Varicose Veins

Question 1

What are varicose veins?

Answer 1

Long tortuous and dilated veins of the superficial venous system.

Question 2

How common are they?

Answer 2

Incidence = 2.6% in women and 2.0% in men.

Prevalence studies are rare and the range reported is wide (2-56% in men and 1-60% in women).

Question 3

What causes them?

Answer 3

Blood from superficial veins of the leg passes into deep veins via perforator veins (perforate deep fascia) and at the sapheno-femoral and sapheno-popliteal junctions. Valves prevent blood from passing from deep to superficial veins. If they become incompetent there is venous hypertension and dilatation of the superficial veins occurs.

Question 4

What risk factors are there?

Answer 4

Prolonged standing, obesity, pregnancy, family history, OCP.

Question 5

How does it present?

Answer 5

Symptoms
• “ugly legs”. Pain, cramps, tingling, heaviness, and restless legs. Studies show these symptoms are only slightly commoner in people with VVs.
Signs
• Oedema; eczema; ulcers; haemosiderin; haemorrhage; phlebitis; atrophie blanche (white scarring at the site of a previous, healed ulcer); lipodermatosclerosis (skin hardness from subcutaneous fibrosis caused by chronic inflammation and fat necrosis).
• On their own VVs don’t cause DVTs (except possibly proximally spreading thrombophlebitis of the long saphenous vein).

Question 6

Differential diagnoses?

Answer 6

• Cellulitis
• Osler-Weber-Rendu syndrome (telangiectasia, recurrent epistaxis and a positive family history - also known as hereditary haemorrhagic telangiectasia)
• Superficial phlebitis
• DVT

Question 7

How would you investigate the patient?

Answer 7

On examination

1. Inspect for: ulcers usually above medial malleolus with deposition of haemosiderin causing brown edges, eczema and thin skin. inspect legs from anterior thigh to medial calf (long saphenous) and the back of the calf (short saphenous). Palpate veins for tenderness (phlebitis) and hardness (thrombosis). If ulcers present palpate pulses to rule out arterial disease.
2. Feel for cough impulse at the sapheno-femoral junction (=incompetence = saphena varix (sometimes mistaken for femoral/inguinal hernia)). Percussion test: tap VVs distally and palpate for transmitted impulse at the SFJ (interrupted by competent valves).
3. Auscultate over varicosities for a bruit, indicating arteriovenous malformation.
4. Examine abdomen, pelvis in females and external genitalia in men (for masses).
5. Doppler ultrasound studies - listen for flow in incompetent valves e.g. the SFJ or the short saphenous vein behind the knee.

Question 8

Treatments?

Answer 8

• Treat any underlying cause
• Education - avoid prolonged standing and elevate legs wherever possible, support stockings, lose weight, regular walks.
• Endovascular treatment…
• Surgery - stripping etc.