Varicose Veins

Overview Varivose veins (VV) are long, torturous and dilated don't veins of the superficial venous system. There is a spectrum ranging from telangiectasias (dilated interdermal venules less than 1 mm), through to reticular veins (non-palpable subdermal veins 1–3 mm) to varicose veins (greater than 3 mm). 35% of the general population affected.

The venous system of the leg can be divided into three groups

• Superficial system: long saphenous medially and short saphenous veins inferiolaterally
• Deep system: Vein between the muscle compartments of the legs following the major arteries
• Perforator veins: Connecting the superficial and deep system

Blood flows from the superficial system to the deep system via the perforator veins in the calf, and also at the Saphenofemoral junction, saphenopopliteal junction and mid-thigh perforators which contain one-way valves.

COMING SOON

Clinical Presentation Patients complain about legs looking ugly. There may be pain, cramp, tingling, heaviness and restless legs. On examination there might be obvious oedema, eczema, ulcers, haemosiderin, hemorrhage, phlebitis, atrophied blanch, lipodermatosclerosis.

Examination

• Tap test - percuss the veins?
• Trendelenburg test elevated the legs 45º and drain the vein, apply a torniquest
  • Phase I: Patient stands, note filling time of veins. If quick → venous insufficiency
  • Phase II:
• Tourniquest test
• Perthe's test

Primary

• Unknown
• Congenital valve absence

Secondary

• Obstruction DVT, enlarged uterus during pregnancy, ovarian tumour
• Valve destruction DVT
• Arteriovenous malformation
• Constipation
• Overactive muscle pumps (i.e. Cyclists)

• Blood from superficial veins drain into the deep veins via perforator veins and at the sapheno-femoral and sapheno-popliteal junctions.
• Valves prevent blood from passing from deep to superficial (prevent back flow).
• If the valve become incompetent, there is blood pooling  resulting in venous hypertension and dilatation of the superficial veins.

Pathophysiology

1. Valve incompetence
2. Poor venous return
3. Venous hypertension
4. Fluid, red and white cells migrate into tissues
5. Swelling, haemosiderin deposition, lipodermatosclerosis
6. Ulcers

Education

• Lose weight
• Regular walks
• Avoid prolonged standing
• Use of compression stockings

Medical Treatment

• Compression stockings - first line
• Radiofrequency ablation (VNUS closure)
• Endovenous laser ablation
• Injection sclerotherapy

Surgical Treatment

• Local 'stab avulsions
• Long saphenous vein stripping (not usually done below the knee due to possible saphenous nerve injury
• Saphenofemoral or saphenopopliteal disconnections.

Complication of Varicose veins

• Varicose veins alone is not a risk for DVT

Complications of surgery

• Bruising
• Recurrence (50% cases at 10years)
• Haemorrhage
• Wound infection
• Spahenous or aural nerve damage with parade thesis (20% numbness)
• Damage to major artery

An international consensus conference initiated the Clinical-Etiology-Anatomy-Pathophysiology (CEAP) classification to categorize chronic venous disorders

Patients with complications of varicose veins (CEAP 3–6); and those with clinical evidence of chronic deep vein insufficiency, especially venous eczema or ulceration, require referral to a vascular surgeon.