Varicose Veins

During a GP teaching session, I met a middle aged man with varicose veins in both legs, for which he had had 6 previous laser therapy interventions for. They kept recurring and they caused him pain and a heavy feeling in his legs. He had previously worked in a job that required him to stand for long periods but was now unemployed, depressed, and a widowed father to two teenage daughters.


Varicose Veins

Definition: long, saccular, tortuous, dilations of superficial venous system, most commonly that of the lower limbs.

Saphena varix = dilation of the saphenous vein at the sapheno-femoral junction

Aetiology/ risk factors:


-valves that normally prevent blood from passing from the deep to superficial veins (via perforator veins) are incompetent, so there is venous hypertension and dilation of the superficial veins.

Primary causes: unknown, congenital valve abnormality (very rare)

Congenital conditions include Klippel- Trenaunay syndrome (port wine stains, varicose veins, hypertrophy of limb tissue) and Parkes Weber syndrome (as KT Image result for lower limb venous anatomy perforatorssyndrome +arteriovenous fistulas)

Secondary causes:

-venous outflow obstruction: DVT, fetus, ovarian tumour, pelvic malignancy, ovarian cysts, ascites  (places pressure on superficial system)

-valve destruction: DVT

-Arteriovenous malformation/ fistula (↑pressure)

-Constipation

-Overactive muscle pumps (cyclists)

R/Fs: prolonged standing, obesity, pregnancy, female, family history, oral contraceptive pill

Image result for lower limb venous anatomy perforators

Epidemiology: common

-increased with age

-10-15% adult men

-20-25% adult women (possibly because they present more)

Symptoms:

Image result for varicose veins-asymptomatic/ cosmetic (majority of people)

-aching legs

-heaviness, swelling

-cramps

-tingling

-itching

-restless legs

Symptoms generally when standing for a long period, so may be worse towards end of day. If they sit down and raise their legs, symptoms disappear.

Signs:

 

Image result for varicose veins thrombophlebitis

Thrombophlebitis

-visible dilated, tortuous veins (especially when standing)

 

-bleeding, haemorrhage- more of a problem in older people with thin skin

-phlebitis, thrombophlebitis

 

 

-oedema

-corona phlebectatica (multiple fine vein branches suggesting underlying chronic venous insufficiency)

-eczema, atrophie blanche (white scarring at the site of a previous, healed ulcer)

 

 

-skin pigmentation- haemosiderin staining, iron left in tissues

-lipodermatosclerosis- lose elasticity, skin becomes fat-like, waxy and hard from subcutaneous fibrosis caused by chronic inflammation and fat necrosis.

-venous ulceration

These skin changes, apart from venous ulceration which we hope to help heal, are not likely to reverse.

Skin changes normally at medial malleolus (where long saphenous vein starts, area highest pressure)

Saphena varix: may be mistaken for hernia

Image result for hemosiderin staining varicose veins

Haemosiderin pigmentation

 

-soft and compressible, may reach size of golf ball or larger

-disappears immediately on lying down

-transmits expansile cough impulse

-may have a bluish tinge

-demonstrates fluid thrill

 

 

CEAP Classification:

CEAP classification of chronic venous disease Clinical classification
C0 No visible or palpable signs of venous disease
C1 Telangiectasies or reticular veins (< 3 mm)
C2 Varicose veins (> 3mm)
C3 Oedema
C4a Pigmentation or eczema
C4b Lipodermatosclerosis or atrophie blanche
C5 Healed venous ulcer
C6 Active venous ulcer

 

 

 

 

 

-Comprehensive classification system for chronic venous disorders

Investigations:

-History and examination:

Start with patient standing

Inspect:

-ulcers (above medial malleolus) with brown edges (haemosiderin deposition), eczema, thin skin and other skin changes (see signs)

-inspect from anterior thigh to medial calf (long saphenous) and back of calf (short saphenous)

Palpate:

-palpate veins for tenderness (phlebitis) and hardness (thrombosis)

