He was the last patient, entering my clinic limping, exhausted, and in pain. Mr. M had just arrived from Canada after a fourteen hours flight. It was a good chance to use the time in finishing a lot of accumulated paper work” he said. Pain and swelling in the leg had developed at the end of the flight and gotten worse with time.

Upon examining Mr. M I found swelling and pain in the leg, associated with tortuous dilated veins. It was clear that he had developed DEEP VENOUS THROMBOSIS (clot in the deep Veins) of the leg.

Three types of blood vessels supply the human tissues namely, arteries, veins, and lymphatic vessels. Arteries bring the blood from the heart, Veins drain the used blood back to the heart, and the lymphatic vessels (microscopic tiny vessels) drain fluid from the tissues to the lymph nodes and thereafter to the veins. Veins in the lower limb are divided in superficial and deep systems. The direction of venous blood flow is from outside to inside the limb, and from down to up. This direction of flow is assured by muscular contractions and by the presence of special valves within the Veins that prevent the back flow of blood. Varicose veins develop if the vessel wall or the valves within the vessel fail. In this case the superficial Veins dilate and become tortuous, giving the appearance of varicose veins.

The incidence of varicose veins increases with age .It is generally more prevalent in women, especially after several pregnancies. Varicose veins are also directly related to body weight and have strong association with occupations, requiring prolonged standing. There has been also a relation with low fiber diet and prolonged sitting.

Patients usually complain of leg heaviness, itching, swelling, pain and, leg cramps at night. All of those are aggravated by sitting and standing for long periods of time and are relieved by raising the lower limb above the level of the heart.

Diagnosing varicose Veins is not enough; it is important to know if they are primary (due to weakness of the wall and or valves), or secondary (due to closure of the deep Veins usually by a clot) as in the case of Mr. M. This can be achieved by Doppler-sonography of the venous system in the leg using ultra-sound waves, or by Venography.

Venographies include injecting contrast solution in the veins and take an x-ray of the limb to detect any clot obliterating the deep Veins.

It is important to begin treatment since longstanding varicose Veins can lead to serious complications. Thrombus formation, deep or superficial, due to blood stagnation in the lower limbs can occur. Brown discoloration and leg ulcers are other complications. They occur due to the passage of blood elements, especially iron, to the skin, causing irritation.

The development of a clot within the veins of lower limb is a serious complication. The clot can migrate with the blood stream to the right side of the heart and lungs thereafter causing major health problems. Prolonged immobilization may lead to blood stasis, a change in the interior of vessel wall, and an increase in the blood coagulation capacity. All of these lead to the development of the clot in the vein. (DEEP VENEOUS THROMBOSIS)

Prevention is better than treatment, an old Arabic wisdom. Better blood movement and less blood coagulability is the strategy. People exposed to surgeries, long hours of standing or sitting (e.g. Long flights, office work, teachers or barbers etc) are at risk of deep venous thrombosis. Frequent leg and foot movement, walking, and raising lower limbs will facilitate blood movement in the veins back to the heart. Wearing special stocking will compress the external veins in the leg. These raise the speed of circulation in the deep veins and prevent risk of stasis of blood. Drugs diluting the blood have the disadvantage of increasing the bleeding in case of any injury. Their use should be limited to people at high risk for developing a clot.

Mild early varicose veins can be treated with medication and wearing special stockings. Injection therapy is another alternative; it gives good results in the treatment of prominent, visible varicose veins. Injecting sclerosing agents in the involved veins leads to the destruction of thier interior lining (endothelium) and their closure. Stocking use is very important after injection therapy for at least three weeks to prevent recurrence.

Surgery is limited to more advanced cases, or recurrent cases after other types of treatment have failed. Stripping of varicose veins is the name of the operation in which we remove the superficial diseased varicose veins and this is done as a day surgery.

Mr. M. was admitted to the hospital and was treated with bed rest and Heparin (blood clotting preventing medicine). He is now healthy, but he has to wear his special stockings for life.