Varicose Veins

Question 1

What are varicose veins?

Answer 1

Turtuous dilated segments of vein associated with valvular incompetence.

Question 2

Pathophysiology

Answer 2

Incompetent valves causes blood flow from the deep venous system to the superficial.

This results in venous hypertension and dilation of the superficial system

Question 3

98% of varciose veins are primary idiopathic.

Secondary causes

Answer 3

DVT

Pelvic masses like pregnancy, uterine fibroids and ovarian masses

Arterivenous malformations like Klippel-Trenaunay syndrome

Question 4

Risk factors

Answer 4

Prolonged standing

Obesity

Pregnancy

FH

Question 5

Clinical features

Answer 5

Usually only present with it as a cosmetic issue

Aching or itching

Skin changes, ulceration, thrombophlebitis or bleeding

Question 6

Examination findings

Answer 6

Great +/- saphenous vein turtuous

Ucleration, varicose eczema, haemosiderin deposition

Question 7

What is saphena varix?

Answer 7

Dilation of the saphenous vein at the saphenofemoral junction in the groin.

Commonly mistaken for a femoral hernia

Can be identified via duplex USS

Management is saphenous ligation

Question 8

Classification system of varicose veins

Answer 8

CEAP Classification

Question 9

Explain CEAP

Answer 9

Question 10

Ix

Answer 10

Gold standard = Duplex Ultrasound to assess valve incompetence and any perforations

Question 11

Conservative treatment

Answer 11

Avoid prolonged standing, weight loss, increase exercise

Compression stockings if interventional treatment is not appropriate

Venous ulcerations -> Four layer banding

Question 12

Indications of surgical intervention

Answer 12

Symptomatic primary or recurrent varicose veins

Lower-limb skin changes like pigmentation or eczema

Superficial vein thrombosis with suspected venous incompetence

Venous leg ulcer

Question 13

Surgical approaches

Answer 13

Vein ligation, stirpping and avulsion

Foam sclerotherapy

Thermal ablation

Question 14

Explain vein ligation, stripping and avulsion

Answer 14

Incision in the groin or popliteal fossa to find the refluxing vein.

It is then tied of and stripped away.

Be mindful of saphenous and sural nerves

Question 15

Explain foam sclerotherapy

Answer 15

Inject a sclerosing agent directly into the varicosed vein.

This leads to inflammation and closure of the vein.

This is done via ultrasound guidance to make sure that the foam does not enter the deep venous system

Question 16

Explain thermal ablation

Answer 16

Heats the vein from the inside by radiofreq or laser.

This causes irreversible damage to the vein which closes it off.

It is done under ultrasound guidance and local or general anaesthetics

Question 17

Complications

Answer 17

Untreated => worsen over time

Post-op;

Haemorrhage

Thrombophlebitis

DVT

Disease recurrence

Nerve damage