Varicose veins

can occur alone or in association with chronic venous insufficiency. 

ANATOMY

The venous system in the lower extremities consists of the 

1. Superficial – Greater Saphenous and Small Saphenous
2. perforating (communicating)
   1. are variable in their location and prevalence
   2. Hunterian and Dodd perforators ( thigh)
   3. Boyd and Cockett perforators (calf)
   4. number of perforators in the foot
3. deep venous systems
   1. gastrocnemius v
   2. peroneal and tibial v (in the calf)
   3. popliteal v (behind the knee)
   4. femoral v (thigh)

draining of blood is done by

1. The long and short saphenous veins, which join the deep system at the saphenofemoral and sphenopopliteal junctions 
2. The perforating veins originating from the long or short saphenous veins 
3. Vessels that drain directly into the deep venous system 

Varicose veins: visible, palpable, dilated (>4 mm), tortuous, elongated, subcutaneous veins

Telangiectasias and reticular veins: are smaller and non-palpable, frequently looks like a spider.

Varicose veins affect the superficial veins of the legs: 

1. Short(lesser) saphenous (posterior, lateral calf)
   1. drains into the popliteal venous system behind the knee(saphenopopliteal junction)
   2. infrequently the lesser saphenous vein drains 🡪 vein of Giacomini🡪 greater saphenous vein.
2. Long(greater) saphenous (medial thigh and calf)
   1. Ankle 🡪 median leg/thigh🡪 empties to femoral vein at saphenofemoral junction
3. their branches
   1. the posterior arch vein(calf-l.s.)
   2. posteromedial vein and anterolateral vein(thigh – l.s.)
   3. inferior epigastric vein (groin –l.s.)

They can be described as 

• mild (few; scattered branch varicose veins)
• moderate (multiple; greater saphenous varicose veins confined to the calf or thigh
• severe (multiple; thigh and calf or greater and lesser saphenous distribution) 

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PATHOPHYSIOLOGY

1. Primary
   1. due to superficial venous insufficiency salary privilege  
   2. Mechanism: 

Congenital/acquired abnormalities of the superficial valve apparatus –>

          valve incompetence 

           increased venous pressure

–>  subsequent distention of the venous wall

2. Secondary
3. venous obstruction
   1. intrinsic – DVT, post-phlebitic syndrome
   2. Extrinsic – actual or “functional” :pelvic tumors, morbid obesity, COPD 
4. venous hypertension from deep or perforating vein valvular incompetence
   1. 30% deep vein incompetence
   2. 50% perforator vein incompetence

Risk factors:

1. Familial/race/ geographic site
2. previous pregnancy
3. prolonged standing
4. increased body mass index / sedentary lifestyle

CLINICAL MANIFESTATIONS

1. Most asymptomatic. 
2. symptoms of aching, cramping, itching, fatigue, and swelling were reported more frequently in participants with varicose veins
3. concomitant chronic venous insufficiency
   1. edema- most commonly in varicosities below the knee
   2. skin changes
   3. ulcers
4. Worse symptoms with prolonged standing and improve with leg elevation and walking. 

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COMPLICATIONS 

primary varicose veins :  uncommon but may require immediate attention including surgical treatment

1. Bleeding
   •  occur spontaneously or following trauma. 
   • Compression and elevation are the initial steps in treatment. 
   • If these are ineffective, surgical repair or resection of the vein is generally required. 
2. Superficial thrombophlebitis
   • Ssx:  erythema, tenderness, and induration over the course of the vein.
   • Rx: evaluation for deep vein thrombosis
3. Ulceration
   • venous ulcers of the lower extremities typically indicates the presence of chronic venous insufficiency involving the deep and communicating systems.

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Evaluation

History 

1. Age at onset of varicosities?
2. family history of varicose veins?
3. prior trauma?
4. deep venous thrombosis?
5. number of prior pregnancies?
6. prior lower extremity surgery?
7. associated symptoms of chronic venous insufficiency?
8. exacerbating (eg, prolonged standing) or alleviating (eg, leg elevation) factors.
9. radiculopathy, peripheral neuropathy, arthritis, claudication?
10. A history of significant PVD, DM, arthritis, or other processes that limit the patient’s mobility should be obtained since they present relative contraindications for sclerotherapy and surgery. 

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Physical examination

Inspection:

1. Get the patient to stand up
2. Describe: Ulcers(anteromedial):: Lipodermatosclerosis::Scars:: Venous eczema
3. Describe visible veins:
   1. Location
   2. Size
   3. Course
   4. Type: Venous stars (blue patch) or gross varicosities
4. Size of the legs: compare ankle girth; increased with swelling

Palpation:

1. Feel along the course of the veins, try to feel the tension in the veins from down up.
2. At saphenofemoral junction get patient to cough. Feel for impulse in veins
3. Do this again at the sapheno-popliteal junction
4. Feel for any tender fascial defects on the medial aspect of the leg
5. Get the patient to lie down. Again feel for any tender fascial defects.
6. Now do the tourniquet test:

Percussion:

Percuss a vein proximally and see if the wave is conducted distally. 

Auscultation:

Listen over varicosities for a bruit or hum as it may indicate an AV fistula.

Clinical tests are relatively insensitive or non-specific and should not normally be performed unless Doppler ultrasound testing is not available. 

