Varicose veins

Question 1

Define varicose veins and summarise its aetiology and epidemiology.

Answer 1

Definition: Veins that become prominently elongated, dilated and tortuous, most commonly the superficial veins of the lower limbs.

Aetiology/risk factors of varicose veins:
- Primary
• Due to genetic or development weakness in the vein wall
• Results in increased elasticity, dilatation and valvular incompetence

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

- RISK FACTORS:
    • Age
    • Female
    • Family history
    • Caucasian
    • Obesity 

Epidemiology:

• COMMON
• Incidence increases with age
• 10-15% of men
• 20-25% of women

Question 2

Describe the history/presenting symptoms of Varicose veins

Answer 2

• Patients may talk about cosmetic appearance
• Aching in legs
• Aching is worse towards the end of the day after standing for long periods of time
• Swelling
• Itching
• Bleeding
• Ulceration
• Infection

Question 3

What are the signs of varicose veins upon physical examination?

Answer 3

• Inspection:
  • Inspect when the patient is standing
• Palpation:
  • May feel fascial defects along the veins
  • Cough impulse may be felt over the saphenofemoral junction
  • Tap Test- tapping over saphenofemoral junction will lead to an impulse felt distally (this would not happen if the valves were competent)
  • Palpation of a thrill or auscultation of a bruit would suggest an AV fistula
• Trendelenburg Test:
  • Allows localization of the sites of valvular incompetence
  • Leg is elevated and the veins are emptied
  • A hand is placed over the saphenofemoral junction
  • The leg is put back down and filing of the veins is observed before and after the hand is released from the saphenofemoral junctions.
  • A doppler ultrasound can be used to show saphenofemoral incompetence
• Rectal or Pelvic Examination
  • If secondary causes are suspected

- Signs of venous insufficiency
  • Varicose eczema
  • Haemosiderin staining 
  • Atrophie blanche
  • Lipodermatosclerosis 
  • Oedema
  • Ulceration

Question 4

What investigations are used to identify varicose veins?

Answer 4

• Duplex Ultrasound (1st line treatment)
  • Locates sites of incompetence or reflux
  • Allows exclusion of DVT

Question 5

How are varicose veins managed?

Answer 5

• Conservative
  • Exercise- improves skeletal muscle pump
  • Elevation of legs at rest
  • Support stockings
• Venous Telangiectasia and reticular veins
  • Laser sclerotherapy
  • Microinjection sclerotherapy
• Surgical
  • Saphenofemoral ligation
  • Stripping of the long saphenous vein (short saphenous vein isn’t stripped because of the risk of damaging the sural nerve)
  • Avulsion of varicosities

Question 6

What are the complications of varicose veins?

Answer 6

• Venous pigmentation
• Eczema
• Lipodermatosclerosis
• Superficial thrombophlebitis
• Venous ulceration
• Complication of treatment:
  • Sclerotherapy- skin staining, local scarring
  • Surgery- haemorrhage, infection, recurrence, paraesthesia, peroneal nerve injury

Question 7

Summarise the prognosis for patients with varicose veins

Answer 7

• Slowly progressive

- High recurrence rates