varicose veins Flashcards
definition of varicose veins
Long, tortuous, & dilated veins of the superficial venous system
cylindrical extension and dilation of superficial veins (diameter > 3 mm) with development of knots and tortuous veins
Thread veins, ‘spider veins’ or reticular veins refer to smaller superficial venous telangiectasias and varicosities.
RF of varicose veins
- prolonged standing
- obesity
- pregnancy
- FH
- the pill
- age
- female
- race - more in caucasians
causes of varicose veins
primary mechanical factors in 95%
secondary to obstruction eg DVT, fetus, pelvic trauma
arteriovenous malformations
overactive muscle pumps eg cyclists
rarely congenital valve absence
primary causes of varicose veins
genetic or developmental weakness in vein wall = reduced elasticity, dilation and valvular incompetence
secondary causes of varicose veins
venous outflow obstruction - pregnancy, pelvic malignancy, ovarian cysts, ascites, lymphadenopathy, retroperitoneal fibrosis
valve damage - after DVT
high flow - arteriovenous fistula
pathology of varicose veins
blood moves from superficial to deep veins via perforator veins which perforate the deep fascia at the saphenofemoral/saphenopopliteal junctions
valves prevent blood from passing from deep to superficial veins
if the valves become incompetent there is venous hypertension and dilation of the superficial vein occurs
weakness of vein wall due to abnormalities of collagen and elastin with fibrosis of the tunica media in advanced stages
venous hypertension and hormonal stages are implicated
epidemiology of varicose veins
common
incidence increases with age
affects 23% pop in US
female more
prevalence: 10–15% adult men, 20–25% adult women
sx of varicose veins
- my legs are ugly
- pain/aching - worse towards the end of the day or after standing long periods
- swelling
- itching
- cramps
- tingling
- heaviness
- restless legs
signs of varicose veins
inspect pt while standing
phlebitis
haemorrhage
signs of venous insufficiency
- oedema
- eczema
- ulcers
- haemosiderin
- atrophie blanche (white scarring at the site of a previous, headed ulcer)
- lipodermatosclerosis - skin hardness from subcutaneous fibrosis caused by chronic inflammation and fat necrosis
palpation of varicose veins
fascial defects along the dilated veins, sites of incompetent perforators
cough impulse of SFJ
The tap test refers to an impulse felt distally along the vein after tapping over the SFJ (normally not present due to competent valves).
document presence of foot pulses
palpation of thrill or auscultation of bruit suggests an AV fistula
renal/pelvic exam performed if secondary causes are suspected
saphena varix
dilation in the saphenous vein at its confluence with the femoral (SFJ)
transmits a cough impulse and may be mistaken for an inguinal or femoral hernia - on closer inspection has a blue tinge
Ix for varicose veins
tourniquet test
trendelenburg’s test
doppler
tourniquet test for varicose veins
Pt lies in bed, leg elevated and veins emptied
Drain the varicosities of blood by supporting their leg above the level of the bed (and “milking” the veins)
Tie the tourniquet around the thigh, at or below the level of the sapheno-femoral junction (where the saphenous vein enters the femoral vein, just below the groin).
Ask the patient to stand.
If veins don’t fill – suggests the sapheno-femoral junction is incomplete
If the veins fill the test can be repeated bringing the tourniquet further down the thigh to assess the perforators.
trendelenburg’s test
localises valvular incompetence
Variation of the tourniquet test
Instead of a tourniquet use your finger
doppler for varicose veins
Assess reflux in veins
Doppler placed over the sapheno-femoral junction and examiner squeezes the calf on the ipsilateral leg
If single sound heard with the doppler – suggests that there is no incompetence
If incompetence, 2 sounds are heard – 1st as the blood flows up the vein as the calf is squeezed, 2nd when blood flows back down the incompetent vein when the calf is released
why perform doppler before surgery
o Previous DVT
o Already had previous varicose vein surgery and they’ve returned
o Where distribution is uncertain
o Good practice for all pts pre-op
important to make sure there is no deep vein obstruction, exclude DVT (important if surgery contemplated) that the deep veins are competent and where the superficial incompetency is
Mx for varicose veins
specialist referral of patients with varicose veins criteria: bleeding, pain, ulceration, superficial thrombophlebitis or a sever impact on quality of life
treat any underlying cause
education - avoid prolonged standing and elevate legs where ever possible, support stockings, lose weight regular walks - calf muscle action aids venous return
Venous telangiectasia and reticular veins - Microinjection or laser sclerotherapy.
endovascular treatment
surgery
endovascular treatment for varicose veins
radiofrequency ablation (VNUS closure) a catheter is inserted into the vein and heated to 120 degrees destroying the endothelium and closing the vein - results as good as conventional surgery at 3 months
endovenous laser ablation (EVLA) - similar to VNUS but uses a laser, outcomes similar to surgical repair after 2yrs
injection sclerotherapy - either liquid or foam can be used. Used for recurrent varicose veins. Liquid sclerosant is indicated for varicosities below the knee if there is no gross saphenofemoral incompetence. It is injected at multiple sites and the vein compressed for a few weeks to avoid thrombosis (intravascular granulation tissue obliterates the lumen). Alternatively foam sclerosant is injected under ultrasound guidance at a single site and spreads rapidly throughout the veins, damaging the endothelium. Ultrasound monitoring prevents inadvertent spread of foam into the femoral vein. It achieves ~80% complete occlusion but is not more effective than liquid sclerotherapy or surgery
surgery for varicose veins
veins marked with patient standing
- saphenofemoral ligation (trendelenburg procedure)
- multiple avultions of varicosities via small stab incisions
- stripping of long saphenous vein from groin to upper calf (striping to ankle isnt needed and may damage the saphenous nerve) [short saphenous not stripped, just ligated - avoid damage to sural nerve]
post-op
- bandage legs tightly and elevate for 24hrs
- early mobilisation
more effective than sclerotherapy in long term
primary indications for surgery for varicose veins
o Oedema
o Skin changes including lipodermatosclerosis
o Venous eczema and ulceration
non-specific symptoms such as aching may not be helped
complications of varicose veins
On their own VVS don’t cause DVTS (except possibly proximally spreading thrombophlebitis of the long saphenous vein).
venous ulcers
vein haemorrhage
venous pigmentation
eczema
lipodermatosclerosis
superficial thrombophlebitis, venous ulceration
infection
complications of treatment
sclerotherapy:
- skin staining
- local scaring
surgery
- haemorrhage
- infection
- recurrence 5-30%
- parasthesia (6%)
- peroneal nerve injury (0.1%)
prognosis of varicose veins
slowly progressive
recurrence rates after surgery can be up to 40%