-if ulceration, palpate pulses to rule out arterial disease

-feel for cough impulse at sapheno-femoral junction (Saphena varix)

-palpation of a thrill suggests an arterio-venous fistula

Percussion:

Percussion test: tap varicose veins distally (medial knee level) and palpate for transmitted impulse at the sapheno-femoral junction (impulse = +ve test = incompetent valves)

Auscultation:

-auscultate over varicosities for a bruit, indicating arteriovenous malformation/ fistula

Doppler U/S probes: listen for flow in incompetent valves e.g. the sapheno-femoral junction, or the short saphenous vein behind the knee (sapheno-popliteal junction). Squeeze the calf muscles, stop squeezing and if there is valve incompetence, you will hear the blood flowing backwards due to valve incompetence- flow on release, lasting 0.5-1 second indicates significant reflux.

Special tests: rarely used now because of Doppler

Trendelenburg’s test:  Patient is flat, leg elevated and veins gently emptied. A hand compresses the sapheno-femoral junction. Patient stands and if the veins fill rapidly, the incompetence is below this level (your hand is doing the job of the valve). If they do not refill, the incompetence is at this junction.

Tourniquet test: as with Trendelenburg’s, but a tourniquet is tied below the level of the sapheno-femoral junction instead. Can move the tourniquet down the limb, until the tourniquet controls re-filling, to determine which level the incompetence is at- above the knee to assess the mid-thigh perforator and below the knee to assess competence between the short saphenous vein and popliteal vein.

Duplex ultrasound (Doppler U/S+ traditional U/S): provides further information, imaging, locate site of incompetence, exclude DVT

Management:

→Treat any underlying cause

Preventative: correct risk factors- lose weight, exercise calf muscles (may be enough if asymptomatic)

Conservative: compression hosiery with graduated compression (can also be used to help diagnosis)

-Educate patient on avoiding prolonged standing and elevating leg(s) whenever possible, weight loss, regular walks

-Specialist referral if: bleeding, pain, ulceration, superficial thrombophlebitis, severe impact on quality of life

Intervention:

Endovascular treatment: (less pain and earlier return to activity than surgery)

Radiofrequency ablation (VNUS closure): catheter inserted into the vein and heated to 120°C destroying the endothelium and ‘closing’ the vein. Results as good as surgery at 3M.

Endovascular laser ablation (EVLA): as above, but uses laser. Outcomes (QOL/recurrence) = surgery after 2 years.

Injection sclerotherapy: can use either liquid or foam. Liquid sclerosant indicated for varicosities below the knee is there is no gross sapheno-femoral incompetence. It is injected at multiple sites and the vein compressed for a few weeks to avoid thrombosis. Alternatively, foam sclerosant is injected under USS guidance at a single site, spreading rapidly throughout the veins, damaging the endothelium- achieves 80% complete occlusion but not more effective than liquid sclerotherapy or surgery.

-After all treatments, legs are bandaged and early mobilisation is encouraged.

Surgery:

Several choices depending on vein anatomy and surgical preference:

e.g. Saphenofemoral ligation (Trendelenburg procedure)

Multiple avulsions- (multiple small incisions, to pull out veins)

Stripping from groin to upper calf (to ankle not needed, and may damage saphenous nerve)

Post-op, legs are bandaged tightly and elevated for 24h.

Surgery is more effective than sclerotherapy in the long term

Complications:

-Oedema, eczema

-Infection, bleeding

-Thrombophlebitis

-Lipodermatosclerosis

-Venous ulceration

-DVT: on their own, varicose veins don’t cause DVTs, except possibly proximally spreading thrombophlebitis of the long saphenous vein

Of treatment: Recurrence. Endovascular: skin burns, nerve injury, bruising, embolism, DVT. Surgery: haemorrhage, infection, paraesthesia or nerve injury.

Prognosis: in general, slowly progressive. Recurrence rates post-surgery can be up to 40%.

References: Cheese & Onion, Rapid Surgery, BMJ Best Practice, Med School E-lectures
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