Vein problems are the stepchild of vascular disease. Arteries get all the attention – after all, our brain, heart, kidneys, and all other organs depend on a continuous flow of fresh oxygen. Veins somehow don’t seem as important (unless, of course, you have the problem). Veins are actually more complicated than arteries because they are more difficult to understand and definitely more difficult to operate on. And that challenge may be why I am continually fascinated with them. The following very limited selection of vein trivia and oddities may be of some interest.
Giraffes don’t get varicose veins!
NASA scientists have studied giraffes extensively in an effort to design the ideal gravity suit for astronauts. The determining factor for the pressure in leg veins is the vertical distance between the heart and the legs, which makes the giraffe’s leg vein pressures by far the highest in the animal kingdom. The giraffe, therefore, should be a slam-dunk candidate for varicose veins and swollen legs. It turns out, however, that the skin in the giraffe’s leg is extremely tough and fibrous, and, contrary to other animals (notably humans), the arteries and veins are concentrated exclusively in the center of the leg. It’s as if giraffes wear permanent support stockings. Try to get an Angeleno to wear support stockings for a day! (And it’s hotter and more humid in Africa.)
In 86 BC, Caius Marius, a Roman general and later tyrant, had the first recorded operation for varicose veins.
Here’s how Plutarch, the great biographer of Greek and Roman times, describes the event:
Marius is praised for both temperance and endurance, of which latter he gave a decided instance in an operation of surgery. For having as it seems, both his legs full of great tumors, and disliking the deformity, he decided to put himself into the hands of an operator. When, without being tied, he stretched one of his legs, and silently, without changing countenance, endured most excessive torments in the cutting, never either flinching or complaining; but when the surgeon went to the other, he declined to have it done, saying “I see the cure is not worth the pain.”
Wise Marius! With today’s local anesthesia techniques, even the largest varicose veins can be removed without the need for general anesthesia or even intravenous sedation. All procedures are done in our office as an outpatient. Patients tyhpically drive home and immediately return to full activities. Even Caius Marius could have returned to his legion posthaste.
Henry VIII suffered from chronic venous disease!
The great King of England had a stupendous appetite for food and wives. Toward the end of his life he weighed some 25 stone (about 350 pounds), and was carried about on a stretcher. He developed painful sores in both legs, which have been interpreted variously as syphilis, the consequences of a jousting injury, or, as I and others surmise, the far more common malady of excessive venous pressure at the ankles (chronic venous hypertension). Late stages of chronic venous hypertension include swelling, discoloration and ulceration. Henry VIII did not wear compression bandages because the physicians of his day believed the wraps would keep evil humours from escaping.
It’s a bit much to speculate that a competent phlebologist (vein specialist) could have changed the course of history, but I suspect a good bariatric (weight) surgeon might have. Weight is an important factor in the development of varicose veins. Others include heredity, pregnancy, female hormones, and long hours standing (sales, hair dresser and doing vascular surgery). Contrary to urban myth, crossing your legs will not give rise to veins or vein problems.
Sclerotherapy (injections) got off to a bad start, but World War I saved the day!
Shortly after the invention of the hypodermic syringe and needle in 1850, every practitioner, charlatan, and surgeon tried to eliminate varicose veins with chemicals. Finally, the Medical Congress of Lyon in 1894 issued a dictum banning the injection treatment of veins. Matters stood that way until World War I, when physicians injecting quinine into veins to treat malaria coincidentally noted scarring of the injected vein. Thus the search began anew for an ideal sclerosant (injected solution). The secret would be to find the best agent to scar the vein wall shut without creating blood clots that could break off and float to the lungs.
The agents we use today have been around for 100 years and each has a long safety record. I use Sotradecol, one of only two medications the Food and Drug Administration (FDA) has approved for sclerotherapy. In both liquid and foam preparation, it is highly effective for treating spider veins and the deeper reticular veins that feed them
Here are some factoids about blood thinners.
We have an extremely complicated but precisely delicate system to control whether our blood clots or stays liquid. This is a rather important, because you want the system to work perfectly if you cut yourself, and you don’t want blood to clot at the least provocation while it is still in your veins. Here are the most common drugs that affect this critically important system:
Warfarin (trade name: Coumadin) has nothing to do with warfare. It comes from the Wisconsin Alumni Research Fund that sponsored the original research into the drug. It appears that spoiled sweetclover hay converts coumadin to dicoumarol, a substance that has the remarkable ability to interrupt the clotting mechanism. Warfarin was first used (and still is, today) as a rat poison. Rats are pretty smart critters, and if they see their closest buddy drop dead immediately after eating a tempting morsel, they will put two and two together and avoid the bait. But, if the rat drops dead three days later (that’s how long it takes the dicoumarol to work in rats and in humans), they have trouble associating the meal with the event. For many years Warfarin was the only blood thinner that could be given by mouth. Unfortunately, many foods and medicines affect the dosage of Warfarin, so its activity needed to be monitored frequently with blood tests. Warfarin cannot be given during pregnancy. Xarelto and Eliquis were recently introduced in the market and have the advantage of not requiring frequent physician monitoring. They are both approved for patients with treating blood clots and atrial fibrillation.
Heparin is a natural substance found in our bodies. In its purified form, it immediately stops blood from clotting. It must be given either directly in the veins or by needle and its activity must be monitored frequently. Both factors make heparin injections impractical for home use. Newer forms of heparin, called low molecular weight heparins (such as Lovenox), are easier to monitor. Some patients develop a peculiar reaction to heparin, so alternates have been developed, mainly a substance (hirudin) derived from leeches (Hirudo medicinalis). Leeches, as you may know, stick their suckers into their victim, inject a blood thinning agent, and gorge themselves on blood. Same principle holds for vampires, but there aren’t enough of them around to interest the pharmaceutical industry.
Aspirin has been around a long time, but its anti-clotting properties weren’t appreciated until recently. It primarily affects the ability of platelets, which are small packets of clotting materials, from aggregating into clots. An 81-milligram tablet of aspirin goes a long way to keeping clots from developing in arteries. Platelets are not a prominent feature of vein clots, however, so aspirin is minimally effective at preventing blood clots from forming in leg veins.
A surprising number of people get the “economy class syndrome,” which is blood clots that form in veins during a long plane ride. The best advice to avoid this distressing condition is to get up and walk the aisle frequently (every two to four hours is about right), especially during a night flight, when your legs are dangling and the blood is pooling. Support stockings are also beneficial if you have varicose veins or are otherwise predisposed to clots.
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