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Varicose veins

Definition
  • Subcutaneous, permanently dilated veins 3 mm or more in diameter when measured in a standing position
Risk Factors
  • increasing age
  • FHx
  • Female gender
  • Increasing numbers of births 
  • DVT
  • Prolonged standing
  • Obesity
Differential diagnosis
  • Telangiectasias
    • Veins are smaller in size (<1 mm). No evidence of reflux on duplex examination 
  • Reticular veins
    • Veins range between 1 mm and 3 mm in diameter. No evidence of reflux on duplex examination
Epidemiology
  • Prevalence rates are higher in industrialised countries and in more developed regions
  • Prevalence of varicose veins increases with age
  • A genetic link exists, and the risk of varicose veins developing if both parents are affected is 90%; 62% risk if 1 parent is affected and female offspring; 25% risk if 1 parent is affected and male offspring; and if no parent is affected, the risk is 20%
Aetiology
  • The exact primary cause of varicose veins remains elusive
  • Valve incompetence is the most common aetiology
    • Blood pools when valves do not function properly, leading to increased pressure and distension of the veins
  • Progesterone is believed to lead to passive venous dilation, which may then lead to valvular dysfunction.
  • Oestrogen produces collagen fibre changes and smooth muscle relaxation, which both lead to vein dilation
Clinical features
  • presence of risk factors
  • dilated tortuous veins
  • leg fatigue or aching with prolonged standing
  • leg cramps
  • restless legs
  • itching
  • bleeding from varices
  • haemosiderin deposition
  • corona phlebectatica
  • lipodermatosclerosis
  • ankle swelling
  • ulceration
  • bleeding from varices
Pathophysiology
  • Veins are thin-walled and lack the muscular walls of arteries
    • Therefore, veins require assistance in blood return.
    • This is provided by valves and muscle pumps.
    • When one of these factors is not functioning properly, venous hypertension and insufficiency can ensue, possibly leading to varicose veins
  • A normal vein wall has 3 smooth muscle layers that all help to maintain vein tone.
  • Varicose veins demonstrate marked proliferation of collagen matrix as well as decreased elastin leading to distortion and disruption of muscle fibre layers
Investigations
  • Duplex ultrasound
    • Reflux is defined as valve closure >0.5 second.
    • For best sensitivity, reverse flow, or reflux, should be measured with the patient standing and with the leg in external rotation.
    • With duplex ultrasound, specific segments affected by reflux can be delineated as superfical and deep truncal veins, perforators, and tributaries can all be visualised.
    • Reflux in the great saphenous vein or common femoral vein can be detected through use of a Valsalva manoeuvre
    • More distal reflux can be elicited by compressing the leg above the Doppler to see if blood is forced back towards the feet.
    • If a great saphenous vein is >6 mm in diameter, reflux is likely to be present.
    • However, reflux in a perforator vein <4 mm in diameter is not considered significant.
  • Duplex ultrasound can be performed not only to assess for valve closure time but also to rule out deep vein thrombosi
Management

a) conservative

b) medical

c) surgical

Prognosis

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