Varicose veins are veins with valve incompetence leading to the back-flow and pooling of blood → tortuous dilated segments of the veins. Incompetent valves allow back-flow from the deep venous system → superficial venous system → venous hypertension and dilation.
If the dilation is >3mm then they are varicose veins, and if between 1-3mm they are considered reticular veins.
Pathophysiology
The overwhelming majority of patients are due to idiopathic causes.
Secondary causes may be due to:
- DVT
- Pelvic mass - such as pregnancy, fibroids etc. Around 40% of women affected during/after pregnancy. As they can compress pelvic veins.
- AV malformations - as seen in Klippel-Trenaunay syndrome.
⚠️ Risk factors
4 major risk factors:
- Prolonged standing
- Obesity
- Pregnancy
- Family history
😷 Presentation
- Cosmetic issues with unsightly, tortuous veins and discolouration of the skin is the main presentation.
- Itching and aching may occur with worsening varicose veins.
These varicose veins will be present in the course of the great and/or short saphenous veins.
Patients may also present with venous insufficiency symptoms such as:
- Venous ulceration
- Varicose eczema
- Haemosiderin deposits - hyperpigmentation.
- Lipodermatosclerosis - hardening of the skin.
- Superficial thrombophlebitis
🔍 Investigations
- 🏆 Duplex US is gold standard to assess the extent of the varicose veins by assessing valve incompetence at the great/short saphenous veins.
- We should also assess for occlusion such as DVT and stenosis.
Tests
Some special tests may be done (no need to learn these):
- Tap test - while applying pressure to the SFJ we tap the distal varicose vein. If there is a thrill at the SFJ then it suggests there is an incompetency between the SFJ and the varicose vein.
- Cough test - while applying pressure at the SFJ we ask the patient to cough. If there is a thrill felt then it suggests dilation at the SFJ (a saphena varix).
- Trendelenburg’s test - with the patient lying down, raise the affected leg to allow the veins to drain. Then apply a tourniquet to the the thigh and ask the patient to stand up. If it is placed distal to the incompetent valve then the varicose vein will not reappear. If it is placed proximally to the incompetent valve the veins will reappear.
🧰 Management
Cosmetics alone is not enough to warrant surgery according to UK criteria.
Conservative treatment
- Compression stockings can be worn if we can not use surgical intervention. This can reduce the risk of complications. An ABPI needs to be taken first.
- Leg elevation
- Weight loss
- Exercise
Surgical treatment
Surgery is indicated if the patient is symptomatic, if there are any skin changes, if there is thrombosis, or ulceration.
Treatment options include
- Vein ligation, avulsion and stripping - where an incision is made in the groin or popliteal fossa and the veins are tilted off and stripped away.
- Foam sclerotherapy - an irritating foam agent is injected into the vein which causes an inflammatory response that seals the vein.
- Thermal ablation - the vein is heated from the inside using RFA or laser catheters to close off the vein.
