Armando Hasudungan
Biology and Medicine videos

Varicose Veins

Overview

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.

Anatomy

COMING SOON

Risk Factors

Risk Factors
Prolonged standing
Obesity
Pregnancy
Personal history
Family history
Contraceptive pill
Smoking

Signs and Symptoms

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
Salpehna Varix Dilatation of the saphenous vein at its confluence with the femoral bein. It transits a cough impulse and may be mistake for an inguinal or femoral hernia. On closer examination it may have a bluish tinge.

Aetioloy

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)

Pathology

  • 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

Management

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
Endovenous ablation is an image-guided, minimally invasive treatment for varicose veins. It uses radiofrequency or laser energy to cauterize (burn) and close the varicose veins

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.
Remember: Many patients are treated for cosmetic concerns alone, so it is important to manage patients’ expectations.

Complication and Prognosis

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

Classification

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

CEAP classification – C (clinical component only)
C0 No visible or palpable signs of venous disease
C1 Telangiectases or reticular veins
C2 Varicose veins
C3 Oedema
C4 Pigmentation, eczema, lipodermatosclerosis, atrophie blanche
C5 Healed venous ulcer
C6 Active venous ulcer
CA Asymptomatic
CS Symptomatic

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.