Varicose veins Flashcards
describe the typical presentation of varicose veins?
visible dilation, aching worse on standing ( and at end of day) , swelling, itching and bleeding
Define varicose veins?
Veins that become prominently elongated, dilated and tortuous, most commonly the superficial veins of the lower limbs.
Permanently dilates – 3mm or more in diameter
what are the risk factors for varicose veins?
Age
Female
Family history
Caucasian
Obesity
Increasing number of births
DVT
explain the aetiology of varicose veins?
Blood from superficial veins of the leg passes into deep veins via perforator veins and at the sapheno-femoral and sapheno-popliteal junctions. Valves prevent blood from passing from deep to superficial veins. If they become incompetent, there is venous hypertension and dilatation of the superficial veins occurs.
what are the primary causes of varicose veins?
Due to genetic or developmental weakness in the vein wall
Results in increased elasticity, dilatation and valvular incompetence
Congenital valve absence
what are the secondary causes of varicose veins?
Due to venous outflow obstruction
- Pregnancy
- DVT
- Ovarian tumour
- Pelvic malignancy
- Ovarian cysts
- Ascites
- Lymphadenopathy
- Retroperitoneal fibrosis
Due to valve damage (e.g. after DVT)
Due to high flow (e.g. arteriovenous fistula)
Constipation
Overactive muscle pumps e.g. cyclists
summarise the epidemiology of varicose veins?
COMMON
Incidence increases with age
10-15% of men
20-25% of women
what are the presenting symptoms of varicose veins?
Patients may complain about the cosmetic appearance
Aching/cramps in the legs
Aching is worse towards the end of the day of after standing for long periods of time
Swelling
Tingling
Heaviness and restless legs
Itching
Bleeding
Infection
Ulceration
what are the signs of variose veins on physical examination?
Inspection
- Inspect when the patient is standing
- Oedema, eczema, ulcers, phlebitis, atrophie blanche, lipodermatosclerosis
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
Rectal or Pelvic Examination
- If secondary causes are suspected
Signs of Venous Insufficiency
- Varicose eczema
- Haemosiderin staining
- Atrophie blanche
- Lipodermatosclerosis
- Oedema
- Ulceration
what are the signs of varicose veins on inspection?
Inspect when the patient is standing
Oedema, eczema, ulcers, phlebitis, atrophie blanche, lipodermatosclerosis
what are the signs of varicose veins on 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
what are the signs of venous insufficiency in varicose veins?
Varicose eczema
Haemosiderin staining
Atrophie blanche
Lipodermatosclerosis
Oedema
Ulceration
what is the goldstandard investigation for varicose veins?
Duplex Ultrasound – GOLD STANDARD
- Locates sites of incompetence or reflux
- The Doppler is placed over the sapheno-femoral junction and the examiner squeezes the calf on the ipsilateral leg. If there is a single sound heard with the Doppler this suggests that there is no incompetence. If there were incompetence in the veins there would be 2 sounds heard with the doppler: the first as the blood flows up the vein when the calf is squeezed, and the second when blood flows back down the incompetent vein when the calf is released.
- If valve closure time is >0.5secs is indicative of reflux in superficial veins; closure time >1.0secs is indicative of reflux in deep system
- Allows exclusion of DVT
- Should defo be done if the pt had had a varicose vein surgery in the past and it has returned
what is the management plan for superficial vein insufficiency ( no PVD)?
1st line: graduated compression stockings
UNLESS the pt is symptomatic with skin changes, venous eczema/ ulceration that hasn’t healed in 2 weeks or recurrent, superficial venous thrombosis and oedema, it is justified to go to sclerotherapy or phlebectomy
If ineffective: phlebectomy or sclerotherapy
In effective: ablative procedures (closing the vein) +/- phlebectomy or sclerotherapy
what is the management plan for deep vein insufficiency?
1st line: phlebectomy and compression stockings
