Varicose veins

Question 1

Define VV.

Answer 1

Subcutaneous, permanently dilated veins 3mm or more in diameter when measured in standing position.

Question 2

Who is most affected - males or females?

Answer 2

· Females.

Question 3

What is the pathophysiology of VV?

Answer 3

· The venous system acts as both a reservoir and a conduit in the return of blood to the heart and lungs.
· Veins are thin and lack the musculature of arteries, therefore they require assistance in blood return.
· This assistance is provided by valves and muscle pumps.
· If the valves or muscle pumps don’t work, venous HTN and insufficiency can ensue, possibly leading to varicose veins.
· Varicose veins demonstrate proliferation of collagen matrix and decreased elastin, leading to disruption and distortion of muscle fibre layers.

Question 4

What is the aetiology of VV?

Answer 4

· Previous episode of DVT.
· Genetics.
· Venous valve incompetence:
- Veins work against gravity.
- Valves work by compartmentalising the blood, leading to better equalisation of pressure throughout the veins and preventing reflux.
- Blood pools when valves don’t function properly, leading to increased pressure and distension of the veins.

· Progesterone leads to passive venous dilation, leading to valvular dysfunction.
· Oestrogen produces collagen fibre changes and smooth muscle relaxation, leading to vein dilation.

Question 5

Common risk factors related to VV?

Answer 5

· Increasing age. 
· FHx.
· Female. 
· Increasing number of births. 
· DVT. 
· Occupation with prolonged standing.
· Obesity.

Question 6

Common signs and symptoms related to VV?

Answer 6

· Dilated tortuous veins. 
· Leg fatigue or aching with prolonged standing. 
· Leg cramps - usually nocturnal. 
· Restless legs. 
· Haemosiderin deposition.

Question 7

Investigation to diagnose VV?

Answer 7

Duplex USS.

Question 8

Differentials?

Answer 8

· Telangiectasias:

• Spider veins.
• No symptoms, only cosmetic concerns.
• No evidence of reflux on duplex.

· Reticular veins:

• Permanently dilated intradermal veins.
• No evidence of reflux on duplex.

Question 9

Treatment option for a patient with symptomatic superficial vein insufficiency, but no PVD?

Answer 9

· Graduated compression stockings.
· Phlebectomy / Sclerotherapy.
· Ablative procedures - stripping and ligations.

Question 10

Treatment option for a patient with deep vein insufficiency?

Answer 10

Phlebectomy / Compression stockings.

Question 11

Complications?

Answer 11

· Chronic venous insufficiency. 
· Haemorrhage. 
· Venous ulceration.
· Lipodermatosclerosis. 
· Haemosiderin deposition.