Varicose veins (SURG) Flashcards
Define varicose veins.
Subcutaneous, permanently dilated veins >/=3mm when measured in standing position, often more noticeable on standing
Where are varicose veins most often located?
Superficial veins of lower limbs due to reflux (incompetent valves) in great saphenous vein (travels above medial malleolus and medial thigh) and small saphenous vein (originates from lateral malleolus)
What are some risk factors for varicose veins? (7)
- increasing age
- family history
- female sex
- increasing numbers of births
- DVT
- obesity
- occupations with prolonged standing
What is the pathway of formation of varicose veins?
Elevated venous pressure –> incompetence of valves –> reflux of blood back into superficial veins –> further elevation of venous pressure –> varicose veins formation
What two things may be linked to varicose veins?
- progesterone is believed to lead to passive venous dilation –> valvular dysfunction
- oestrogen produces collagen fibre changes and smooth muscle relaxation –> vein dilation
What are the clinical features of varicose veins? (6 + 5)
- dilated tortuous veins
- leg fatigue or aching with prolonged standing
- leg cramps
- restless legs
- swelling
- skin changes:
- haemosiderin deposition (brown hyperpigmentation)
- corona phlebectatica (multiple fine vein branches that suggest underlying chronic venous insufficiency)
- varicose eczema AKA venous stasis
- lipodermatosclerosis (hard/tight skin, then champagne bottle appearance)
- atrophie blanche (hypopigmentation)
What skin changes are seen in varicose veins? (5)
- haemosiderin deposition (brown hyperpigmentation)
- corona phlebectatica (multiple fine vein branches that suggest underlying chronic venous insufficiency)
- varicose eczema AKA venous stasis
- lipodermatosclerosis (hard/tight skin, then champagne bottle appearance)
- atrophie blanche (hypopigmentation)
How do we examine patients for dilated tortuous veins in varicose veins?
Patient standing and skin examined visually and by palpation for irregularities and bulges consistent with varicose veins
What is the first-line investigation for varicose veins?
Duplex US (handheld Doppler probe) –> assesses for reversed flow, will demonstrate retrograde venous flow
- valve closure time <0.5s = reflux
- valve closure time >1s = reflux in deep system (needs stenting/reconstruction)
- helps localise site of valvular incompetence
What are some differential diagnoses for varicose veins? (2)
- telangiectasias (small veins, <1mm)
- reticular veins (permanent dilated intradermal veins, ASx, 1-3mm)
What are some indications for treatment of varicose veins? (5)
- oedema
- lipodermatosclerosis
- venous eczema or ulcers
- unsightly appearance
- bleeding, pain, thrombophlebitis, significant psychological morbidity
What conservative management is there for varicose veins?
- graduated compression stockings (+ emollient)
- frequent elevation of legs
- lifestyle changes (weight loss and exercise)
When would you refer a patient with varicose veins to secondary care?
- significant lower limb Sx e.g. pain, discomfort or swelling
- previous bleeding from varicose veins
- skin changes secondary to chronic venous insufficiency (pigmentation, eczema)
- superficial thrombophlebitis
- active/healed venous ulcer
What interventional approaches are there to treat varicose veins?
- endothermal ablation (usually 1st line) - radiofrequency ablation OR endovenous laser treatment
- foam sclerotherapy - irritant foam –> inflammatory response –> vein closure
- surgery - ligation or stripping (of great saphenous vein)
What medications can we give for varicose veins? (2)
- LMWH for up to 30 days / fondaparinux for 45 days
- NSAIDs - for superficial thrombophlebitis
What are some complications of varicose veins? (5)
- chronic venous insufficiency
- haemorrhage
- venous ulceration
- lipodermatosclerosis
- haemosiderin deposition
Describe the prognosis of varicose veins.
Generally resolution of symptoms occurs in >95% of patients
