Varicose Veins

Background

  • Valve insufficiency in the veins (usually in the leg) cause a back up of pressure in the venous system.  Thin walled superficial veins are unable to cope with higher pressures and so dilate and become tortuous.
    • The most common valves involved are located at the sapheno-femoral junction
  • Varicose veins are extremely common, with an incidence of around 2.5% of women and 2% of men.
    • Age, pregnancy, liver disease, previous DVT and family history all seem to increase the risk of varicose veins

History

  • Quite often patients present without any symptoms – veins are bothering them because of aesthetic reasons
    • Important to ask about symptoms e.g. itching, discomfort, heaviness of the legs, night cramps, oedema, burning, paraesthesia, excercise intolerance, weakness, restless legs etc.
      • Classic picture is of dull ache which is worse with prolonged standing
    • Check SOCRATES i.e. onset, duration, timing/change, exacerbating/alleviating factors etc
  • Make sure also to ask about
    • PMHx- Varicose veins (and any previous assessments/management), DVT, trauma, oedema, liver problems, cardiovascular disease; and Drug history
    • Social history- in particular, occupation that may involve prolong standing

Examination

  • Inspection
    • Inspect both legs fully exposed with the patient standing first
      • Usually inspect from the anteromedial aspect of the thigh to the lateral aspect of the leg (long saphenous vein route); and then the back of the calf (short saphenous)
      • Look also for skin changes e.g. haemosiderin deposition, eczema, ulcers, thinned skin etc
  • Palpation
    • Palpate the varicosities for tenderness (thrombophlebitis- normally should be painless); if they are hard this may suggest thrombosis
      • See if the veins will empty and refill with palpation
    • Palpate the skin if there any changes
    • Cough impulse test (whilst standing- tests for saphenofemoral insufficiency)
      • Locate the saphenofemoral junction by locating the femoral pulse then moving medially (vein) then two fingerbreadths inferiorly
      • Compress the area and ask the patient to cough
        • If a ‘thrill’ is felt, suggests that the valve here is incompetent
    • Elevate the leg to around 15 degrees and check the rate of vein emptying
  • NB Other special tests e.g.
    • Trendelenberg test (tests for the location of the incompetent valve using a tourniquet at the level of the saphenofemoral junction to prevent refilling on standing- shows incompetence at the level of the SFJ; Note the tourniquet can be applied lower down the leg to check at which level the incompetence arises)
    • Perthes’ manoeuvre (using a tourniquet to prevent superficial filling and asking the patient to activate calf muscles by standing on tip toes repeatedly- normally emptying the varicosities by paradoxically filling in deep vein obstruction) have been used in the past but have now become surplus due to evaluation by Doppler USS.
  • You should also auscultate varicosities and check for pitting oedema and peripheral pulses (a JVP assessment may also be appropriate where oedema is present).

Management

  • Lifestyle – although unlikely to reverse the process, losing weight and exercise will prevent deterioration and further varicosities
    • NB Compression stocking may also prevent further varicosities but are not recommended for management unless further management (intervention) is not possible)
  • Interventional management
    • Endothermal ablation
    • USS guided foam sclerotherapy
    • Avulsion
    • Ambulatory phlebectomy
    • Injection sclerotherapy

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