Varicose Veins


DEFINITION
A
bnormal dilation of the superficial veins draining the lower limbs, associated with increased venous pressure and valvular incompetence.

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INCIDENCE

Common.
Age
Primary occur first often at puberty.
Secondary associated with older age.
Sex
F>M.
Risk Factors
Genetics:
Family history.
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AETIOLOGY
May be primary or secondary.

Primary

More common in women.
Hormonally influenced
- come on at puberty, during pregnancy and maybe at menopause
- exacerbated by OCP and menstruation.

Secondary
Degenerative
DVT
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BIOLOGICAL BEHAVIOUR

Anatomy

see here

Pathophysiology

Primary
Now considered a 'bottom up' disease rather than a 'top down' disease (ie starts in the low leg)

Superficial system collects blood from superficial tissues.
When calf muscle pumps (250 mmHg), deep system is emptied north
When calf muscle relaxes, pressure gradient means the blood flows from superficial to deep.
Valves prevent retrograde flow into the superficial system during calf contraction.

Primary problem is incompetence of the perforating system, or failure of their valves
This allows blood to reflux into the superficial system
Progressive dilation follows
--> progressive failure of superficial vein valves
--> elongation of superficial veins, causing them to become tortuous

High pressure in superficial veins may be sufficient to impair the nutrition of the subcut tissue and dermis
--> contributes to ulcer formation.

Varicose veins = disorder of  superficial and perforating veins
- strong genetic predisposition.
- female distribution due to muscle-relaxin effects of progesterone, pressure effects of uterus.
- may get better with delivery then worsen with the next pregnancy.
It is possible to get vulval and posterior thigh varices with involvement of tributaries of the internal iliac vein.

Complications
1. Thromboplebitis
- superficial thrombosis in a varicose vein; inflammation from a hard lump
- inflamed; may be confused for an infection
- extension to deep veinous system is a major threat
--> if >15cm or clincal signs of concerning spread, arrange urgent duplex then +/- operative ligation of the saphenofemoral jx
--> consider full anticoagulation if thrombophlebitis continues up the knee.
2. Haemorrhage
- rupture is accompaneid by profuse bleeding while limb dependent.
- may exsanguinate
--> lie down immediately and elevate limb; pressure to bleeding point; avoid tourniquets for venous bleeding or worsens.
3. Ulceration
- see chronic venous

Secondary
Post-thrombosis
Thrombosis in the deep veins increases pressure in the deep system.
This reverses the normal flow.
Ie from deep to superficial.
In this situation the muscle pump is ineffective and blood collects in the superficial leg veins.
The increased pressure and volume dilates the superficial system causing varicosity.
Removing these superficial veins would only make it all much worse.
Chronic venous stasis
Can get
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MANIFESTATIONS

Spectrum from tiny venous flares / spider veins
To huge veins present many years

Symptoms
Result from fluid congestion and inadequate venous return

Local

85% have aching in the leg, worse as the day goes on.
- throbbing occurs with same frequency.
50% get cramp at night (ask).
30% get swelling of ankles and feet.
10% get an ache in the groin, sometimes confused for hernia pain.

Take a careful DVT history.

Signs
Observe
Sex
- if male, and no family history, may be secondary, even without a DVT history.


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INVESTIGATIONS

1. Duplex USS is exam of choice
- Venography is no longer used; poor risk to benefit ratio.
Provides an image and information about hte blood flow velocity.
Major indications:
- defining incompetence of the major saphenous systems
- identifying level where SSV enters popliteral (operative planning)
- locating incompetent perforators
- excluding DVT

Major causes of recurrence are:
- incompetence developing in second system (e.g. SSV after GSV treatment)
- incompetence of perforating veins at jx of middle and lower thirds of thigh.
- recurrence following saphenofemoral ligation
--> this is probably NOT failure to treat major tributaries
--> rather, probably neovascularization; ie. multiple tiny channels develop between deep and superficial systems through scar tissue.

2. Doppler ultrasound probe
see exam notes

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MANAGEMENT

Principles


Few sequelae if untreated --> treatment not essential
Unless pre-ulcerative secondary venous tissue changes, or with complications

Options

1. Elastic Compression Stockings
Do not cure
But provide relief from symptoms of swelling adn tiredness, and prevent complications
Particularly useful in the pregnant.
Range of stockings are available
- low, medium, high grade
- for most varicose vein patients, want a grad 2 (20-30 mmHg) stocking
A good diagnostic challenge
- if relieves symptoms, then likely due to the veins
- if fail to relieve, consider other causes.
Beware patients with inadequate pedal pulses.

2. Injection-Compression Therapy (Slerotherapy)
Not an option for major uncontrolled sites of deep to superficial incompetence
Injected with chemical irritant then compression applied to stick inflamed vein together
- inhibits recanalization
Can inject small amounts of hypertonic saline into superficial telangiectatic veins / spider veins for cosmetic control.

3. Surgical Removal
See notes
Treat the junction, the trunk, and the branches
Preop uss to define nerve position and locate

1. Saphenofemoral ligation
- skin crease 3cm long below and lateral to the pubic tubercle, 1cm above groin crease
Dissect LSV and tributaries
2cm above and below FV
Ligate, divide

*High tie now no longer considered essential in principles in era of RF ablation / laser, where top tributaries are not treated.
- as above, the proximal recurrences are probably neovascularizations.

- though obviously must be done in conjunction with stripping

2. Saphenopopliteal ligation
Similar to above
duplex to guide knowledge of jx.
avoid sural nerve, which runs with the SSV

3. Stripping
- limited to groin to knee
- below this level may get troublesome neuritis of the saphenous nerve.

4. Perforators
- incise over perforating vein as passes to deep fascia
- pre-op duplex to localise
- ligate and divide beneath deep fascia
- usually reserved for recurrent veins or patients with secondary venous tissue changes or ulceration.

5. Multiple stab avulsions of tributaries
- crochet hook and extract with serial hemostats
- next one 2-4cm away and proceed

4. Radiofrequency or endovenous laser ablation
Now considered standard of care over surgical stripping with US guidelines
Heat treatment to destroy trunk of long superficial vein
Additional treatments for enlarged and superficial branching veins.

Other points

Risks are bleeding / haematoma, lymphatic damage / lymphoedema, and nerve injury.
Recurrence rate 15-20% at 5y

Firmly compression bandage after surgery to promote hemostasis
Prevent DVT with early mobilization and heparin
Outer bandages removed at 24-48h and elastic stockings applied for 2w while tendence to swell.

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