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
Managementa) conservativeb) medical c) surgicalPrognosis |
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