Open to Discussion

  Have you ever thought you knew a subject only to find out that most everything you learned might be wrong? That happened to me this week regarding varicose veins.

  As a young person, I viewed varicose veins as an unsightly problem “old people” had with their legs. My father, who was a surgeon and also had very bad varicose veins, told me that these bulging veins on his legs looked bad, could cause pain, and occasionally caused a large ulcer. For that reason, he planned to have them “stripped out” after I finished playing in a Little League All-Star Baseball Tournament when I was 12 years old. I could hardly wait to get through with the games so Dad could have his legs fixed. I certainly did not want him to develop a large ulcer!

  When I became a surgeon, I found out much more about varicose veins and chronic venous insufficiency. I was taught they were caused by damage to the valves in the veins resulting in increased blood pooling in the lower extremities. This extra pressure in the veins caused them to stretch, and created all kinds of problems. This damage resulted in the failure of the calf muscle pump, predisposing the individual to the development of a varicose ulcer. Varicose veins also could result if the venous system were blocked by blood clots or other problems. I learned that operative removal was the way to treat veins with damaged valves to prevent further problems. Let me assure you, I did my fair share of operations ridding patients of those dreadful veins.

  Now, Dr. Thom Rooke and Mrs. Cindy Felty tell me that developing varicose veins may not be bad at all, and in fact, actually may be a blessing!¹ They remind us that varicose veins are very common, affecting more than half of the population. As we age, the incidence increases even more. The question is then raised that, if more than half the population has varicose veins, aren’t the ones without them the abnormal ones? (Fortunately, that makes me one of the “normal” ones!)

  If varicose veins are a sign of chronic venous insufficiency which predisposes patients to develop a chronic venous ulcer, why don’t we see more venous ulcers? Half the population of the United States has varicose veins and chronic venous insufficiency, yet only about 2 million people, or about 1.0% to 1.5% of the population, develop a venous ulcer annually.² If the occurrence of venous ulcers is so low in this population, is it possible there are other, more important factors in the development of a venous ulcer? Is it possible that a problem so common might not be so bad after all? Dr. Rooke and Mrs. Felty report that the factors contributing to the development of varicose veins are the same ones that help patients develop arterial collateral circulation. This has been supported by studies showing patients with varicose veins are less likely to need lower extremity bypass operations than people without varicose veins.^1,3 Interestingly, these same factors influencing the development of arterial collateral circulation also promote the formation of lymphatic vessels.^1,4 Is the incidence of lymphedema the same in patients with varicose veins as in those without them? There is evidence to suggest that patients with lymphedema have a lower incidence of varicose veins than do those who do not have lymphedema.¹

  This is extremely troubling yet interesting information. It is troubling because it contradicts many of the “truths” we have been taught about varicose veins and their consequences. It is interesting because it may change the way we think about and treat patients with varicose veins. New or conflicting information always causes problems, but further investigation and research can help solve the issues. Read journals, talk to others about the topic, and hear the most up-to-date information on many wound care issues at this month’s Symposium on Advanced Wound Care. The acceptance or rejection of this new information could have far-reaching consequences in the treatment of many patients.

  By the way, my father never did have his varicose vein operation. At the time of his death at age 89, he still had his very large varicose veins but never developed a venous ulcer. I have my fingers crossed that I will follow suit!