Varicose veins

• Varicose veins:

  • Dilated, tortuous veins which mainly occur in the superficial venous system of the legs
  • Around a third of the population develop them at some point in their life
  • Often are asymptomatic or only a cosmetic concern
  • Some patients experience severe aching and/or itching
  • Can develop complications - venous ulceration, bleeding, permanent changes to skin pigmentation
• Anatomy:

  • Superficial veins drain into the deep venous system via perforation veins - mainly at the saphenofemoral and saphenopopliteal junctions
  • Blood flow can only move unidirectionally towards the deep veins due to the presence of one-way valves in the superficial veins
  • This is the overcome the hydrostatic pressure imposed on the distal blood by gravity, the effect of which is greatest in the lower limbs
• Pathophysiology:

  • Develop due to the incompetence of the one-way valves, leading to leaking, retrograde flow and consequently pooling of blood in the superficial venous system
  • The weaker, thinner walls of the superficial veins make them more prone to the effects of the high-pressure build-up of blood, leading to distension of the venous walls and tortuosity of the affected venous segment
  • This manifests as bulging of the skin over the affected vein
• Most varicose veins are idiopathic

  Secondary causes arise from mechanisms of venous outflow obstruction which can either be:

  • Intravascular e.g DVT
  • Extravascular e.g. pelvic masses - tumours, fibroids, pregnancy
  • Progesterone and oestrogen are also believed to have vasodilatory properties which can predispose to or worsen already existing varicose veins
• Risk factors:

  • Family history
  • Older age
  • Pregnancy - risk increases with more pregnancies
  • Female
  • History of DVT
  • Other - obesity, prolonged standing/sitting, previous lower limb fracture
• Common symptoms:

  • Pain - often described as a dull ache or burning of the skin
  • Leg fatigue, discomfort or worsening pain after prolonged standing - relief with elevation
  • Leg cramps - usually nocturnal
  • Restless legs
  • Haemosiderin deposition
  • Heaviness of the legs
• Less common symptoms:

  • Itching after prolonged standing - venous eczema
  • Ankle oedema
  • Lipodermatosclerosis - inflammation and hardening of the skin and subcutaneous tissue = inverted champagne bottle appearance
• Severe presentations that require urgent vascular referral:

  • Ulceration - indicated serious chronic venous insufficiency
  • Haemorrhage - especially if the variceal segments are large or over bony prominences
  • Thrombophlebitis
• Examination:

  • Peripheral venous exam
  • Should be assessed with the patient standing at first and then lying down
  • Inspection - size, location and extension of dilated veins. Look for associated signs and complications e.g. ulceration, thrombophlebitis
  • Palpation - press over the distended vein, should empty then refill but thrombosed veins will be firm and possibly tender. Press calf for tenderness
  • Do abdominal exam to exclude secondary causes such as pelvic tumours
• Investigations:

  • Usually a clinical diagnosis and investigations not required
  • Duplex ultrasound scan can confirm diagnosis by assessing for reflux of blood in less obvious cases - also rules out DVT
  • ABPI needed to exclude arterial disease before compression therapy is considered
• Classification:

  • clinical, aetiology, anatomical and pathophysiology (CEAP) classification system
  • C0 = no visible or palpable varicose veins
  • C1 = telangiectasia
  • C2A = asymptomatic varicose veins
  • C2S = symptomatic varicose veins
  • C3 = ankle oedema
  • C4 = skin changes due to chronic venous disease
  • C5 = healed venous ulcer
  • C6 = active venous ulcer
• Referral to vascular services:

  • Generally any patient with symptomatic or recurrent varicose veins, or have signs of complications, should be referred
  • Patients with CEAP C2-C3 can be referred routinely
  • Patients with C4-C6 should be referred urgently
  • Any patient with bleeding varicose veins and/or significant ulceration should be referred to a vascular service for consideration of urgent intervention.
• Conservative management:

  • Main option is compression therapy using bandages or stockings
  • Compression therapy is not recommended unless surgical intervention is declined or considered inappropriate
  • Important to exclude arterial insufficiency by doing APBI
• Surgical management:

  • Endovenous techniques or open surgery
  • Both techniques aim to treat the origin of the varicose veins, which involves either eliminating the saphenofemoral or saphenopopliteal junctions
  • First line = endothermal ablation - radiofrequency ablations or endovenous laser treatment
  • Open - ligation and stripping
• Complications:

  • Bleeding
  • DVT
  • Superficial thrombophlebitis
  • Changed to skin pigmentation
  • Ulceration