Dr Hirannmayee V
Varicose Veins are present in up to 40% of population. They may be associated with considerable morbidity. Around 70% of patients with chronic venous insufficiency have evidence of superficial venous incompetence on duplex imaging. Prevalence – 35%, Severe Varicose Veins – 10%,
Chronic Venous Insufficiency (CVI) – 8% and Ulcer is 2%.
Key words – Varicose veins, Homeopathy.
- The word Varicose is derived from Latin word ‘Varix’ meaning distended vein.
- Varicose veins are dilated, Tortuous, elongated veins of leg. There is reversal of blood flow through the faulty valves.
- Varicosities are more common in lower limb because of erect posture and long column of blood has to be supported which can lead to weakness and incompetency of valves.
- About 10- 20% of general population develop with peak incidence in 4th to 5th decade.
- It affects 10-20% of population in western countries, only 5 % in India.
- In Bangalore about – 3- 5% of total population suffer from venous problems.
RISK FACTORS –
- Heredity, female sex,
- occupation that demands prolonged standing, immobility,
- Raised intraabdominal pressure- Like in sports, tight clothing,
- pregnancy, raised progesterone levels,
- Altered oestrogen- progesterone ration,
- Chronic constipation and high heels.
AETIOLOGY OF VARICOSE VEINS
Primary varicosities due to:
- Congenital incompetence or absence of valves.
- Weakness or wasting of muscles-defective connective tissue and smooth muscle in the venous wall.
- Stretching of deep fascia.
- Inheritance (family history) with FOXC2 gene.
- Klippel-Trenaunay syndrome, avalvulia,
- Parkes-Weber syndrome. Here varices are of atypical distribution.
- Recurrent thrombophlebitis.
- Occupational standing for long hours (traffic police, guards, sportsman).
- Obstruction to venous return like abdominal tumour, retroperitoneal fibrosis, lymphadenopathy, ascites.
- Pregnancy (due to progesterone hormone), obesity, chronic constipation.
- AV malformations-congenital or acquired.
- Iliac vein thrombosis.
- Tricuspid valve incompetence.
- Long/great saphenous vein varicosity.
- Short/small saphenous vein varicosity.
- Varicose veins due to perforator incompetence.
1)Thread veins (or dermal flares/telangiectasis/spider veins are 0.5-1 mm in size):
Are small varices in the skin usually around ankle which look like dilated, red or purple network of veins (Venulectasia). Spider naevi/venous flares are common in females.
2) Reticular varices (1-3 mm in size):
Are slightly larger varices than thread veins located in subcutaneous/subdermal region.
They are dilated, tortuous, elongated superficial veins located in the subcutaneous tissue (Saphenous compartment) equal or more than 3 mm in diameter measured in standing
4) Combination of any of above.
- C- Clinical signs (grade 0-6); (A) for asymptomatic or (S) for symptomatic presentation
- E- Etiological classification: Congenital (Ee), Primary (Ep), Secondary (Es), No venous aetiology (En) .
- A- Anatomic distribution: Superficial (As), Deep (Ad) or Perforator (Ap), No venous Location identified(Pn).
- P- Pathophysiologic dysfunction: Reflux (Pr), Obstructive (Po), Both, or No Pathology identified(Pn).
GRADING OF CLINICAL SIGNS (C)
- No visible or palpable signs of venous diseases
- Telangiectases, reticular veins or malleolar flare
- Varicose veins
- Oedema without skin changes
- Skin changes due to venous diseases like pigmentation, eczema or lipodermatosclerosis 4a-pigmentation; 4b-lipodermatosis, atrophic blanche
- Skin changes as above with healed ulceration
- Skin changes as above with active ulceration.
- Fibrin cuff theory
- White cell trapping theory
- Incompetence of venous valves – Stasis of blood – Chronic ambulatory venous hypertension — Defective microcirculation – RBC diffuses into tissue planes -, Lysis of ABC’s -, Release of haemosiderin – Pigmentation – Dermatitis – Capillary endothelial damage – Prevention of diffusion and exchange of nutrients -, Severe anoxia Chronic venous ulceration (Fibrin cuff theory).
