Varicose Veins Flashcards
What are varicose veins?
Varicose veins = dilated, tortuous, superficial veins - most commonly found in the legs.
=> visible & palpable
=> indication of superficial lower extremity venous insufficiency
=> for most, varicose veins = cosmetic concern but may become severe over time and cause complications
What causes a varicose veins?
Normal physiology:
=> blood from superficial venous capillaries is directed upward via one-way valves into superficial veins.
=> This drains via the perforator veins and at the saphenofemoral and saphenopopliteal junction => pass through a muscular fascial layer, into the deep veins.
Pathology of varicose veins:
=> Primary valve incompetence in the affected vein (95%)
=> Secondary to DVT, pelvic tumours, arteriovenous malformations, overactive muscle pump
=> results in reflux of blood + increased pressure in the vein distally.
=> unlike deep veins, which have thick walls and confined by fascia, superficial veins can’t withstand high pressures and eventually becomes dilated and tortuous.
=> weakness or degeneration of the vein wall may also lead to development of varicose veins
The increase in venous pressure in the leg is marked with incompetence in deep veins too
What are the risk factors for varicose veins?
=> Increasing age
=> Family hx of varicose veins
=> Female sex
=> Pregnancy - increases blood volume + intra-abdominal pressure => distended veins
=> Obesity
=> Prolonged standing or sitting
=> Hx of DVT - valvular damage + increased pressure
What is the prevalence of varicose veins?
Prevalence of varicose veins increases with age and often develop during pregnancy
What are the complications for varicose veins?
=> Bleeding esp. when varicose veins are large, traumatized, or located over bony prominences
=> Superficial vein thrombosis - characterized by hard, painful veins
=> Deep vein thrombosis
=> Changes in skin pigmentation
=> Skin ulceration - in 3–6% of people with varicose veins
=> Depression - due to cosmetic skin changes
What are the symptoms of varicose veins?
=> Swollen, enlarged veins in legs
=> Blue / dark purple
=> Lumpy, bulging, twisted appearance
=> Aching, heavy, discomfort in affected leg
=> Pain / cramps
=> Oedema feet / ankles
=> Burning or throbbing legs
=> Restless leg + muscle cramp esp at night
=> Eczema, thin skin over affected vein
=> Symptoms worse during warm weather; prolonged standing
=> Symptoms improve with walking or raising your legs and resting
How do you diagnose varicose veins?
=> Symptoms + hx of trauma, DVT, ulcerations, bleeding from varicose veins or previous surgery of varicose veins.
=> Identify risk factors for varicose veins i.e. prolonged standing or family hx of varicose veins
=> Examine the affected leg visually and by palpation with the patient standing and lying for irregularities / bulges consistent with varicose veins
Note extent, size, and location of the dilated veins to help exclude telangiectasias and reticular veins.
- Varicose veins = >3 mm when standing
- Telangiectasias (aka spider or thread veins) = intradermal veins that are less than 1 mm in diameter.
- Reticular veins = permanently dilated intradermal veins between 1–3 mm in diameter, may be tortuous but usually asymptomatic
Assess for any complications
How do you manage varicose veins?
Bleeding varicose veins => admit to a vascular service / seek specialist advice from vascular surgeon
If not bleeding:
=> Advice to relieve symptoms and reduce the risk of complications:
i) Lose weight (if overweight or obese).
ii) Light to moderate physical activity
iii) Avoid exacerbating symptoms, such as sitting or standing for long periods of time.
iv) Elevate the legs when possible
Refer for interventional treatments if:
i) Primary or recurrent varicose veins assoc. with lower limb symptoms i.e. pain, aching, discomfort, swelling, heaviness, and itching.
ii) Lower-limb skin changes i.e pigmentation or eczema due to chronic venous insufficiency.
iii) Superficial vein thrombosis
iv) Active venous leg ulcer - break in the skin below the knee - not healed within 2 weeks
v) A healed venous leg ulcer.
If referral not indicated, offer compression stockings
Why is it important to exclude arterial insufficiency before prescribing compression stockings?
Important to exclude arterial insufficiency before prescribing compression stockings because if arterial circulation is impaired, compression may further impair the arterial supply and result in pressure damage, limb ischaemia, and amputation
=> Ankle brachial pressure index (ABPI) = most reliable way to detect arterial insufficiency.
=> Absence of foot pulses may indicate arterial insufficiency
The ABPI is the ratio of the ankle systolic blood pressure to the brachial systolic blood pressure
=> <0.5 — severe arterial insufficiency - compression stockings are contraindicated + urgent referral
=> >0.5 - 0.8 — arterial disease or mixed arterial/venous disease is likely. Compression should be avoided.
=> 0.8 and 1.3 — arterial disease is unlikely - compression stockings safe to wear.
=> >1.3 — due to arterial calcification i.e. diabetes, rheumatoid arthritis, systemic vasculitis, atherosclerotic disease, and advanced chronic renal failure.
What are the signs of a varicose vein?
=> Hyperpigmentation i.e. brown-red discolouration due to haemosiderin deposition
=> Venous eczema - itchy, red, scaly / flaky skin - may develop blisters/crusts on the surface
=> Lipodermatosclerosis - painful, hardened, tight skin
=> Atrophie blanche - star-shaped, ivory-white, depressed, atrophic scars with surrounding pigmentation
=> Areas of active or healed ulceration
=> Superficial vein thrombosis - hard, painful veins
=> Oedema
=> Phlebitis
What is the treatment for varicose veins?
Endovascular treatment:
=> Radiofrequency ablation - collapses the vein
=> Endovenous laser ablation - outcome similar to surgery
=> Injection sclerotherapy
Surgery:
=> Saphenofemoral ligation
=> Multiple avulsions i.e. stripping veins from groin to upper calf
