
The efficacy of these extracts is related to their ability to accomplish the following6–8:
• Increase the integrity of the venous wall
• Inhibit the breakdown of the compounds composing the ground substance