Varicose Veins Flashcards
Define varicose veins.
Varicose veins are subcutaneous, permanently dilated (tortuous) veins 3 mm or more in diameter when measured in a standing position
What is the aetiology of varicose veins?
Primary (95% - venous valve incompetence - blood passes from superficial to deep veins via perforator veins and at the saphenofemoral and saphenopopliteal junctions. Veins work against gravity and valves work by compartmentalising blood –> better equalisation of pressures throughout vein and preventing reflux . Blood pools when valves do not function properly –> increased pressure and distension.
Secondary - to obstruction e.g. DVT, fetus, pelvic tumour, to arteriovenous malformations, to overactive muscle pumps e.g. (in cyclists), rare congenital valve absence
Or no venous cause identified
How common are varicose veins?
More common in developed countries
10% of males and 20% of females >15yrs will have varicose veins
Increases with age
How can hormones lead to varicose veins?
Progesterone –> passive venous dilation which may lead to valvular dysfunction
Oestrogen –> collagen fibre changes and smooth muscle relaxation which leads to venous dilation
What are the risk factors for varicose veins?
- increasing age
- FHx - 90% risk if both parents are affected
- female
- multiple pregnancies (due to increased body fluid, intra-abdominal pressure and oestrogen, progesterone and relaxin)
- DVT (causes valvular damage)
- prolonged standing
- obesity
What are the symptoms of varicose veins?
- heaviness in legs
- cramps
- pain - dragging pain at angle at end of the day and throbbing pain when you put feet up at the end of the day.
- restless legs
- itching
- ankle swelling
- ulceration
- bleeding from varices
What are the signs associated with varicose veins?
- dilated tortuous veins
- oedema
- eczema
- ulcers
- haemosiderin
- haemorrhage
- phlebitis
- atrophie blanche (at site of previous healed ulcer)
- lipodermatosclerosis (skin hardness from subcutaneous fibrosis caused by chronic inflammation and fat necrosis)
- corona phlebectatica (see image)
What is saphena varix?
Dilatation at the sapheno-femoral junction. It transmits a cough impulse and may be mistaken for an inguinal or femoral hernia, but on closer inspection it may have a bluish tinge.
What investigations should you do for varicose veins? (1)
Duplex ultrasound -
- assesses for reversed flow;
- valve closure time >0.5 second is indicative of reflux in the superficial system, while valve closure time >1.0 second is indicative of reflux in the deep system
What are the indications for surgery of varicose veins?
- symptomatic primary or symptomatic recurrent varicose veins
- venous leg ulcers that have not healed within 2 weeks
- lower limb skin changes (pigmentation, lipodermatosclerosis)
- superficial vein thrombosis with venous incompetence
- healed venous leg ulcers
(cosmetic reasons alone do not qualify under NICE; these patients with confirmed varicose veins and truncal reflux on venous duplex should be offered endothermal ablation (or foam sclerotherapy if suitable) and should only be offered compression hoistery uf interventional treatment is unsuitable)
What is the management approach for varicose veins?
- Graduated compression stockings
- +/- Lifestyle intervention - weight loss, leg elevation, exercise (especially aqua-aerobics)
- Phlebectomy or sclerotherapy, endovenous radiofrequency or laser ablation
- Open surgery
- Perforator surgery - improves ulcer healing
- Iliac vein stenting or open venous reconstruction - used in deep vein obstruction
What are the surgical options for varicose veins?
Avulsion/phlebectomy - small incisions are made along the varicose vein and then pulled out with forceps.
Stripping - small incisions are made at the ends of the varicose vein and an endoluminal hook and wire is used to pull out the vein. Usually under GA.
Injection sclerotherapy - involves sealing the vein from within by injecting an irritant sclerosant. Unfortunately the procedure is associated with skin discoloration in about 10% of patients and 30% risk of recurrence if there is valvular incompetence, and is thus being used less often. A variant of injection sclerotherapy involves injecting a foam that blocks the vein, but there is a very small risk of the foam embolising into the venous system
Radiofrequency/laser/mechanico-chemical ablation - endoluminal catheter is inserted into the long saphenous or short saphenous vein and a tip used to deliver high-energy radio waves (VNUS) that seal the vein from within. Or you can use a laser (EVLT) to achieve the same effect.
What are the complications of varicose veins?
- Chronic venous insufficiency
- Venous ulceration
- Lipodermatosclerosis
- Haemosiderin deposition
- Haemorrhage - erosion of varices can lead to bleeding which may require surgical intervention
What is the prognosis with varicose veins?
Usually symptom resolution with intervention in 95%
Varicosities will likely occur with time as varicose veins are a progressive disease
Long saphenous vein distribution - medial calf and thigh
Complications shown = haemosiderin deposition
