Varicose veins are enlarged, tortuous veins that most commonly occur in the legs, although they can appear elsewhere. The basic underlying problem lies with the veins, and when the condition has progressed significantly, the skin. Veins are blood vessels that carry blood back to the heart. In the legs, the veins must work against gravity to deliver blood to the heart. There are two systems of veins in the legs: the deep veins, which most people cannot see or feel, and the superficial veins. The deep veins are the most important, as they carry 90% of the blood from the legs to the heart. The deep veins are located near the arteries, and it is the deep veins that are mainly affected by the most common severe forms of varicose veins. Superficial veins are not as important to the circulation of the legs, and varicose veins in the superficial veins do not pose a significant threat to the health of the legs. When veins become varicose, it is usually because the valves in the veins are not functioning properly. Valves act as one-way flaps to prevent blood from flowing backwards as it moves up the legs. If a valve fails to function, blood can flow in the reverse direction, back down the leg. This is called venous reflux. In the superficial veins, this results in blood being forced into smaller veins near to the skin, causing the veins to become swollen and distended. If varicose vein progress significantly in the superficial veins, they can sometimes cause skin damage and/or sores.
Varicose veins develop over time, and an understanding of this process is essential in advancing treatment options for this condition. The prevalence of varicose veins ensures that a knowledge of varicose veins and time will be beneficial in numerous medical specialties. In order to better explore the impact of aging on varicose veins, we will review potential mechanisms and discuss whether or not they are unique to the aging process.
Definition of Varicose Veins
Varicose veins can cause muscle cramps and a heavy feeling in the legs, but more severe symptoms include swelling, throbbing, and edematous skin. Skin changes in the leg caused by long-term pooling of blood are called stasis dermatitis. The skin becomes discolored and thin, it can easily be injured and take a long time to heal. In severe cases, long-standing varicose veins can lead to sores or ulcers on the legs.
This disease primarily occurs in the great saphenous vein and the small saphenous vein, but could happen in any superficial or deep vein. Superficial veins become varicose when their walls lose elasticity and cause the blood to pool. The effect of deep veins becoming varicose is damage to the valves and saphenous vein junction. High venous pressure is the cause of all varicose veins.
Varicose veins are abnormally enlarged superficial veins often seen in the legs. Normally, blood circulates from the heart to the rest of the body via arteries, which carry oxygen-rich blood from the heart to tissue. Blood vessels called capillaries and then go into veins. Veins usually carry deoxygenated blood back to the heart, but the veins in the leg must work against gravity in order to push blood back up to the heart. Muscle contractions in the lower legs act as pumps, and elastic vein walls help blood return to the heart. Tiny, one-way valves in the veins open as blood flows toward the heart and then close to stop blood from flowing backwards. If the veins are too stretched or the valves are too weak, the blood will flow back and collect in the vein. This high venous pressure will cause the veins to become varicose.
Varicose veins are a frequent and persistent complication of cardiovascular disease. They often progress and increase with age and are a common cause of discomfort. Women are more affected than men. About 20% of the adult population will develop varicose veins at some time in their lives.
Prevalence of Varicose Veins in Aging Population
Varicose veins are a common condition in the Western world. Approximately 40% of the population can expect to suffer from this condition at some point in their lives. It has always been considered a disease of the elderly, occurring in approximately 1 in 2 people over the age of 65. While it is considered possible for varicose veins to occur in any body, at any age, there is an increasing amount of evidence to suggest that it is a disease of primary of middle and old age. This is important to clarify as there is a difference between the development of spider veins and the development of veins that could be classified as varicose. The latter is a more serious condition and can affect people in different ways. Some may be genetically predisposed to varicose veins and could have been developing them from an early age. Others may only develop varicose veins during pregnancy and/or start to notice them later on in life. The cutoff point where it is more likely for symptoms to result from a cause becomes more apparent from the age of 40. This is the age where primary varicose vein occurrence is on the increase and would be a good defining point of entry into “old” age.
Importance of Understanding the Impact of Time on Varicose Veins
Some common features of aging, such as color changes like brown discoloration near the ankle and the thinning of the skin, make it difficult to distinguish varicose eczema from other skin conditions that cause swelling and skin changes on the lower leg, and the treatment for this is often unsatisfactory. Gaining a better understanding of how vein disease causes these skin changes may lead to improved diagnosis and treatments for conditions that are sometimes unrelated to severe vein disease.
