Varicose Veins Flashcards
What are varicose veins?
Varicose veins are tortuous dilated segments of vein associated with valvular incompetence.
Briefly describe the pathophysiology of varicose veins
They arise from incompetent valves, which permit blood flow from the deep venous system to the superficial venous system (at the sapheno-femoral junction and sapheno-popliteal junction, but other perforating veins exist). This results in venous hypertension and dilatation of the superficial venous system.
What are the causes of varicose veins?
98% of varicose veins are primary idiopathic varicose veins. Secondary causes may include deep venous thrombosis, pelvic masses (e.g. pregnancy, uterine fibroids, and ovarian masses), or arteriovenous malformations (such as Klippel-Trenaunay Syndrome).
What are the risk factors for varicose veins?
There are four major risk factors for the development of varicose veins:
- Prolonged standing
- Obesity
- Pregnancy
- Family history
What are the clinical features of varicose veins?
Patients will typically present initially with cosmetic issues, presenting with unsightly visible veins or discolouration of the skin
Worsening varicose veins may then cause aching or itching. Subsequent complications if left untreated can include skin changes, ulceration, thrombophlebitis or bleeding (often presenting post-trauma).
On examination, varicosities will be present in the course of the great and / or short saphenous veins. They can also present with clinical features of venous insufficiency, such as ulceration, varicose eczema, or haemosiderin deposition.
What is saphena varix?
A saphena varix is a dilatation of the saphenous vein at the saphenofemoral junction in the groin. As it displays a cough impulse, it is commonly mistaken for a femoral hernia; suspicion should be raised in any suspected femoral hernia if the patient has concurrent varicosities present in the rest of the limb. These can be best identified via duplex ultrasound and management is via high saphenous ligation.
What investigations should be ordered for varicose veins?
Gold standard for varicose vein investigations is via duplex ultrasound (best done by a trained technician), assessing valve incompetence at the great/short saphenous veins and any perforators. Deep venous incompetence, occlusion (deep venous thrombosis) and stenosis must also be actively looked for.
Can concurrect varicose veins and DVT be treated?
If a patient is identified to have a concurrent DVT, you cannot treat their superficial incompetence, as the venous blood will have no route back. Consequently, any patient with deep venous incompetence is typically offered non-surgical management.
Briefly describe the non-invasive treatment of varicose veins
Patient education is very important, such as avoiding prolonged standing, weight loss, and increase exercise (promotes calf muscle action).
NICE guidance only recommends the use of compression stockings if interventional treatment is not appropriate. This is because compression stockings are good at preventing complications of varicose veins but need to be worn for the rest of the patients life.
Any venous ulceration from deep venous incompetence generally requires four-layer bandaging (graduated compression aiming to move blood from distally to proximally), unless there is evidence arterial insufficiency.
What is the NICE criteria for surgical treatment for varicose veins?
In the UK, patients with varicose veins should be referred to a vascular service if they meet the following NICE criteria:
- Symptomatic primary or recurrent varicose veins
- Lower‑limb skin changes, such as pigmentation or eczema, thought to be caused by chronic venous insufficiency
- Superficial vein thrombosis (characterised by the appearance of hard, painful veins) with suspected venous incompetence
- A venous leg ulcer (a break in the skin below the knee that has not healed within 2 weeks)
What are the surgical options for varicose veins?
The treatment options that are available include:
- Vein ligation, stripping and avulsion
- Foam sclerotherapy
- Thermal ablation
Briefly describe vein ligation, stripping and avulsion
Making an incision in the groin (or popliteal fossa) and identifying the responsible, refluxing vein, before tying it off and stripping it away. The surgeon must be aware of surrounding arterial and nervous structures, such as the saphenous and sural nerves.
Briefly describe foam sclerotherapy
Injecting a sclerosing (irritating) agent directly into the varicosed veins, causing an inflammatory response that closes off the vein. This is done under ultrasound guidance to ensure the foam does not enter the deep venous system, however this method only requires a local anaesthetic.
Briefly describe thermal ablation
Involves heating the vein from inside (via radiofrequency or laser catheters), causing irreversible damage to the vein which closes it off. This is done under ultrasound guidance and also may be performed under local (or general) anaesthetic.
What are the complications of varicose veins?
Untreated varicose veins will worsen over time and indeed many patients who have treated varicose veins often require re-intervention surgery.
Whilst the complications will be specific for each procedure, typical complications seen post-operatively include haemorrhage, thrombophlebitis (important for foam or ablation treatments), DVT (important for any endovenous treatments), disease recurrence and nerve damage (specifically saphenous or sural nerves).