SYMPTOMS IN VARICOSE VEINS
- Dragging pain, postural discomfort
- Heaviness in the legs
- Night-time cramps-usually late night
- Oedema feet
- Itching (feature of CVI) Discolouration/ulceration in the fee/painful walk.
- Visible dilated veins in the leg with pain, distress,
- nocturnal cramps,
- feeling of heaviness,
- Pedal oedema, pigmentation, dermatitis, ulceration, tenderness, restricted ankle joint movement.
- Bleeding, thickening of tibia occurs due to periostitis.
- Positive cough impulse at the saphenofemoral junction.
- Saphena varix-a large varicosity in the groin which becomes visible and prominent on coughing.
- Trendelenburg test I – Vein is emptied by elevating the limb and a tourniquet is tied just below the saphenofemoral junction (or using thumb, saphenofemoral junction is occluded). Patient is asked to stand quickly. When tourniquet or thumb is released, rapid filling from above signifies saphenofemoral incompetence.
- Trendelenburg test II – after standing tourniquet is not released. Filling of blood from below upwards rapidly can be observed within 30-60 seconds. It signifies perforator incompetence.
2) Perthe’s test:
- The affected lower limb is wrapped with elastic bandage and the patient is asked to walk around and exercise.
- Development of severe cramp like pain in the calf signifies DVT.
3) Modified Perthe’s test:
- Tourniquet is tied just below the saphenofemoral junction without emptying the vein. Patient is allowed to have a brisk walk which precipitates bursting pain in the calf and also makes superficial veins more prominent.
- It signifies DVT. DVT is contraindicated for any surgical intervention of superficial varicose veins. It is also contraindicated for sclerosant therapy.
3)Three tourniquet test
- To find out the site of incompetent perforator, three tourniquets are tied after emptying the vein.
- At saphenofemoral junction.
- Above knee level.
- Another below knee level.
- Patient is asked to stand and looked for filling of veins and site of filling. Then tourniquets are released from below upwards, again to see for incompetent perforators.
- In standing position, when lower part of the long saphenous vein in leg is tapped, impulse is felt at the saphenous junction or at the upper end of the visible part of the vein. It signifies continuous column of blood due to valvular incompetence.
- On standing, the site where the perforators enter the deep fascia bulges and this is marked. Then on lying down, button like depression (crescent like) in the deep fascia is felt at the marked-out points which confirms the perforator site.
- Esmarch bandage is applied to the leg from below upwards followed by a tourniquet at saphenofemoral junction. After that the bandage is released keeping the tourniquet in the same position to see the “blow outs” as perforators.
7) Morrissey’s cough impulse test:
- The varicose veins are emptied. The leg is elevated and then the patient is asked to cough. If there is saphenofemoral incompetence, expansile impulse is felt at saphenous opening. It is a venous thrill due to vibration caused by turbulent backflow.
- On standing, proximal segment of long saphenous vein is emptied with two fingers. Pressure from proximal finger is released to see the rapid filling from above which confirms saphenofemoral incompetence. Examination of the abdomen has to be done to look for pelvic tumours, lymph nodes, which may compress over the veins to cause varicosity.
- Haemorrhage: Venous haemorrhage can occur from the ruptured varicose veins or sloughed varicose veins, often torrential, but can be controlled very well by elevation and pressure bandage.
- Pigmentation (hemosiderosis), eczema and dermatitis. Periostitis causing thickening of periosteum. It delays healing of ulcer due to poor perfusion of ulcer bed.
- Venous ulcer.
- Marjolijn’s ulcer-due to unstable scar of long duration very well-differentiated squamous cell carcinoma.
- Ankylosis of the ankle joint is due to fibrosis of soft tissues around ankle joint-fibrous ankylosis.
- Talipes equinovarus-wherein patient walks on the tip of toes like horse.
- Calcification of the wall of varicose veins or of sclerosed soft tissue.
- Recurrent thrombophlebitis, clot formation on the superficial system often at perforator level which often get infected causing fever and tenderness over the spot.
- Deep venous thrombosis per se due to varicose vein is rare but can occur if there is associated deep vein disease or recurrent thrombophlebitis.
- With the patient standing, the Doppler probe is placed at saphenofemoral junction and later wherever required.
- Basically, by hearing the changes in sound, venous flow, venous patency, venous reflux can be very well-identified.
