Varicose veins

Epidemiology:

• Female:male ratio of 3:1
• ~2% of the population
• Up to 50% of 65-75 year olds may have them
• The major complication is the nutritional change in the skin which may eventually go on to ulceration

Classification:

Primary:

• Poorly understood aetiology
• There is deep to superficial incompetence only
• The varicosities appear without an obvious underlying cause

Secondary:

• The varicosities occur because of some other cause:
• Obstruction
• Thrombo-inflammatory destruction of valves, in both the communicating and deep veins

Secondary varicose veins:

Less common than the primary type. Causes include:

• Deep or (less common) superficial venous thrombosis with recanalisation and consequent deep and/or deep to superficial valve destruction
• Obstruction with venous HT – a proximal injury or obstruction from a tumour
• Congenital or acquired arteriovenous fistulae with increased pressure and flow being transmitted from the arterial side of the circulation

Secondary varicose veins are associated with the syndrome of chronic venous insufficiency, which is considered below

Secondary effects of varicose veins:

Perivenous tissue changes:

• Interstitial oedema
• Possible decreased oxygenation of cells, with nutritional disturbance
• Ulceration

Skin changes:

• Lipodermatosclerosis:
• Pigmentation (due to extrusion of RBCs (diapedesis) and their subsequent dissolution
• Thickening if the subcutaneous tissues
• Skin atrophy

Symptoms of varicose veins:

• Ugly appearance
• Aching
• Pain on exercise
• Ankle swelling
• Restless legs
• Pigmentation and depigmentation
• Eczema
• Attacks of superficial phlebitis
• Ulceration
• Bleeding into the subcutaneous tissues

Investigations:

The investigations described below are for localisation of incompetent deep to superficial communications and for identification of valvular insufficiency in deep veins

Continuous wave ultrasound:

• Used to detect points of incompetence, e.g. at the saphenofemoral junction

Duplex Doppler scanning:

• The anatomy can be clearly shown
• Valves can be visualised
• Reflux is demonstrated by the reversal of the direction of flow using the same principle as with continuous flow Doppler

Venous pressure studies:

• Not used routinely
• Helpful in sorting out a complex problem of recurrence after surgery or of deep venous insufficiency

Venography

Management of primary varices:

By definition, these are the varices in the superficial system with:

• Deep to superficial incompetence at one or more sites
• No evidence of disease in the deep veins

Once it is certain that the symptoms and signs in the leg are associated with the varices, there are 3 options:

• Compression hose
• Sclerotherapy
• Surgery

Compression hose:

The indications are:

• Mild symptoms
• Those without skin changes
• The elderly
• Those who refuse other treatment
• Most pregnant women

Patients should be instructed to apply compression hose before they get up in the morning and only remove the support last thing at night

Compression sclerotherapy:

• The principle is to produce sterile chemical inflammation in a vein kept empty by compression; thrombosis and obliteration of the lumen follow
• The solutions most commonly used are 5% ethanolamine oleate or 3% sodium tetradecyl sulphate
• The method is suitable only for isolated varices without a large site of deep to superficial incompetence, because if this exists, recurrence rates are very high
• Further uses are:
• Obliteration of isolated incompetent perforating veins, especially after surgery
• Vulval varices which persist after pregnancy

Surgery:

Clinical feature Indication Contraindication

Pain Definite Doubts as to cause

Phlebitis Varicose veins the only cause Other causes not excluded

Bleeding Episode of considerable bleeding Minor bleeding

Skin changes To prevent ulceration

Ulceration Adjunct to healing Cannot correct venous HT

Technique:

• Aim is to interrupt, by ligation, the major points of incompetence between the superficial and deep venous systems
• To remove, if appropriate, the varices for both functional and cosmetic reasons
• Can be done as day-surgery cases