Another reason the impact of time on varicose veins needs to be better understood is it carries an interest related to the natural history of a very prevalent and bothersome disease. By learning more about the changes that occur as vein disease worsens and its effects on the skin, researching scientists and physicians can develop ways to stop or reverse these changes. Presently, it is known that the most severe forms of superficial vein disease result in the development of skin damage and ulceration, but relatively little is known about how and why this occurs.
It is not only important to understand that varicose veins are unlikely to disappear, it is of increasing importance to understand the impact of time on varicose veins if appropriate methods of treatment or prevention are to be implemented. Varicose veins are symptomatic of underlying vein disease. The progression of this disease is the cause of the frequently disturbing changes to the skin and soft tissues that occur over time. Understanding the impact of time on the progression of vein disease will enable patients to make more informed decisions about treatment options and allow physicians to provide patients with better advice regarding the expected results of those treatments.
Causes of Varicose Veins
There are a number of risk factors for varicose veins. Age is an important and unchangeable risk factor. The normal wear and tear of aging may cause the valves in the veins to weaken and fail. This is due to continuous use of the veins, which increases the likelihood of weak or damaged valves. Women have a higher chance of developing varicose veins than men. This is believed to be due to hormonal changes in women premenstruation or post menopause, including pregnancy. During pregnancy, the growth of the fetus increases the pressure on the abdomen, which can restrict blood flow from the legs to the pelvis. This can cause vein enlargement. Hormonal medications, including birth control pills and postmenopausal estrogen, also increase the risk of developing varicose veins. These medications have been shown to alter the vein walls as well as the valves. This increases the likelihood of vein weakness as well as increasing the potential for blood to reflux.
The pooling of blood in the veins is usually caused by damaged or diseased valves in the veins. Normally, arteries transport blood from the heart to the rest of the body, and veins return blood from the rest of the body to the heart. To return blood to the heart, the veins in the legs must work against gravity. Muscle contractions in the lower legs act as pumps, and elastic vein walls help blood return to the heart. Tiny, one-way valves in the veins open as blood flows toward the heart, then close to stop blood from flowing backward. If the veins are weak or damaged, the blood can back up and flow in the opposite direction. This is known as venous insufficiency and is a cause of varicose veins.
Age-related Factors
The valve and the vein wall are also subject to damage with age. Persistent and habitual pressure on the valves from standing exacerbates valve damage. Patients who stand for long periods at work are more likely to develop varicose veins. Age causes wear and tear on the valves and over time they become incompetent. High-pressure reflux can occur even with mild incompetence of the valves. Erosion of the valve tissue from the hydrostatic force can lead to the development of vein wall dilation and a varicosity. Damage to the vein wall can also occur from habitual muscle pump failure. The loss of muscle bulk with age leads to a reduction in the efficacy of the calf muscle pump at increasing the velocity of blood flow up the veins. This can lead to the stagnation of blood in the veins and the eventual development of a varicose vein.
Age is the most significant factor in the development of varicose veins. Statistical studies of patients with varicose veins have demonstrated that developing varicose veins is virtually a certainty as we age. By the time we reach our 70s, a large proportion of the population will have some degree of varicose veins. In our teens and twenties, our skin and the connective tissue making up the vein wall are at their most elastic and resilient. This means that the vein can stretch to accommodate regurgitating blood flow without losing its shape or allowing the valves to become incompetent. With age, the skin becomes less elastic with a reduction in collagen and it loses some of its protective properties. This predisposes the skin to damage and allows for the development of a varicosity.
Genetic Predisposition
This is based on a study of families with a history of symptomatic varicose veins, that concluded inheritance of HCH, skin changes, reflux by color duplex, and deep venous abnormalities was most commonly seen. It should be noted that genes themselves are not modifiable, but identification of the genes and gene regulators that affect venous function may give rise to future methods of prevention for those at high genetic risk. These methods may involve altering the venous risk factor profile of an individual to prevent the occurrence of varicose veins. This concept is not unlike the macular degeneration prevention trial, whereby lifestyle and nutritional supplements are manipulated in those at high risk, based on genetic risk profile, in order to prevent a particular health outcome.