- Doppler test: When a handheld Doppler (continuous wave 8 MHz flow detector) is kept at SFJ, typical audible, ‘whoosh signal’ >0.5 sec while performing Valsalva manoeuvre is the sign of reflux at SFJ. It is also used at SPJ and at perforators.
2) Duplex scan:
- It is a highly reliable U/S Doppler imaging technique (here high-resolution B mode ultrasound imaging and Doppler ultrasound is used) which along with direct visualisation of veins, gives the functional and anatomical information, and also colour map.
- Examination is done in standing, lying down position and with Valsalva manoeuvre. Hand-held Doppler probe is placed over the site and visualised for any block and reversal of flow. DVT is very well-identified by this method. Venous haemodynamic mapping NHM/Cartography is essential prior to surgery.
It is a non-invasive method which measures volume changes in the leg. It gives functional information on venous volume changes and calf muscle pump insufficiency.
2 times – Air plethysmography
4) Ambulatory venous pressure (AVPJ:
It is an invasive method. Needle inserted into dorsal vein of foot and is connected to transducer to get its pressure which is equivalent to pressure in the deep veins of the calf. Ten tiptoe manoeuvres are done by the patient.
With initial rise in pressure, pressure decreases and eventually stabilises with a balance. Pressure now is called as ambulatory venous pressure (AVP). After stopping exercise, veins are allowed to refill with return of pressure to baseline.
Time required for pressure to return to 90% of baseline is called as venous refilling time (VRT). Raise in AVP signifies venous hypertension. Patients with AVP more than 80 mmHg has got 80% chances of venous ulcer formation.
Ascending venography –was very common investigation done before Doppler period. A tourniquet is applied above the malleoli and vein of dorsal venous arch of foot is cannulated. Water soluble dye injected, flows into the deep veins (because of the applied tourniquet). X-rays are taken below and above knee level. Any block in deep veins, its extent, perforator status can be made out by this. It is a good reliable investigation for DVT. If DVT is present, surgery or sclerotherapy are contraindicated.
Descending venogram is done when ascending venogram is not possible and also to visualise incompetent veins. Here contrast material is injected into the femoral vein through a cannula in standing position. X-ray pictures are taken to visualise deep veins and incompetent veins.
Here non-ionic, iso-osmolar, no thrombogenic contrast is injected directly into the variceal vein to get a detailed anatomical mapping of the varicose veins. It is used in recurrent varicose veins.
1) Conservative treatment: –
- Elastic crepe bandage application from below upwards or use of pressure stockings to the limb-pressure gradient of 30-40 mm Hg is provided.
- Elevation of the limb-relieves oedema. Two short times, during day and full night, elevation of foot with feet above the level of heart and toes above the level of nose is the method.
- Unna boots-provide nonelastic compression therapy. It comprises a gauze compression dressing that contain zinc oxide, calamine, and glycerine that helps to prevent further skin break down. It is changed once a week.
- Pneumatic compression method-provide dynamic sequential compression. These methods reduce the AVP, reduce transcapillary fluid leakage by increasing SC pressure and improve cutaneous microcirculation.
2)Drugs used for varicose veins:
- Calcium dobesilate: 500 mg BO. Calcium dobesilate improves lymph flow; improves macrophage mediated proteolysis; and reduces oedema.
- Diosmin: It is micronized purified flavanoid fraction. It protects venous wall and valve, and it is anti-inflammatory, profibrinolytic, anti-oedema, lymphotropic.
- Diosmin 450 mg + Hesperidin 50 mg (DAFLON 500 mg). Mainly used in relieving night cramps but not to improve healing of ulcers.
- Toxerutin 500 mg BO, TIO.
- Antierythrocyte aggregation agent which improves capillary dynamics. , Benzopyrones, saponins, plant extracts, Ruscus (venular a 1-adrenergic receptor partial agonist) coumarins are different drugs used.
3) Injection-sclerotherapy: and compression treatment
Fegan’s technique: By injecting sclerosants into the vein, complete sclerosis of Walls can be achieved.
4) Surgical/operative treatment –
- Indications – Positive Trendelenburg test – esp in saphano-femoral incompetence.
- Contraindications – Pregnancy, OCP’s and Thrombophlebitis.
