Vascular: Varicose Veins

Question 1

what are varicose veins and why can these occur?

Answer 1

VVs = tortuous dilated segments of vein associated with valvular incompetence.

Leakage through a valve allows retrograde flow of blood, from deep to superficial venous system… superficial veins cannot withstand high pressure… become dilated and tortuous. Failure of 1 valve puts pressure on its neighbour and may cause varicosity of entire local superficial venous network.

98% are primarily idiopathic (?genetic). Secondary causes include: DVT, pelvic masses (e.g. pregnancy, uterine fibroids, ovarian masses) or AV malformations (e.g. Klippel-Trenaunay syndrome).

Question 2

suggest risk factors for development of VVs

Answer 2

• family history
• older age (>65 yrs)
• pregnancy
• obesity
• prolonged standing

Question 3

describe the symptoms caused by VVs

Answer 3

Often asymptomatic but causing cosmetic issues, e.g. visible veins, skin discolouration.

Worsening VVs:

• pain, aching
• swelling (often worse on standing or at end of day)
• pruritis

Question 4

describe the possible signs of VVs on examination

Answer 4

i) varicosities present in course of great and/or short saphenous veins

+/- features of venous insufficiency:

ii) oedema
iii) varicose eczema
iv) haemosiderin skin staining
v) lipodermatosclerosis or atrophie blanche
vi) thrombophlebitis
v) venous ulcers (usually over medial malleolus)
vi) saphena varix (dilation of saphenous vein at saphenofemoral junction in grain, displays cough impulse)

Question 5

how would you investigate a person with VVs?

Answer 5

Duplex USS, assessing for:

• valve incompetence at great/short saphenous veins and perforators
• deep venous incompetence
• occlusion (DVT) and stenosis

Question 6

describe the management options for VVs

Answer 6

Non-surgical:

1. lifestyle changes, e.g. avoiding prolonged standing, weight loss, increase exercise
2. compression stockings if interventional Tx not appropriate

Surgical:

3. vein ligation, stripping or avulsion
4. foam scleropathy: injection of sclerosing (irriating) agent under US guidance directly into affected veins, causing inflammatory response that closes of vein
5. thermal ablation: heating vein from inside using radiofrequency or laser catheters under US guidance, causing irreversible damage to vein and closing it off

Question 7

describe the possible complications of untreated VVs

Answer 7

Will worsen over time:

1. haemorrhage
2. thrombophlebitis
3. chronic venous incompetence (venous HTN)… venous ulcers, oedema, skin pigmentation, varicose eczema, atrophie blanche and lipodermatosclerosis