Recent years have seen increasing evidence for genetic factors influencing the development of varicose veins. A case control study of female twin pairs estimated the heritability of varicose veins to be 62%, a value comparable to that for type 2 diabetes mellitus. A Swedish study using the Swedish Total Population Register and the Swedish Hospital Discharge Register to analyze the risk of a child who has both parents affected by varicose veins also supports a genetic predisposition. Probandwise concordance rates based on parental status and affected offspring status were significantly different. That is, a child whose parent(s) are affected by varicose veins has a greater risk of developing varicose veins themselves. It has also been suggested that inheritance of any one of the many risk factors for varicose veins discussed above may lead to an increased risk of developing symptomatic varicose veins.
Lifestyle Factors
Lifestyle factors over which an individual has some control may hasten the onset of varicose veins. Long periods of standing work aggravate previously existing valve dysfunction and are a high risk factor for first-time development of varicose veins. The concept that occupations which demand a lot of sitting work also promotes the development of varicose veins seems to be intuitive but has been slower to gather support from research studies. Prolonged sitting, particularly with the legs in dependent positions, has been shown in various studies to be associated with a higher incidence of varicose veins. This is due to the increased venous pressure in the legs compared to other forms of sedentary work. High-intensity competitive impact sports and activities, and leg injury have also been associated with a higher prevalence of varicose veins. Regular weight-bearing exercise is known to improve the tone of the musculo-venous pump and has a protective effect against the onset of varicose veins. Gaitz et al showed that walking or running more than 10 miles a week was associated with a significantly lower risk of the first-time occurrence of varicose veins compared to individuals who walked under 2 miles a week. Finally, in the realm of avoidable or modifiable risk factors, numerous studies have shown an association between smoking and an increased prevalence of varicose veins, therefore giving yet another reason for smokers to quit the habit.
Effects of Aging on Varicose Veins
Unfortunately, age makes it less likely that varicose veins and their associated problems will improve after treatment and more likely that they will recur. This is because the cause of the veins, which is damage to the vein walls and valves, may be too far advanced for simple repair. Additionally, older people are generally less active than younger people, and it is important to maintain an active lifestyle after vein treatment to ensure the best results. Though exercise cannot cure vein disease, it can prevent it from getting worse. If veins do recur, further treatment may be necessary. It is therefore important to weigh the cosmetic results of vein treatment against the potential for improvement in symptoms and the risk of new or recurrent veins.
Aging is the most important factor that causes the development of varicose veins. The passage of time leads to wear and tear on the vein walls and valves, and this damage allows the pooling of blood in the veins, which produces the bulging and coloring that can be seen on the skin. Many people develop some type of vein problem during their lifetime. The most common are spider veins and varicose veins. These vein problems are usually not serious, although they can cause discomfort. On rare occasions, vein problems can be a sign of more serious conditions such as blocked deeper veins or blood clots. Spider veins, a milder type of varicose veins, are the most common leg vein issue. They occur in approximately 70% of women and 30% of men. Spider veins occur in the skin itself and look like a web of red, purple or blue lines. They can cause burning or itching. Varicose veins are enlarged bulging veins. Although they look terrible, they can cause varied symptoms. These include heavy and aching legs, swelling in the ankles, night cramps, and swollen, tired legs.
Weakening of Vein Walls
Veins have adapted to these effects by pooling the blood into the relaxed areas of the calf muscles. This is to help blood flow return to the heart and to buffer the effects of gravity. However, this can be to the detriment of the veins as the years go by. The combined effect of the wear and tear and the increased pressure exerted on the veins can cause the vein walls to stretch and become distended, and over time the one-way valves become incompetent. This will cause blood to flow backwards and pool in the area just above the ankles, some of it getting forced through the vein walls and into the surrounding tissue. This is known as venous hypertension; the increased output of blood into the tissue can cause varicose veins to form.