- Types of operation – Ligation
- Ligation with stripping
- Trendelenburg operation – Juxta femoral flush ligation
- Subfascial ligation of Cockett and Dodd.
- Subfascial Endoscopic Perforator Surgery(SEPS)
- In Murphy’s repertory:
Clinical, Rubric: VEINS, sub-rubric: varicose-
ARN, CALC., CALC-F., CARB-V., FL-AC., HAM., LYCPS., PULS., SEP.13
In Murphy’s repertory: chapter: Clinical, Rubric: VEINS, sub-rubric: varicose ulcers-
CARD-M., CAUST., FL-AC., LACH., LYC., PULS.13
- In Boericke’s repertory:
Chapter: Circulatory System: Rubric: VEINS, Sub rubric: veins varicosed: Calc-f., Calc-i., Card-m., Fl-ac., Ham., Lyc., Puls., Staph., Vip., Zinc.
- In Synthesis Repertory.
1)Extremities – Varices – Lower Limbs
Arn., Calc., Carb-v., Fl-ac., Ham., Lyc., Lycps-v., Puls., Zinc.
Ambr.,Ant-t.,Ars.,Carbn-s.,Caust.,Crot-h.,Ferr.,Graph.,Hep.,Kali-ar.,Kreos.,Lach., M-aust.,Nat-m.,Nux-V.,Plb., Sec.,Sulph.,Thuj.
Acon.,apis.,arg-n.,aur-m.,bufo.,calc-ar.,calc-f.,calc-p.,calc-s.,calc-sil.,carc. card-m.,cench.,clem.,coloc.,con.,ferr-ar.,kali-c.,lac-can.,mill.,paeon.,psor.,sabin.,sars, scir.,sep.,sil.,spig.,staph.,stont-c.,sul-ac.,vanil.,vip.
2)Painful – calc.,Fl-ac.,sec.,Sulph.
- Acts on lower tissues of body much like Siliciea but follows and precedes well although their modalities differ, Ac-fl is better by cold applications. Slow, deeply destructive effects.
- Decay of long bones, ulcerations, bedsores, and varicose veins. Limbs go to sleep with dropsy of limbs. Atony of capillary and venous system.
- Ulcers, red edges and vesicles.
- Modalities – << heat of room, warmth, warn drinks, standing, rising, morning.
>> cold bathing, walking, rapid motion, open air, sitting.
- It is found in the surface of bones, the enamel of teeth in elastic tissues and in the cells of the epidermis. A powerful tissue remedy for hard, stony glands, varicose veins and malnutrition of bones.
- Veins dilate and become varicose inflamed. Tendency to adhesions after operations. Indurations of stony hardness, tonsils, tumours, neck after injury, margins of ulcers. Indurations threatening suppuration. Glands enlarge and become stony hard.
- Modalities >> by rubbing, continued motion, warm applications, heat, rubbing, warm drinks.
<< beginning of motion, cold, wet, damp weather, rest, changes of weather, drafts, sprains.
- Acts upon the venous circulation and capillaries. The blood seems to stagnate, causing blueness, coldness and ecchymoses. Vitality becomes low from loss of vital fluids .
- A lowered vital power from loss of fluids after drugging after other diseases in old people with venous congestions.
- Wounds heal and break out again. Blue, cold and bruised. Marbled with venous over distention. Burning in various places. Varicose ulcers, carbuncles. (Ars., Anthr.) Ulcers, varicose, easily bleeding, pus smelling like Asafoetida, heal and break out again. Varicose veins during pregnancy. Wants to be fanned always.
- The principle action of this remedy is on the veins especially of rectum, genitals, limbs and throat, producing venous congestion, varicose veins, haemorrhoids and haemorrhages. It is also a valuable remedy for open painful wounds and burns of the first degree as a local application. Acts upon the coats of the veins causing relaxation with consequent engorgement.
- Venous congestion, haemorrhages, varicose veins and haemorrhoids. Passive venous haemorrhages from any part. Veins, painful, varicose, sore, cutting, swollen inflamed. Painful, hard, knotty. In haemorrhoids there is much bleeding and marked soreness of the part, the back feels as if it would break, (Aesc. hip. has little or no bleeding). Tense bursting feeling in haemorrhoids, joints or lower limbs.
