Varicose Veins

Question 1

Definition

Answer 1

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

Question 2

Aetiology (primary)

Answer 2

o Due to genetic or developmental weakness in the vein wall

o Results in increased elasticity, dilatation and valvular incompetence

Question 3

Aetiology (secondary)

Answer 3

o Due to venous outflow obstruction
· Pregnancy
· Pelvic malignancy
· Ovarian cysts
· Ascites
· Lymphadenopathy
· Retroperitoneal fibrosis

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

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

Question 4

Risk factors

Answer 4

o Age
o Female
o Family history
o Caucasian
o Obesity

Question 5

Epidemiology

Answer 5

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

Question 6

Presenting symptoms

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

Signs on physical examination (inspection and palpation)

Answer 7

· Inspection
o Inspect when the patient is standing

· Palpation
o May feel fascial defects along the veins
o Cough impulse may be felt over the saphenofemoral junction
o Tap Test - tapping over the saphenofemoral junction will lead to an impulse felt distally (this would not happen if the valves were competent)
o Palpation of a thrill or auscultation of a bruit would suggest an AV fistula

Question 8

Signs on physical examination (Trendelenburg test)

Answer 8

Trendelenburg test

o Allows localisation of the sites of valvular incompetence

o Leg is elevated and the veins are emptied

o A hand is placed over the saphenofemoral junction

o The leg is put back down and filling of the veins is observed before and after the hand is released from the saphenofemoral junction

o A Doppler ultrasound can be used to show saphenofemoral incompetence

Question 9

Signs on physical examination (other)

Answer 9

· Rectal or Pelvic Examination

o If secondary causes are suspected

· Signs of Venous Insufficiency
o Varicose eczema
o Haemosiderin staining
o Atrophie blanche
o Lipodermatosclerosis
o Oedema
o Ulceration

Question 10

Investigations

Answer 10

· Duplex Ultrasound

o Locates sites of incompetence or reflux

o Allows exclusion of DVT

Question 11

Management plan

Answer 11

· Conservative
o Exercise - improves skeletal muscle pump
o Elevation of legs at rest
o Support stockings

· Venous Telangiectasia and Reticular Veins
o Laser sclerotherapy
o Microinjection sclerotherapy

· Surgical
o Saphenofemoral ligation
o Stripping of the long saphenous vein
o Avulsion of varicosities
o NOTE: short saphenous vein isn't stripped because of the risk of damaging the sural nerve

Question 12

Possible complications

Answer 12

· Venous pigmentation
· Eczema
· Lipodermatosclerosis
· Superficial thrombophlebitis
· Venous ulceration

· Complications of Treatment

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

Question 13

Prognosis

Answer 13

· Slowly progressive

· High recurrence rates