Varicose Veins

Question 1

What are varicose veins?

Answer 1

Varicose veins are long tortuous dilated veins of the superficial venous system that occur when the valves in the affected veins become incompetent. This causes blood to pool leading to venous hypertension and thus dilation. This valvular impenitence commonly occurs at the saphenofemoral and saphenopoliteal junction and so most varicose veins will follow the distribution of the long or short saphenous veins. There are 2 main types of varicose veins – Trunk (Left), Reticular (Right).

Question 2

What are the causes of varicose veins

Answer 2

Common – Primary Vein Failure, Overuse of muscle in the leg (long term standing, cyclists)

Other causes – Congenital valve problems, AV malformation, DVT

Question 3

What will you find/ask about on a history taking of varicose veins?

Answer 3

May be relieved by elevating leg and worse on standing
Visible Varicose Vein
Leg Heaviness
Oedema
Tingling/Burning
Pain along the course of the vein – a dull ache that is worse on prolonged standing
Restless leg syndrome
Night Cramping
Chronic Venous insufficiency – Eczema (Itching), Ulcers, Telangiectasia, Pigmentation, Lipodermatosclerosis 

Risk Factors:
Prolonged standing
Pregnancy
Obesity
Family history 
OCP use 
Previous DVT

Specific questions to ask in a history taking:
Establish why the patient has presented – Is it purely a cosmetic problem, this will not be treated under the NHS
Ask about previous vein problems in the leg e.g. DVT, Thrombophlebitis
Ask about their job, may require prolonged standing
Ask if the varicose veins have bled – This is an indication of urgent referral due to risk of ulcer/infection

Differentials:
Telangiectasia - Spider veins that are purely cosmetic
Reticular Veins - Chronically dilated veins, normally asymptomatic
Cellulitis – Red inflamed area of skin with no varicosity visible, will be hot
DVT – Red painful swollen calves with risk factors for DVT

Question 4

What will you find/look for on an examination of varicose veins?

Answer 4

Examine while standing
Assessing the veins:
Confirm they are veins - Press on any suspected veins, wait for them to drain and then release to see them refill – Confirms they are in fact a vein
Confirm they are varicose veins - Tap on the varicosity and feel the saphenofemoral junction (medial of the femoral pulse). Will feel a fluid thrill if there is valvular incompetence (confirming a varicose)
What is the affected vein (Posterolateral below the knee = short saphenous vein. Medial along the whole leg = Long saphenous vein)
Signs of Chronic Venous insufficiency:
Eczema (pic 2), Ulcers, Telangiectasia, Pigmentation, Lipodermatosclerosis (Hardened skin from Subcutaneous fibrosis), Hemosiderin (pic 1), Atrophie Blanche (pic 3, White scarring at base of healed ulcers), Oedema, Phlebitis
Look for signs of or current bleeding - This is an indication of urgent referral due to risk of ulcer/infection

Special Tests:
Trendelenburg’s test (not usually performed)– Lie with leg in air, tie tourniquet around thigh at level of saphenous opening, release the tourniquet and see if the vein fills from the top or the bottom. Filling from the top indicates a faulty vein below the tourniquet. If this is the case, lower the tourniquet and repeat until the level of the incompetent valve is found.
Perthes Manoeuvre (Not really done but know about it) – Tie tourniquet around varicose veins, get patient to stand on and off tip toe. If superficial vein only affected it will drain, if deep veins affected it will fill
Tap Test – Tap the vein and feel for a thrill at the saphenofemoral junction

Question 5

What investigations will you use in Varicose Veins?

Answer 5

Imaging:
Hand held Doppler – Can be used but is not as good as Duplex
Duplex US - assesses for reversed flow and can assess a long valve closure time (indicative of varicose veins)

Question 6

What is the treatment of varicose veins?

Answer 6

Only trunk type treated 
Indications for treatment
Bleeding
Ulceration
Thrombophlebitis
Severe impact on QOL
Should not cosmetic reasons 

Lifestyle:
Avoid standing for extended periods
Elevate legs when possible
Regular exercise - Aid venous return
Lose weight
Compression stockings - increase venous return

Non-Surgical:
Endothermal Ablation (1st Line) - Radiofrequency Ablation with 120-degree catheter inserted into vein destroying it
Foam Injection sclerotherapy (2nd Line) – Sclerosant (Sodium Tetradecyl Sulphate) injected that blocks up vein.

Surgical:
Only used if non-surgical options failed or contraindicated
Ligation of the saphenofemoral junction with vein stripping