- Neuralgia of internal saphenous nerve. Tense, bursting feeling in limbs and joints.
- Modalities – << from injuries, bruises, pressure, warm, moist air, open, humid, cold, jar touch during day, open air, Motion and exertion, rainy weather.
- Pains, worse from letting the affected limb hang down. (Vip.) Veins full, varicose, painful. Veins in forearms and hands swollen. Milk leg. Periostitis.
- Inclination to stretch the feet. Feet red inflamed, swollen, oedematous. Cold sweat on legs. Foul foot sweating.
- Pulsatilla affects the emotions, veins, mucous membranes, respiration and one side. Changeable nature is one of its most important keynotes. Erratic temperatures in fevers. Wandering pains shift rapidly from one part to another.
- Haemorrhages, passive, vicarious, blood dark, easily coagulating. Varicose veins. Heaviness. Scraping, jerking, tearing, ulcerative pains, wandering pains. Numbness, partial, hands, feet etc. of the part lain on of suffering parts. Chilly but craves for open air.
- Calcarea patient is fat, fair, flabby and perspiring and cold, damp and sour. Children crave eggs and eat dirt and other indigestible things, are prone to diarrhoea.
- Cramps in muscles which draw limbs. Varicose veins, burning in veins. In all cases where there is improper nutrition and indigestion.
- Cold damp feet, feel as if damp stockings were worn. Cold, clammy, hands, knees. Old sprains. Weakness of limbs. Glands swollen. Nettle rash, better in cold air. Petechial eruptions.
- Unhealthy, ulcerating, flaccid. Small wounds do not heal readily. Cold like snake, flaccid, unhealthy. Visible quivering of skin from head to foot, followed by giddiness. Milk white spots. Glands swollen. Nettle rash, better in cold air. Petechial eruptions. Chilblains.
- The venom of common affects the blood and blood-vessels, leading to haemorrhage and inflammation of the vessel
- A keynote for Vipera in cases of phlebitis and varicose veins is “Worse on letting the limb affected hang down,” as if it would burst with fullness. The region of the vessel affected is inflamed and sensitive.
- The bursting feeling appears to be at the root of this characteristic. Blue lower limbs. Shuffling gait caused by paralysis of foot. Varicose veins and acute phlebitis. Veins swollen, sensitive, bursting pain. Severe cramps in lower limbs.
- Boils, carbuncles with bursting sensation, relieved by elevating parts. Ulcers. Gangrene.
- Pains in limbs on becoming heated. Chilblains. (Agar.) Weakness and trembling of the hands, when writing during menses. Eczema on hands. Feet in continued motion, cannot keep still.
- Large varicose veins on legs. Sweaty. Convulsions with pale face. Transverse pains, especially in upper extremity. Soles of feet sensitive
- Lightning-like pain of locomotor ataxia, sweaty feet with sore toes. Formication of feet and legs as of insects crawling over the skin, prevents sleep, better rubbing and pressure. Burning in tibia. Paralysis of feet. Ulcerative pain in heel worse walking. Pain in deltoid worse raising arm.
- Sriram Bhat M.SRB’s Manual of Surgery.5thNew Delhi.Jaypee Brothers medical Publishers(P) Ltd.2016.pg 221-238.
- S.A Concise textbook of surgery.1st edition.Calcutta.Print book.1994 pg196-204,
- Murphy R.Lotus Materia medica.3rd rev edi.New Delhi:B Jain Publishers.July 2021.pg 408-415,417-419,462-467,810-813,887-890,1596-1604,2040-2042,2063-2070
- Murphy Homeopathic medical repertory.3rd revised edi. New Delhi:B Jain Publishers(P)Ltd;2010.pg 492,493.
- W. Pocket Manual of Homoeopathic Materia medica with Indian medicine and repertory. New Delhi. Indian Books and periodicals Publishers; July 2011.pg-860
- Rajgopal Shenoy K. Manipal manual surgery,2nd2nd edi. New Delhi.Bangalore.CBS Publishers & Distributers.2008.pg 90-99.
Dr Hirannmayee V.
PG Scholar, MD Part-1
Dept of Practice of Medicine, GHMC, Bengaluru
Under the Guidance of Dr Veerabhadrappa.C
Associate Professor and PG guide.