VARICOSE VEINS Flashcards
What are varicose veins?
Long, tortuous, dilated veins of the superficial venous system which normally occur in the legs but can occur elsewhere.
What is the epidemiology?
Extremely common. Incidence of 2.6% in women and 2% in men.
More common with increasing age and post-pregnancy
How is it caused? (pathophysiology)
Blood from superficial veins drain into the deep veins via perforator veins (perforate deep fascia) and at the sapeno-femoral and sapheno-popliteal junctions.
Valves prevent blood from flowing from the deep to superficial veins. If these valves become incompetent then there is venous hypertension and dilatation of the superficial veins occurs.
What are the cause of valve incompetence?
• Idiopathic
• Congenital valve disease – very rare; primary cause
• Obstruction due to DVT, foetus, ovarian tumour
• Valve desctruction due to DVT
• Arteriovenous malformation – causes increased pressure
• Constipation – causes increased pressure
Overactive muscle pumps (e.g. cyclists)
What are the risk factors?
- Pregnancy
- Obesity
- Prolonged standing
- Family history
- Oral contraceptive pill
What are the symptoms?
- “My legs are ugly”
- Pain
- Cramps
- Tingling
- Heaviness
- Restless legs
- Itching
- May be aggravated by prolonged standing, pregnancy, menstruation, sexual intercourse
What are the signs?
- Oedema
- Venous eczema – due to waste products building up in the leg
- Ulcers
- Haemosiderin
- Haemorrhage
- Phlebitis
- Atrophie blanche – white scarring at the site of a previous healed ulcer
- Lipodermatosclerosis - skin hardness from subcutaneous fibrosis caused by inflammation and fat necrosis
What investigations would you do?
Trendelenburg’s Test
Perthes’ Manoeuvre
Cough impulse at saphenofemoral junction
Percussion test
What do you look for in percussion test?
• Tap VVs ditally and palpated for transmitted impulse at the SFJ (interrupted by competent valves)
Doppler USS
• Listen for flow in incompetent valves when calf is squeezed
• This has superseded all the above tests but doctors are asked to understand the principles behind those tests
What is/ do you see with Perthe’s manouvre?
- This manoeuvre is used to distinguish antegrade flow from retrograde flow in superficial varicosities.
- Antegrade flow is an indicator of collateral flow around a deep venous obstruction.
- A tourniquet is applied to a varicose leg in such a way that the superficial veins are compressed without pressure being applied to the deep vessels.
- The patient is then asked to stand repeatedly on tiptoe, activating the calf muscles.
- Normally this would empty the varicosities but, in the presence of deep vein obstruction, they would paradoxically become congested.
What is/ do you see with Trendelenberg’s sign?
- not to be confused with Trendelenberg’s sign for adductor weakness in the hip
- This can sometimes distinguish patients with superficial venous reflux from those with incompetent deep venous valves.
- The patient should lie flat with the leg elevated, allowing the veins to empty. A tourniquet is applied to the thigh at the saphenous opening.
- If the valve is competent, the vein should fill from below.
- If the valve is incompetent, the vein will fill from above on removal of the tourniquet.
- This can be repeated at various levels, until the location of an incompetent vale is located.
Treatment
Treat any underlying cause Education Endovascular treatment Radiofrequency ablation Endovenous laser ablation Injection sclerotherapy Surgery
What education advise would you give?
- Avoid prolonged standing
- Support stockings
- Lose weight
- Regular walks (aid venous return)
What surgical options are there?
• Saphenofemoral ligations (Trendelenburg procedure)
• Multiple avulsions
• Stripping from groin to upper calf
Very effective long-term
What is injection sclerotherapy?
o Liquid or foam sclerosealant is injected into the vein
o Liquid requires vein compression for a few weeks
o Foam spreads rapidly
