Varicose Veins

Question 1

Define Varicose Veins?

Answer 1

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

Question 2

What are the primary causes of Varicose Veins?

Answer 2

Due to genetic or developmental weakness in the vein wall

Results in increased elasticity, dilation and valvular incompetence

Question 3

What are the secondary causes of Varicose Veins?

Answer 3

Due to venous outflow obstruction
Due to Valve damage (e.g. after DVT)
Due to high flow (e.g. arteiovenous fistula)

Question 4

What are some examples of causes that are linked to venous outflow obstruction in Varicose Veins?

Answer 4

Pregnancy
Pelvic Malignancy
Ovarian Cysts 
Ascites 
Lymphadenopathy
Retroperitoneal Fibrosis

Question 5

What are the risk factors for Varicose Veins?

Answer 5

Age 
Female
Family History
Caucasian
Obesity

Question 6

What is the epidemiology of Varicose Veins?

Answer 6

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

Question 7

What are the presenting symptoms of Varicose Veins?

Answer 7

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 8

How do we inspect a patient with Varicose Veins?

Answer 8

When standing

Question 9

What are the signs of Varicose Veins on palpation?

Answer 9

May feel fascial defects along the veins
Cough impulse may be felt over the saphenofemoral junction
Tap Test
Palpation of a thrill or auscultation of a bruit would suggest an AV fistula

Question 10

What is the Tap Test in the palpation of Varicose Veins?

Answer 10

Tapping over the saphenofemoral junction will lead to an imoulse felt distally (this wouldn’t happen if the valves were competent)

Question 11

What is the Trendelenburg Test in the physical examination of Varicose Veins?

Answer 11

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 ater the hand is released from the saphenofemoral junction
A Doppler US can be used to show saphenofemoral incompetence

Question 12

When we do a Rectal or Pelvic examination for Varicose Veins?

Answer 12

If secondary causes are suspected

Question 13

What are signs of Venous Insufficiency?

Answer 13

Varicose Eczema 
Haemosiderin Staining 
Atrophie Blanche 
Lipodermatosclerosis 
Oedema 
Ulceration

Question 14

What investigation would you do for Varicose Veins and why?

Answer 14

Duplex US
Locates sites of incompetence or reflux
Allows exclusion of DVT

Question 15

What is the conservative management plan for Varicose Veins?

Answer 15

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

Question 16

What can we do to manage Venous Telangiectasia and Reticular Veins?

Answer 16

Laser sclerotherapy

Microinjection Sclerotherapy

Question 17

What is the surgery management plan for varicose veins?

Answer 17

Saphenofemoral ligation
Stripping of the long saphenous vein
Avulsion of varicosities

Question 18

Why isn’t the short saphenois vein stripped in the surgical management plan of varicose veins?

Answer 18

Their is a risk of damaging the sural nerve

Question 19

What are the complications of Varicose Veins?

Answer 19

Venous Pigmentation 
Eczema 
Lipodermatosclerosis 
Superficial Thrombophlebitis 
Venous Ulceration

Question 20

What are the complications of treatment of Varicose Veins?

Answer 20

Sclerotherapy - skin staining, local scarring

Surgery - haemorrhage, infection, recurrence, paraesthesia, peroneal nerve injury