Varicose Veins

Question 1

What is the definition of varicose veins?

Answer 1

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

Question 2

What is the aetiology of primary varicose veins?

Answer 2

Due to genetic or developmental weakness in the vein wall

Results in increased elasticity, dilatation and valvular incompetence

Question 3

What is the aetiology of secondary varicose veins?

Answer 3

Due to venous outflow obstruction

• Pregnancy
• Pelvic malignancy
• Ovarian cysts
• Ascites
• Lymphadenopathy
• Retroperitoneal fibrosis

Due to valve damage (e.g. after DVT)

Due to high flow (e.g. arteriovenous fistula)

Question 4

What is the risk factors of varicose veins?

Answer 4

Age

Female

Family history

Caucasian

Obesity

Question 5

What is the epidemiology of varicose veins?

Answer 5

COMMON

Incidence increases with age

10-15% of men

20-25% of women

Question 6

What are the presenting symptoms of varicose veins?

Answer 6

Patients may complain about the cosmetic appearance

Aching in the legs

Aching is worse towards the end of the day of after standing for long periods of time

Swelling

Itching

Bleeding

Infection

Ulceration

Question 7

What are the signs of varicose veins upon physical examination?

Answer 7

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 the 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 localisation 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 filling of the veins is observed before and after the hand is released from the saphenofemoral junction
• 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 8

What are the appropriate investigations for varicose veins?

Answer 8

Duplex Ultrasound

• Locates sites of incompetence or reflux
• Allows exclusion of DVT

Question 9

What is the management plan for varicose veins?

Answer 9

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  
- Avulsion of varicosities  
NOTE: short saphenous vein isn't stripped because of the risk of damaging the sural nerve

Question 10

What are the possible complications of varicose veins?

Answer 10

Venous pigmentation

Eczema

Lipodermatosclerosis

Superficial thrombophlebitis

Venous ulceration

Complications of Treatment

• Sclerotherapy - skin staining, local scarring
• Surgery - haemorrhage, infection, recurrence, paraesthesia, peroneal nerve injury

Question 11

What is the prognosis for patients with varicose veins?

Answer 11

Slowly progressive

High recurrence rates