As human beings age, several stages are encountered by our bodies. The effects of these progressive changes may begin to be noticed on the venous system, the first obvious signs of this being on the legs. The effects are believed to be starting at the trauma the veins have encountered. Over the years, the veins in the legs have been subjected to a considerable degree of wear and tear, as they have worked to pump blood back to the heart, and more importantly, if the person has had a job which involves prolonged standing or sitting, the force of gravity shall go against the downward flow of the blood from the legs.
Decreased Elasticity
Sun damage to the skin, a common occurrence in fair-skinned, older individuals, can cause the skin to become thin and fragile over a long period of time. This is also the case with varicose veins, as the loss of integrity in the vessel walls can cause them to rupture with the slightest knock or cut to the leg. This can result in fairly severe bruising to the skin and can take a long time to heal due to the impaired blood flow associated with varicose veins. In more serious cases, thin vessel walls can cause the skin to break with no obvious trauma, resulting in a wound that leaks blood into the surrounding area, forming a brown spot from blood pigments and iron. This is known as a varicose eczema, and the presence of any cuts or sores on the legs can lead to infection, so it is always best to have these things examined by a doctor. Lastly, the most serious complication of this is the venous leg ulcer, open wounds near the ankle that are very slow to heal and can be very painful. Eczema and leg ulcers are topics that will be covered in much more detail in a later article.
With time, elastin and collagen, the key connective tissues in skin and blood vessel walls, become less firm and less elastic. This causes the skin to lose its tone and to wrinkle, and the blood vessels to lose their form, stretch, and leak. While all these things naturally occur in the skin and veins as time goes on, there are added factors that can accelerate these processes in the veins of the legs.
Impaired Blood Flow
Pressure within veins in the lower leg is considerably higher when standing compared with reclining. This pressure is transmitted to the small veins lying just under the skin (reticular veins) and the tiny veins within the skin (telangiectasia). If the pressure is sufficiently high, it will cause damage to the inside of the small veins. This is the most important factor leading to skin damage caused by varicose veins. Iron pigment from the cells within the vein will be released into the surrounding skin, causing a brownish, often speckled pigmentation. White blood cells escaping from the vein in response to the vein wall damage will cause inflammation in the skin. Both the iron pigment and the inflammation can result in skin symptoms such as eczema or, in more severe cases, a pigmented area of skin surrounded by a white area which is a healed venous ulcer.
Increased Risk of Complications
Effect of aging has also been found to increase the propensity of developing complications involving venous disease. In a review of 68 patients over age 65, prior to needing surgery, 75% were found to have skin changes caused by venous disease including pigmentation or inflammation due to chronic blood cell breakdown and poor healing ulcers. An association has been noted between age and presence of active or healed venous ulcers and is said to double for each decade after 65. Although genetic factors and deep vein disease play a part in the development of venous leg ulcers, it has been well documented that sustained ambulatory venous hypertension is the greatest factor and varicose veins are the common underlying cause. Due to the chronic nature and substantial disability caused by venous ulcers, it is crucial to identify those at risk in order to prevent their occurrence and treat the underlying pathology. In an extension Haemodynamical study, 40 healthy individuals and 40 patients with varicose veins matched for age and gender were compared through a method of plethysmography and found that in normal subjects, ambulatory venous pressure is lowest in the early morning, during the day and highest during the night. However, in patients with varicose veins, the decrease in venous pressure during the day is blunted and does not achieve the levels found in normal subjects during rest. This means that those with varicose veins are constantly working their calf muscle pump to maintain a normal level of venous pressure and when this is unremitting and uncompensated, it predisposes the development of chronic venous insufficiency and ulcers.
Prevention and Management of Varicose Veins in Aging Individuals
The most effective exercises to prevent varicose veins are low-impact activities that use the calf muscles, such as walking, cycling, and swimming. On the other hand, high-impact activities and weightlifting are not advisable because they can cause the dilation of the veins due to the increase in blood pressure. Step-ups and sit-ups should also be avoided because they put too much pressure on the leg veins.
Exercise also helps to reduce blood pressure, one of the causes of varicose veins, by strengthening the heart and circulatory system. In addition to these benefits, exercise also helps to prevent obesity, another cause of varicose veins, and strengthens the muscle tone of the body. This is especially important in preventing varicose veins because strong muscle tone aids in the prevention of blood pooling in the veins.
