Varicose veins

Notes

Overview

Varicose veins are dilated superficial veins commonly found on the lower limbs.

Though often asymptomatic they may cause distressing symptoms and cause cosmetic upset. They are common, and prevalence increases with age and in pregnancy.

Aetiology

Varicose veins develop due to increased pressure in small superficial veins.

In healthy veins, a one way system back to the heart is maintained by valves. This also protects small superficial veins from the increased pressures experienced within the deep compartments of the leg.

Venous insufficiency may occur due to valvular incompetence resulting in raised pressures in the superficial veins and the development of varicosities.

Risk factors

Varicose veins increase with age and in multiparous women. 

  • Age
  • Pregnancy
  • Obesity
  • Female gender
  • Previous DVT

Clinical features

Varicose veins are frequently asymptomatic beyond their cosmetic appearance but they may cause debilitating symptoms.

Symptoms

  • Pain / tenderness 
  • Pruritus
  • Cramps 
  • Restless legs
  • Cramps 
  • Bleeding

Signs

  • Dilated superficial veins
  • Bleeding
  • Lipodermatosclerosis
  • Venous eczema
  • Ulcers

Investigations

The imaging of choice in varicose veins is duplex US.

Duplex US: Patients requiring referral to vascular surgery should undergo US. It demonstrates venous reflux, and allows mapping and surgical planning.

Referral

Some patients will require referral to vascular surgery for consideration of interventional techniques.

The following patients should be referred to vascular surgery. Clinical judgement can be used for those not fitting the below criteria.

  • Symptomatic primary or recurrent varicose veins
  • Skin changes (hyperpigmentation, venous eczema) related to chronic venous insufficiency
  • Superficial vein thrombosis and suspected venous incompetence.
  • Active venous ulcer
  • Healed venous leg ulcer.

Management

Management may be divided into conservative and interventional techniques.

Conservative

  • Advice: The nature of varicose veins should be explained including possible complications, though they should be assured the serious ones are rare.
  • Weight loss: Appropriate weight loss is advised.
  • Exacerbating factors: Avoid factors like prolonged standing or sitting. Legs should be elevated where possible.
  • Compression stockings: Compression stockings should be offered once arterial disease is excluded.

Interventional

  • Sclerotherapy: Injection of irritant foam into vessel resulting in closure of the vein.
  • Endothermal ablation: Minimally invasive technique that uses radiofrequency ablation or laser ablation to cause destruction and closure of the vein.
  • Phlebectomy: Also termed stab avulsions, multiple small cuts are made and the veins tugged out in strips through the skin.
  • High ligation and vein stripping: The long saphenous vein is tied at the saphenofemoral junction and vein stripped.

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