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Varicose Veins

1. ANATOMY

Deep and superficial veins of the lower limb

Perforator veins

  • Veins that connect superficial veins to deep veins
  • Travel from superficial fascia through an opening into the deep fascia before entering deep veins
  • They have valves so blood flow is one way
  • Reversal of blood flow occurs due to incompetence of perforators – leads to varicose veins

2. VARICOSE VEINS

  • Dilated, tortuous, elongated veins in the leg
  • Due to reversal of blood flow through faulty valves in the perforators

Epidemiology

  • More common in females
  • Family history
  • Occupations which necessitate long periods of standing – security guards, surgeons, nurses

Etiology

Primary varicosities

  • Congenital incompetence/absence of valves
  • Weakness/wasting of muscles – defective connective tissue and smooth muscle in vessel wall
  • Stretching of deep fascia
  • Inheritance of FOXC2 gene

Secondary varicosities

  • Recurrent thrombophlebitis
  • Occupational – standing for long hours
  • Obstruction to venous return – abdominal tumour, lymphadenopathy, ascites
  • Pregnancy, obesity, chronic constipation
Pathogenesis
  • Venous system in the lower limb is maintained by
    • Valvular competence
    • Venous patency
    • Calf muscle pump
  • Incompetence of valves leads to venous reflux, which causes venous hypertension and subsequent venous wall dilation and tortuosity
  • Weakening of the venous endothelial wall and valves occurs due to
    • Shearing pressure due venous hypertension
    • Increased matrix metalloproteinase activity on endothelium
    • Changes in venous constriction and relaxation properties
    • Recurrent inflammation

Types of varicose veins

  • Thread veins – AKA telangiectasis/spider veins (0.5-1mm)
    • Small varices in the skin which look like a dilated, red, purple network of veins
  • Reticular varices – slightly larger (1-4mm)
  • Varicose veins – dilated palpable veins, specifically located in saphenous compartment (>4mm)

Classification – CEAP classification

  • Clinical signs – grades 0-6
  • Etiological classification – congenital, primary, secondary, no venous etiology
  • Anatomic distribution – superficial, deep, perforator
  • Pathophysiologic dysfunction – reflux, obstructive, both, or no pathophysiology identified

Clinical features

  • Aching pain, postural discomfort
  • Heaviness in the legs
  • Visible dilated veins in the leg
  • Edema of the feet
  • Pruritis
  • Discolouration/ulceration

Tests

  • Trendelenburg test – the affected leg is raised to empty the veins. Tourniquet is tied around the saphenofemoral junction (SFJ) to constrict the saphenous vein. The patient is then asked to stand
    • Negative test – with the tourniquet in place the veins fill within 30 seconds; upon removal of the tourniquet there is an increased rate of filling. This means the filling occurs due to incompetency of the perforator veins
    • Positive test – with the tourniquet in place, the varicosities remain collapsed for 30 seconds. Once the tourniquet is removed the saphenous vein rapidly fills with blood from above. This indicates that the valves of the saphenous vein at the SFJ are incompetent, but the valves of the perforator veins are still intact
  • Perthe’s test – assesses the patency of the deep femoral vein
    • The limb is elevated and an elastic bandage is applied firmly from to obliterate the superficial veins only. The patient is asked to walk for 5 minutes
    • If deep system is competent, the varicose veins become less distended as the blood is able to pass from the superficial veins to the deep veins and back to the heart (suggests incompetency of the superficial veins)
    • If the deep system is incompetent, the varicose veins remain distended as the blood is unable to pass from the superficial to the deep veins; the patient will also feel pain in the leg (signifies DVT)
  • Cough impulse test – hand is placed over the SFJ and patient is asked to cough
    • If there is saphenofemoral incompetence an impulse is felt over the SFJ

Investigations

  • Venous Doppler – whooshing sound at SFJ
  • Duplex scan – combination of visual ultrasound and audible Doppler
  • Venography

Treatment

Conservative

  • Pressure stockings
  • Elevation of limb – to relieve edema
  • Pneumatic compression

Pharmacological

  • Calcium dobesilate – improves lymph flow, reduces edema
  • Diosmin therapy – to increase venous tone

Sclerotherapy

  • Injection sclerotherapy – agents used can be sodium tetradecyl sulphate (STDS), ethanolamine oleate
  • Foam sclerotherapy – STDS mixed with air, to form a foam

Operative

  • Trendelenburg operation – juxtafemoral flush ligation of great saphenous vein
  • Stripping of vein – avulses the vein and obliterates the tributaries
  • Endovenous laser therapy and radiofrequency ablation

Complications

  • Haemorrhage – rupture of varicose veins
  • Pigmentation, eczema, dermatitis
  • Periostitis – thickening of periosteum
  • Venous ulcers
  • Lipodermatosclerosis
  • Ankylosis – of ankle joint due to fibrosis of soft tissue
  • Deep venous thrombosis
  • Recurrent thrombophlebitis – clot formed on superficial system at perforator level gets infected
    • Causes localised fever and tenderness
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