Varicose veins

Question 1

What is the definition of varicose veins?

Answer 1

Tortuous and dilated veins

Question 2

How common are varicose veins?

Answer 2

Common, 10-20% of men and 25-33% of woman

Question 3

What is the pathology of varicose veins?

Answer 3

• Most commonly in the legs
• Normal pathology
• Blood collected from superficial venous capillaries is directed upwards and inwards via a one way valve
• These then drain into deeper veins buried under the fascia
• Disease pathology
• Leakage of valves cause retrograde flow back into the vein
• Superficial veins cannot withstand high pressure
• Pregnancy:
• Hormones increase the pliability of the venous walls and valves
• Expansion of the circulating blood volume
• Pressure on the IVC from the growing uterus
• Obstruction to venous flow e.g. DVT, trauma, tumours, cirrhotic liver
• = become tortuous and dilated

Question 4

What are the risk factors/aetiology of varicose veins?

Answer 4

• Pregnancy
• Obesity
• ↑ age
• Thrombophilia

Question 5

What are the signs/symptoms of varicose veins?

Answer 5

• Itchy legs
• Discomfort in legs – dull ache, worse after prolonged standing
• Heaviness in legs
• Night cramps
• Oedema
• Burning sensation of legs
• Paraesthesiae
• Exercise intolerance
• Restless legs
• Made worse after exogenous hormones, menstruation and occasionally sex
• Pressing over the area that is a varicose vein will cause the vein to empty and then fill again
• Chronic venous insufficiency:
• Ulcers
• Lipodermatitis
• Pigmentation
• Telangiectasia
• Eczema
• Fluid thrill felt at the level of the valve = incompetent
• Trendelenburg test
• Patient in supine position
• Leg is flexed at the hip and raised above heart level
• Veins will empty due to gravity
• Tourniquet is applied around the upper thigh
• Patient then stands
• If veins fill quicker than 30 sec = valvular incompetence below the level of the tourniquet in the deep/communicating veins
• If there is sudden filling when tourniquet is removed = superficial veins are incompetent

Question 6

What diseases present similarly to varicose veins?

Answer 6

• Cellulitis
• DVT
• Superficial phlebitis

Question 7

What investigations are needed to diagnose varicose veins?

Answer 7

FBC

Doppler US

Question 8

What are the surgical treatments for varicose veins?

Answer 8

• Endothermal ablation
• US guided foam sclerotherapy – image guided injection of sclerosant foam
• Avulsion – part of the vein is excised using a vein hook/forceps
• Stripping – a wire is used to pull out the entire vein
• Ambulatory phlebectomy – under LA, multiple small incisions are made and the vein is hooked out and extracted
• Injection sclerotherapy

Question 9

What are the non pharmacological treatments for varicose veins?

Answer 9

• Compression stockings – only if interventional treatment is not appropriate, make sure arterial disease is excluded
• Weight loss
• Exercise
• Avoid prolonged standing
• Keep legs elevated as much as possible