Varicose Veins

Question 1

Define

Answer 1

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

Question 2

Causes

Answer 2

Primary

• Due to genetic or developmental weakness in the vein wall
• Results in increased elasticity, dilatation and valvular incompetence

Secondary

• 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 3

Risk Factors

Answer 3

Age

Female

Family history

Caucasian

Obesity

Question 4

Epidemiology

Answer 4

COMMON

Incidence increases with age

10-15% of men

20-25% of women

Question 5

Symptoms

Answer 5

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 6

Signs

Answer 6

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 7

Investigations

Answer 7

Duplex Ultrasound

Locates sites of incompetence or reflux

Allows exclusion of DVT

Question 8

Management

Answer 8

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

Question 9

Complications

Answer 9

• 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 10

Prognosis

Answer 10

Slowly progressive

High recurrence rates