Varicose veins Flashcards
Varicose veins
Tortuous, dilated veins of the superficial venous
system
Pathophysiology of varicose veins
Valve failure → ↑ pressure in sup veins → varicosity
3 main sites where valve incompetence occurs
Sapheno- femoral junction
Sapheno-popliteal junction
Perforators: draining the long saphenous vein
- 3 medial calf perforators
- 1 medial thigh perforator
Causes of varicose veins
Primary- idiopathic (congenitally weak valves)
Secondary • Valve destruction causing reflux: DVT, thrombophlebitis • Obstruction: DVT, foetus, pelvic mass • Constipation • AVM • Overactive pumping (e.g. cyclists)
Risk factors for varicose veins
- Prolonged standing
- Pregnancy
- Obesity
- OCP
- FHx
Symptoms of varicose veins
- Cosmetic defect
- Pain, cramping, heaviness
- Tingling
- Eczema - severe
- Swelling
Signs of varicose veins
• Skin changes:
- Venous stars
- Haemosiderin deposition
- Venous eczema
- Lipodermatosclerosis - wine glass sign
- Atrophie blanche
- Ulcers: medial malleolus
- Oedema
- Thrombophlebitis
Investigations for varicose veins
• Duplex ultrasonography
- Anatomy
- Presence of incompetence
- Obstruction or reflux
Referral Criteria
• Bleeding • Pain • Ulceration • Superficial thrombophlebitis • Severe impact on QoL - symptomatic - not healed in 2 weeks - skin changes
If have DVT cannot do varicose vein surgery
CEAP Classification
Clinical signs (1-6 + sympto or asympto)
Etiology
Anatomy
Pathophysiology
Conservative Mx
- Lose weight
- Relieve constipation
- Avoid prolonged standing
- Regular walks
- Class II Graduated Compression Stockings
- Skin care
- Maintain hydration with emollients
- Treat ulcers rapidly
Minimally invasive mx of varicose veins
Injection sclerotherapy
Endovenous laser or radiofrequency ablation
Glue ablation
Varicose veins post op
- Compression bandage for 24hrs
* Compression stockings for 1 month
Indications for surgery
(Rare)
• SFJ incompetence
• Major perforator incompetence
• Symptomatic: ulceration, skin changes, pain
Surgical procedures
- Saphenofemoral ligation
- Short saphenous vein ligation: in the popliteal fossa
- Multiple avulsions
- Perforator ligation
- Subfascial endoscopic perforator surgery (SEPS)
Post op for varicose veins after bigger surgery
• Bandage tightly
• Elevate for 24h
• Discharged with compression stockings +
walk daily
Venous leg ulcers (75%)
Painless, sloping, shallow ulcers
• Usually on medial malleolus
• Associated with haemosiderin deposition and
lipodermatosclerosis
• RFs: venous insufficiency, varicosities, DVT, obesity
Arterial leg ulcers (2%)
- Painful, deep, punched out lesions
- Occur at pressure points
- Other signs of chronic leg ischaemia
Neuropathic ulcers
- Painless with insensate surrounding skin
* Warm foot with good pulses
Complications of ulcers
- Osteomyelitis
* Development of SCC in the ulcer (Marjolin’s ulcer)
Investigations for leg ulcers
• ABPI if possible • Duplex ultrasonography • Biopsy may be necessary - Look for malignant change in Marjolin’s ulcer • Swab and Culture
Mx of venous ulcers
• Refer to leg ulcer community clinic
- Graduated compression stockings
- Venous surgery
- Optimise risk factors: nutrition, smoking
- Analgesia
- Bed Rest + Elevate leg
- 4 layer graded compression bandage (if ABPI >0.8)
Saphena Varix
Dilatation of the saphenous vein at the saphenofemoral junction in the groin.
Displays a cough impulse, it is commonly mistaken for a femoral hernia
Varicose Veins and Concurrent DVT
Cannot treat their superficial incompetence, as the venous blood will have no route back
Varicose eczema
Dry and scaly
Itchy
Bursting pain and tightness on walking
Resolves with elevation
Is for varicose eczema’s
Doppler ultrasound scan
Thx of varicose eczema
Conservative with compression stockings if ABPI above 0.8 and analgesia
Does saphena varicose display a cough reflex
Yes
Suspect if femoral hernia and varicose veins
