About half of Americans older than 50 have varicose veins -- veins that are swollen and often can be seen bulging beneath the skin. They often are colored dark purple or blue and are found most often on the backs of the calves or the inside of the leg. (The thickened, twisted or dilated parts of the vein are called varicosities.)
For most, fortunately, varicose veins are chiefly a cosmetic problem. But if varicose veins are accompanied by other symptoms, such as leg pain when standing for a prolonged period, swelling of the feet, ankles or legs, itching over the vein, or if skin changes color or gets drier, thinner or develops scales, it could be a sign of a serious ailment.
About 40 percent of women and 25 percent of men in their 50s have varicose veins. The incidence increases with age. About 70 percent of women and 40 percent of men in their 70s have them.
The job of veins is to return blood to the heart so it can be recirculated. To do this, the veins in the legs have to work against gravity. Muscle contractions in the lower leg act as pumps. Tiny valves in the veins open to send blood up to the heart, then close to keep blood from flowing back downward. Varicose veins occur when these valves weaken, causing blood to pool in the legs. The veins appear blue because they contain blood that has released its oxygen.
With age, veins lose elasticity and valves weaken. A tendency to develop varicose veins can run in families. Some people are born with fewer valves in their veins, valves that don't work properly, or abnormalities in the vein wall that cause the valves to leak.
"The most important predictor is genetic," said Ellen Dillavou, director of venous services and vascular surgery at UPMC. "On top of genetic, if you have multiple pregnancies, or you have to stand for long periods of time, that can push you closer [to having varicose veins]."
If both parents have varicose veins, "there is almost a 75 percent chance their children will develop them, too," said Satish Muluk, a vascular surgeon at Allegheny General Hospital. If one parent has varicose veins, the odds their children also will is about 50 percent, he said.
Pregnancy increases the flow of blood in the body but decreases the flow upward from the legs to the pelvis. Pressure is placed on the legs by the child growing in the uterus. The hormones estrogen and progesterone have a relaxation effect, which can weaken vein walls.
People who stand or sit for long periods of time are at greater risk. Those who are overweight and don't exercise increase their risk.
The obese may not have vein problems, but "all of the extra weight causes a lot of pressure in the tissues around the leg and ankle," Dr. Dillavou said.
Exercise is important, she said, because "the veins themselves don't have any muscles in them. The muscles squeeze the veins and push the blood."
The stronger the muscles are, the more effective they are at pumping blood back up to the heart. The best exercise for preventing varicose veins is walking, Dr. Dillavou said.
So losing weight and working out more can reduce the risk of acquiring varicose veins and ameliorate the effect of existing varicose veins. Avoid standing or sitting for long periods and elevate the legs while sleeping and whenever else the opportunity presents itself. (It's easier for the blood to flow back to the heart when it is flowing downhill.)
Wearing compression stockings also helps. They squeeze the leg, which reduces the amount of blood in and pressure on the legs. Don't try to choose a pair yourself. You should seek a doctor's help in determining how much pressure should be applied to your leg.
Many who have varicose veins assume they are a natural consequence of old age. Only about 10 percent of those afflicted seek medical treatment for them. If varicose veins are unsightly only, that's OK.
But anyone with any of the symptoms listed above -- especially swelling of the leg, flaking or itching skin, or skin ulcers near the ankle -- should see a doctor right away. The ulcers, a possibly serious condition, can be caused by fluid leaking into the skin tissue when blood backs up instead of returning to the heart. A coalition of professional groups has prepared a self-assessment test accessible at: www.RethinkVaricoseVeins.com.
Other vein concerns
Some people who ought to see a doctor don't because they have symptoms "that are very subtle and develop over time," Dr. Muluk said. They become accustomed to mild pain, change their lifestyles to accommodate it and don't think to tell their doctor about it.
People have three kinds of veins: superficial veins, which lie close to the skin; deep veins, which lie in groups of muscles; and perforator veins, which connect the superficial to the deep veins.
Varicose veins are a mild form of chronic venous insufficiency, a condition when the walls or the valves of veins are not working effectively. In deep veins, CVI can have more serious complications. Its causes vary.
More than 30 million people have varicose veins. But no more than 5 or 10 percent of CVI sufferers are likely to develop serious health problems, Dr. Dillavou said.
Dr. Muluk estimated the proportion may be as low as 1 or 2 percent: "It's fair to say the percentage is very small, but that still ends up being a large number of people."
Another condition that can cause leg pain -- phlebitis -- is an inflammation of a vein that can lead to a blood clot. It's not considered serious in a superficial vein, but it is potentially more dangerous in a deep vein. The principal cause is local trauma to the vein, such as insertion of an intravenous catheter, or IV. Phlebitis also can be caused by prolonged inactivity, such as long car or airplane trips, or being bedridden by an illness or after surgery. The chief symptoms are redness, warmth, swelling and pain. Phlebitis may be accompanied by a low-grade fever.
Phlebitis is uncomfortable, but it usually isn't dangerous. More serious is a blood clot or clots in a deep vein, called deep vein thrombosis. Blocking circulation in the vein is serious enough, causing pain and swelling, but if a portion of the blood clot breaks loose and travels first to the heart and then to the lungs, it can be fatal. It can block a pulmonary artery, causing a serious, life-threatening complication, with shortness of breath, rapid heartbeat and chest pain. If this clot, called a pulmonary embolism, is large enough to keep the flow of blood from the right side of the heart from entering the lungs, death can be instantaneous.
Varicose vein treatment
There are new nonsurgical treatments for varicose veins. They work by sealing the diseased vein shut. Blood that normally would flow through these veins is rerouted to other veins. The sealed vein dries up, shrinks and is absorbed by the body.
Radiofrequency ablation uses heat to contract the collagen in the vein walls, causing them to collapse. Laser ablation heats the blood in the diseased vein, causing it to coagulate and close off the vein.
Terrance Krysinski of the Vein Institute of Pittsburgh performs laser ablation as an outpatient procedure using only a local anesthetic. The procedure takes about an hour, after which, he said, "the patient is immediately ambulatory and ready to resume normal activities."
In sclerotherapy, a chemical is injected into the vein, which causes it to seal. It also is an outpatient procedure, used most often to treat small veins. Sometimes several injections are needed to seal off a vein.
The most common types of surgery are vein stripping (the surgeon ties off the diseased vein from the groin to the calf below the knee, then removes it) and angioplasty and stenting. The surgeon uses a balloon (angioplasty) or a metal-scaffold tube (stent) to hold open the blocked artery. Angioplasty and stenting are used to correct deep vein problems, Dr. Muluk said.
Ablation largely has replaced vein stripping for treatment of CVI in superficial veins.
"We hardly ever recommend surgery," Dr. Dillavou said, "because the minimally invasive treatments work just as well or better."
Jack Kelly: firstname.lastname@example.org or 412-263-1476.