Trandelenburg-Brodie test 

1. to identify sites of valvular incompetence.
2.  Place the patient in the supine position with the leg elevated until all varicosities collapse. 
3. Place a tourniquet or blood pressure cuff (inflated above venous but below arterial pressure) around the mid-thigh, and have the patient stand. 
4. The veins should refill slowly over the next minute. 
5. Immediate filling indicates incompetent perforating veins. 
6. Remove the tourniquet. 
7. If the veins fill further, valves in the greater saphenous vein may be incompetent. 
8. The sensitivity for detecting reflux is 0.75 to 0.91 but specificity of 0.15 when compared with duplex

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Imaging 

1. Duplex ultrasound
   1. current standard noninvasive examination
   2. identify the competence of the saphenofemoral and saphenopopliteal junctions
   3. less sensitive in identifying incompetent perforators

2. Hand-held Doppler
   1.  can also help determine the presence of reflux in the perforating veins

SEVERITY MEASURES

CEAP classification – C (clinical component only)2
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

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MANAGEMENT 

Aim: improved symptoms and appearance. 

1. Varicose veins are a progressive disease and will steadily worsen. 
2. Many patients simply require some reassurance and explanation regarding the natural history of the disease.
3. Uncomplicated veins, without significant pain, can safely be managed with reassurance only. 
4. However, the ‘tea party’ system of referral is common, where patients have a relative or friend who has had a particular type of treatment, and have their mind set on having a similar treatment. 
5. It is also common for patients to have conducted their own web based research, and to have decided in advance which type of treatment they want. 
6. Although these patients may often not have a definite medical indication for intervention, it is often quite difficult to persuade them otherwise, and this may be a good reason to refer them for a specialist opinion.
7. Treatment for primary varicose veins
   1. conservative measures such as
      1. leg elevation
      2. compression stockings
   2. sclerotherapy
   3. surgery. 
8. Telangiectasias and reticular veins
   1. External laser therapy
9. Perforator vein incompetence
   1. perforator ligation at the time of surgery.
10. Deep venous insufficiency
    1. are not good candidates for sclerotherapy or surgery, due to a high rate of recurrence and poor postoperative healing due to venous stasis. 
    2. treat underlying chronic venous insufficiency
    3. can be worsened by the removal of superficial veins. 

Compression stockings

• initial treatment
• Compression stockings decrease venous pressure, venous reflux, and residual venous volume while they are being worn, but these effects regress soon after removal of the stockings 
• Contraindication
  •  severe arterial insufficiency  

Graduated compression stockings 

• Exert higher pressure at the ankle and gradually less pressure proximally to the knee or thigh, depending upon their length. 
• Four different classes
  • Ready-to-wear
  • lightweight compression (support) stockings (8 to 20 mmHg, available over-the-counter)
  • Class I (20 to 30 mmHg) stockings
  • Class II (30 to 40 mmHg) stockings
• As long as a patient has easily palpable foot pulses or an ankle-brachial index over 0.6, it is safe to fit Class 2 below-the-knee compression stockings
• Because discomfort and compliance are often issues, patients with primary varicose veins should initiate therapy with daily use of support stockings and advance to Class I and then Class II compression stockings as needed to control symptoms. 
• The pressure exerted by stockings diminishes with repeated washings and two to three pairs are required per year to maintain adequate compression. 
• may be complicated by skin irritation and contact dermatitis. 
• Wearing a cotton stocking under the compression stocking may be helpful in patients who develop skin problems. 

Endovenous therapy

• sclerotherapy – using liquid or foam (can be ultrasound guided, UGFS)
  • A small amount of foam is usually injected at the sapheno-femoral junction under ultrasound guidance. 
  • This results in intense venospasm, subsequent contact with the vein wall, and sclerosis then occurs. 
  • Compression is applied and successive segments treated; 8 mL of foam is generally the maximum used
• endovenous laser therapy (EVLT)
• radiofrequency ablation (RFA)
• mechanical – using steam or rotating catheter

• While open surgery remains the ‘gold standard’, most veins can be treated successfully with a range of options. 
• There is a clear worldwide trend toward less invasive methods of treatment for varicose veins, with rates for laser, radiofrequency and sclerotherapy increasing every year. 
• A recent review of the literature revealed the following:
  • no significant difference in short term outcomes between the modalities
  • complications were few and mostly minor
  • new varices may develop in 10% of patients within the first year after any treatment
  • the technical failure rate was highest with UGFS
  • both RFA and UGFS were associated with a faster recovery and less postoperative pain than EVLT and stripping
  • the shortest time to return to work was seen in the UGFS and RFA groups
  • there were significantly more cases of superficial phlebitis in the UGFS and RFA groups
  • the mean cost per treatment was lowest in the UGFS group and highest in the RFA and EVLT groups.
  • Recent guidelines recommend against UGFS alone for the treatment of GSV incompetence

• In trying to advise the individual patient on how to proceed, it is helpful to consider which patients should not undergo endoluminal treatment. This would apply in cases where the varicose veins are:
  • overly large (>2 cm diameter) – thermal treatment may fail, and there is a high risk of deep vein thrombosis
  • overly tortuous – endoluminal catheters may not pass up the vein
  • very close to the skin – skin burns are more likely, and in cases of thrombophlebitis – endoluminal catheters may not pass up the vein.

Surgery 

• combination of ligation, axial stripping, and stab phlebectomy may be applied as needed to the GSV, SSV, tributary veins and perforating veins

 Indications 

1. significant symptoms 
2. recurrent superficial thrombophlebitis
3. bleeding, ulcers, other venous stasis changes
4. cosmetic concerns.