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