Varicose veins

Question 1

What are varicose veins?

Answer 1

• Varicose veins are dilated and tortuous superficial veins, commonly affecting the lower limbs.
• They develop due to the incompetence of the valves between the deep and superficial venous systems, which results in retrograde flow and pooling of blood in the superficial venous system.

Question 2

Describe the epidemiology of varicose veins

Answer 2

Varicose veins are a common condition, affecting up to one-third of adults.
- occurs more with advancing age
- F> M due to hormonal influences.
- Individuals with a family history of varicose veins, or those who have prolonged standing in their occupations, are also at an increased risk.

Question 3

What causes varicose veins?

Answer 3

The development of varicose veins involves a complex interplay of factors that ultimately lead to venous insufficiency and valve incompetence. These factors include:
- age
- female sex
- family history
- obesity
- lack of movement
- and prolonged standing

Hormonal factors, such as:
- increased progesterone levels during pregnancy or from oral contraceptive use, can also lead to dilatation of the veins and valve dysfunction.

Question 4

What are the risk factors for varicose veins?

Answer 4

1. Primary
   - Due to genetic or developmental weakness in the vein wall
   - Results in increased elasticity, dilatation and valvular incompetence
   - Congenital valve absence
2. Secondary
   Due to venous outflow obstruction
   - Pregnancy
   - DVT
   - Ovarian tumour
   - Pelvic malignancy
   - Ovarian cysts
   - Ascites
   - Lymphadenopathy
   - Retroperitoneal fibrosis:
   *Due to valve damage (e.g. after DVT)
   *Due to high flow (e.g. arteriovenous fistula)
   *Constipation
   *Overactive muscle pumps e.g. cyclists
3. Age
4. Female
5. Family history
6. Caucasian
7. Obesity

Question 5

What are the presenting symptoms of varicose veins?

Answer 5

• Dilated tortuous veins 
• Visible superficial veins
• Oedema
• Venous ulcers
• Haemorrhage
• Patients may complain about the cosmetic appearance
• Aching/cramps in the legs: worse towards the end of the day of after standing for long periods of time
• Swelling
• Tingling
• Heaviness and restless legs
• Itching
• Bleeding
• Infection

Question 6

What signs of varicose veins can be found on physical examination?

Answer 6

1. Leg fatigue or aching with prolonged standing 
2. Leg cramps 
3. Restless legs 
4. Haemosiderin deposition = discolouration
5. Corona phlebectatica  (visible cutaneous blood vessels at the ankle with four components: “venous cups,” blue and red telangiectases, and capillary “stasis spots.”)
6. Oedema, eczema, ulcers, phlebitis, atrophie blanche, lipodermatosclerosis
7. May feel fascial defects along the veins
8. Cough impulse may be felt over the saphenofemoral junction
9. Tap Test - tapping over the saphenofemoral junction will lead to an impulse felt distally (this would not happen if the valves were competent)

Question 7

What investigations are used to diagnose/ monitor varicose veins?

Answer 7

1. Doppler ultrasound: The key diagnostic method for varicose veins. It provides information on the anatomy of the veins and the competence of the valves.
2. Duplex ultrasound: Used to measure blood flow and detect blockages or abnormalities of the veins.
3. Venography: May be considered in complex cases where other investigations are inconclusive.
4. MR venography: May be used when non-invasive tests are inconclusive and surgery is being considered.

Question 8

How is varicose veins managed?

Answer 8

1. Endovenous ablation
2. Phlebectomy (uses a small scalpel or needle to remove varicose veins that lie just beneath the surface of the leg)
3. Injection sclerotherapy: Injection of sclerosant substance at several points in the vein, leading to occlusion
4. Surgery: avulsion therapy or stripping of the vein
5. Compression stockings may be offered if interventional treatment is unsuitable (e.g., in pregnancy) or if the patient is unwilling to have intervention. These need to be replaced and re-measured every 3 months. 
6. Lifestyle modifications such as weight loss, leg elevation, and exercise (especially aqua-aerobics). 

Question 9

What complications may arise following varicose veins?

Answer 9

• Chronic venous insufficiency
• Haemorrhage
• Venous ulceration
• Lipodermatosclerosis (subcutaneous fibrosis and hardening of skin)
• Haemosiderin deposition 

Question 10

Describe the prognosis of varicose veins?

Answer 10

• Generally resolution of symptoms occurs in >95% of patients.
• Progressive disease and therefore new varicosities do not necessarily represent treatment failure. 
• High recurrence rates