Varicose Veins
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Varicose veins are dilated, tortuous veins in the leg.
Most varicose veins are primary; the remainder are secondary to other
disorders such as deep venous thrombosis or pelvic occlusion.
Varicose veins occur in young adults and incidence increases with age to 80%
at 60 years. Women are affected more frequently than men.
Varicose veins are asymptomatic in the majority of people, yet remain one of
the most common reasons for surgical referral in the developed world.
Prominent varicosities usually develop slowly, over a period of 10-20 years. In
most cases, the process begins in the groin with failure of the sapheno-femoral
valve.
The long saphenous system is involved in 90% of cases; the short system, in
10%.
Causes
Congenital:
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absence of valves in the iliac veins
abnormal vein wall elasticity
arteriovenous fistulae e.g. Robertson's giant limb
Acquired:
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obesity in women (but not in men)
prolonged standing
parity - women are affected six times more often than men, the majority of
cases following a second or third pregnancy; important factors may include:
o impaired venous return, due to pressure on the iliac veins from the
pregnant uterus
o high level of progesterone which alters collagen structure, sometimes
irreversibly, and relaxes smooth muscle
previous deep vein thrombosis - valves damaged when the veins recanalise
It is currently thought that the wall of the vein is weak in patients with varicose veins
and that valvular incompentence follows rather than causes the dilatation of the vein.
This theory is supported by the observation that early dilatation is usually distal to an
incompetent valve not proximal as might be expected if the damaged were caused by
a descending valve incompetence.
There are three types of varicose veins:
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trunk varicosities are large varicose veins which lie along the path of the long
or short saphenous veins
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reticular varicosities are small dilates veins which lie away from the path of
the main saphenous veins
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telangiectasiae are very small dilatations also called spider veins
Incompetent valves commonly develop:
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in the groin, where the long saphenous vein joins the femoral vein
in the lower medial thigh, where the mid-thigh perforator joins the deep
system at the adductor canal
behind the knee, where the short saphenous vein joins the popliteal vein
behind the medial border of the tibia, where several veins perforate the deep
fascia of the calf
Symptoms
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disfigurement:
o patients are frequently disturbed by the poor cosmetic appearance of
their legs
o both their concern and their symptoms may worsen in the summer
when the legs are warm and exposed
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pain:
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legs frequently ache, especially after prolonged standing
patients often describe a dull, heavy, "burning" sensation that becomes
more severe as the day progresses
in women, symptoms may worsen in the few days prior to
menstruation
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itching:
o the skin over the varices may itch
o may be associated with varicose eczema
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heaviness
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worry:
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patients may present because of concern about possible complications
such as ulceration
Examination:
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varices appear on standing and disappear when recumbent
positive Brodie-Trendelenburg test
doppler flow studies identify 'backflow' through incompetent valves
Investigation
Ideally all patients with varicose veins would have colour duplex ultrasound scanning
to determine the characteristics of blood flow in the leg. Unfortunately this is not
possible and so duplex scanning is reserved for the following groups of patients with:
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recurrent varicose veins
a history of superficial thrombophlebitis
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a history of DVT
varicose eczema
haemosiderin discolouration
lipodematosclerosis
venous ulceration
Treatment of varicose veins may be indicated to relieve discomfort, to prevent or
ameliorate complications, or for cosmetic reasons.
Methods:
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conservative
surgical:
o sclerotherapy - permanent obliteration of varices
o open operation - removal of varices with ligation of incompetent
perforaters
o alternatives to the current operative techniques are being introduced (1)
 endovenous obliteration using radiofrequency (diathermy) or
laser has been devised to close the long saphenous vein, an
alternative to the traditional "stripping."
 "powered phlebectomy" - this is another new technique that
obviates the need for multiple "phlebectomies" to avulse calf
varicosities, thus giving a more cosmetically favourable
outcome.
About one-third of cases can be managed by offering common sense advice as to how
to take care for their legs.
Complications caused by the varicose ulcers themselves include:
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haemorrhage:
o bleeding may be profuse because of the high venous pressure
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superficial thrombophlebitis
Complications caused by associated venous hypertension include:
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ankle oedema
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varicose eczema
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lipodermatosclerosis:
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atrophie blanche
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severe excoriation from scratching
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venous ulceration