Varicose veins

Question 1

Define varicose veins

Answer 1

Veins that become prominently elongated, dilated & tortuous, most commonly the superficial veins of the lower limbs

Question 2

Primary causes of varicose veins

2

Answer 2

Due to genetic or developmental weakness in vein wall

Results in increased elasticity, dilatation & valvular incompetence

Question 3

Secondary causes of varicose veins

3

Answer 3

Due to venous outflow obstruction
Due to valve damage (e.g. after DVT)
Due to high flow (e.g. arteriovenous fistula)

Question 4

Venous outflow obstructions

6

Answer 4

Pregnancy
Pelvic malignancy
Ovarian cysts
Ascites
Lymphadenopathy
Retroperitoneal fibrosis

Question 5

Risk factors for varicose veins

5

Answer 5

Age 
Female
FH
Caucasian 
Obesity

Question 6

Epidemiology of varicose veins

prevalence, age, gender

Answer 6

COMMON
Incidence increases w/ age
10-15% of men, 20-25% of women

Question 7

Presenting symptoms of varicose veins

8

Answer 7

Patients may complain about cosmetic appearance
Aching in legs
Aching worse towards end of day or after long period of standing
Swelling
Itching
Bleeding 
Infection
Ulceration

Question 8

Signs of varicose veins on physical examination - inspection

Answer 8

When patient is standing

Question 9

Signs of varicose veins on physical examination - palpation

4

Answer 9

May feel fascial defects along veins

Cough impulse may be felt over sapheno-femoral junction

Tap test
- tapping over sapheno-femoral junction will lead to impulse felt distally (wouldn’t happen if valves were competent)

Palpation of thrill or auscultation of bruit would suggest AV fistula

Question 10

Signs of varicose veins on physical examination - trendelenberg test
(5)

Answer 10

Allows localisation of sites of valvular incompetence

Leg elevated & veins emptied

Hand placed over sapheno-femoral junction

Leg put back down & filling of veins observed before & after hand is released from sapheno-femoral junction

Doppler US can show sapheno-femoral incompetence

Question 11

Signs of varicose veins on physical examination -rectal or pelvic exam

Answer 11

If secondary causes suspected

Question 12

Signs of varicose veins on physical examination -venous insufficiency
(6)

Answer 12

Varicose eczema
Haemosiderin staining
Atrophie blanche 
Lipodermatosclerosis
Oedema
Ulceration

Question 13

Investigations for varicose veins

1.2

Answer 13

Doppler US
Locates sites of incompetence or relax
Allows exclusion of DVT

Question 14

Management of varicose veins

3 groups

Answer 14

Conservative
Venous telangiectasia & reticular veins
Surgical

Question 15

Management of varicose veins - conservative

3

Answer 15

Exercise - improves skeletal muscle pump
Elevation of legs at rest
Support stockings

Question 16

Management of varicose veins - venous telangiectasia & reticular veins
(2)

Answer 16

Laser sclerotherapy

Microinjection sclerotherapy

Question 17

Management of varicose veins - surgical

3

Answer 17

Sapheno-femoral ligation
Stripping of long saphenous vein
Avulsion of varicosities

Question 18

Complications of varicose veins

5

Answer 18

Venous pigmentation 
Eczema
Lipodermatosclerosis
Superficial thrombophlebitis
Venous ulcerations

Question 19

Complications of varicose veins - treatment

2

Answer 19

Sclerotherapy - skin staining, local scarring

Surgery - haemorrhage, infection, recurrence, parasthesia, peroneal nerve injury

Question 20

Prognosis of varicose veins

2

Answer 20

Slowly progressive

High recurrence rates