Varicose veins Flashcards
Define:
Vein that become prominently elongated, dilated and tortuous. Most commonly the superficial veins of the lower limbs
Aetiology:
Blood flows from the superficial veins to the deep via the perforator veins. Back flow is prevented by valves.
when there is valve incompetencey this allows the back flow of blood and venous hypertension
Primary causes of varicose veins:
Congenital or development weakness in the vein wall leading to dilation, increased elasticity and valvular incompetence.
congenital valve absence
Secondary causes of varicose veins:
Venous outflow obstruction: DVT Pregnancy ovarian/pelvic malignancy ovarian cysts ascites lymphadenopathy constipation overactive muscle pumps as in cycalists high flow e.g. arteriovenous fistula damage to the valve (post DVT)
Risk factors:
Age Female Family history Caucasian Obesity
Epidemiology:
Common
more common in females
more common with increasing age
10-15% of men
20-25% of women
Symptoms:
- Patients may complain about the cosmetic appearance
- Aching/cramps in the legs
- Aching is worse towards the end of the day of after standing for long periods of time
- Swelling
- Tingling
- Heaviness and restless legs
- Itching
- Bleeding
- Infection
- Ulceration
Signs:
Inspection
o Inspect when the patient is standing
o Oedema, eczema, ulcers, phlebitis, atrophie blanche, lipodermatosclerosis
Palpation
o May feel fascial defects along the veins
o Cough impulse may be felt over the saphenofemoral junction
o Tap Test - tapping over the saphenofemoral junction will lead to an impulse felt distally (this would not happen if the valves were competent)
o Palpation of a thrill or auscultation of a bruit would suggest an AV fistula
Trendelenburg Test
o Allows localisation of the sites of valvular incompetence
o Leg is elevated and the veins are emptied
o A hand is placed over the saphenofemoral junction
o The leg is put back down and filling of the veins is observed before and after the hand is released from the saphenofemoral junction
• Rectal or Pelvic Examination
o If secondary causes are suspected
Signs of venous insufficiency:
Varicose eczema
Oedema
Ulceration
lipodermatosclerosis
Haemosidern staining
Investigations:
Duplex ultrasound:
-locates site of the incompetence of reflux and exclude DVT
Management:
• For symptomatic superficial vein insufficiency (no PVD)
o 1st line: graduated compression stockings
o If ineffective: phlebectomy or sclerotherapy
o In effective: ablative procedures +/- phlebectomy or sclerotherapy
For deep vein insufficiency
o 1st line: phlebectomy and compression stockings
What is conservative treatment:
Exercise
support stockings
elevate legs above the heart
what is endovascular treatment:
Radiofrequency ablation: catheter inserted into the vein and heated to 120 degrees destroying the endothelium and closing the vein
Endovenous laser ablation: similar concept but uses a laser
Injection sclerotherapy: liquid injected at multiple sites and vein compressed for a few weeks to avoid thrombosis OR foam injected under ultrasound guidance at a single site and spreads rapidly through the veins, damaging the endothelium.
Phlebectomy: minimally invasive procedure using a small scalpel to remove varicose veins
what is surgical management:
Stripping of the long saphenous vein
Avulsion of varicosities
NOTE: short saphenous vein isn’t stripped because of the risk of damaging the sural nerve
Post op: bandage legs tightly and elevate for 24 hours
complications:
Venous pigmentation Eczema lipodermatosclerosis superficial thrombophlebitis venous ulceration