As well as maintaining a healthy weight, regular exercise is also beneficial in preventing varicose veins. This is because exercise helps to improve blood flow from the legs to the heart, so the heart doesn’t have to work as hard to pump blood back up from the legs. This is contrary to the belief that standing, which causes pooling of blood in the veins, is a direct cause of varicose veins. Although it can exacerbate the condition for those who are already predisposed to it, studies have shown that it is not a direct cause.
Furthermore, being overweight can result in varicose vein symptoms being much more severe and harder to come back from, so maintenance of a healthy weight is important in preventing varicose veins.
Lifestyle modifications are the first line of action to prevent or mitigate varicose veins. Among the many risk factors for varicose veins, the one with the biggest impact is obesity, which is known to cause the development or worsening of varicose veins.
Lifestyle Modifications
Lifestyle-related habits have been shown to greatly affect the development of varicose veins and the comfort level experienced by individuals afflicted with the condition. The old adage that an ounce of prevention is worth a pound of cure is very applicable in the case of varicose veins. There are many things that individuals prone to varicose veins can do to prevent the condition from developing or progressing. Exercise can improve the circulation in your legs. Although prolonged standing is an aggravating factor for those who already have the condition, there is no evidence to suggest that it’s actually a cause. In fact, exercising calf muscles can be beneficial as it helps to push blood up from the legs and back towards the heart. Using breaks at work to take a 10-15 minute walk can be very beneficial. Losing weight can also improve the symptoms of varicose veins, it’s not so much the cosmetic appearance, but the excessive fatty tissue can put increased pressure on the veins. Diet can also affect your weight and there are some simple dietary changes that can also make you more comfortable, e.g. reducing salt consumption to lessen water retention. Finally, avoiding long periods of sitting or standing and elevating the legs when possible to decrease pressure in the lower legs can be beneficial. Basically, anything that reduces the pressure in the veins of the lower legs or improves circulation is a good thing.
Compression Stockings
Research into the use of compression stockings in the treatment of varicose veins is characterized by a large variability in the construction of the stockings and the compression applied. This makes it difficult to determine whether there is a ‘best’ stocking and what level of compression is ideal. Most of the work has focused on the treatment of associated chronic venous insufficiency, as it is this disease that varicose veins ultimately reflect. However, the pathology of varicose veins and chronic venous disease is often assumed to be the same and the two are frequently discussed together in the literature without separating them. Compression stockings are known to improve symptoms of aching and swollen legs in those suffering from varicose veins. The mechanism by which they do this is not fully understood. It is thought that the external pressure exerted by the stocking compresses the veins and helps the venous valves to function properly. This in turn prevents pooling of blood in the lower limbs and reduces ambulatory venous hypertension. This means that the stocking could be preventing further progression of varicose veins and venous disease rather than just relieving symptoms. One small study has used air plethysmography to measure venous filling with the aim of calculating the optimal interface pressure to reduce venous filling in varicose veins. Despite the fact that compression stockings are a first line treatment for varicose veins, there is still much that is unknown about their precise cause and pathophysiology. This highlights the need for further research into this very common condition.
Medical Interventions
Endoscopic variceal surgery: This procedure is rare and is usually only utilized if there are ulcerated veins present. An endoscopic probe is passed through a small incision in the skin to clear the affected veins.
Phlebectomy: This is a method of physically removing the varicose vein from the leg. Several tiny incisions are made in the skin through which the vein is removed. This can be performed under local anaesthetic and does not require stitches. A variation of this method is more recently utilized through the use of special glue and a procedure known as ‘SAP’ (sealing the affected perforator vein). The affected non-saphenous veins are removed a few weeks later using a tiny hook. This method avoids the need for the patient to wear pressure stockings and allows a rapid return to normal activities.
Tie and strip: This involves tying off the vein through a small incision further down the leg and removing the vein from the site of the injection. Stripping is usually performed – literally pulling the affected vein out from the bottom up using a thin plastic wire. This procedure should prevent varicose veins from recurring.
Surgery is generally the recommended treatment for more severe varicose veins. It is usually carried out under general anaesthetic but can also be carried out under local anaesthetic. The surgical options for varicose veins include:
