VARICOSE VEINS

VARICOSE VEINS - Joseph A. Florence, MD
BASICS
DESCRIPTION
• Permanent dilation and tortuosity of superficial veins usually occurring in the legs and feet. May result from congenitally incomplete valves, or valves that have become incompetent. Affects legs where reverse flow occurs when dependent.
• System(s) Affected: Cardiovascular; Skin/Exocrine
ALERT
Ulceration of varicose veins has a high rate of infection which can lead to sepsis.
Geriatric Considerations
• More common, usually valvular degeneration, but may be secondary to chronic venous deficiency
• Recommended therapy: Elastic support hose and frequent rests with legs elevated rather than ligation and stripping
Pregnancy Considerations
• Frequent problem
• Use of elastic stockings recommended for individuals who have a history of varicosities or when activities involve a great deal of standing
EPIDEMIOLOGY
• Predominant age: Middle age
• Predominant sex: Female > Male (5:1)
Incidence
• 45 per 1,000 (National Health Interview Survey NHIS95)
• The National Women's Health Information Center (NWHIC) estimates that 50% of all women are affected by varicose veins.
RISK FACTORS
• Increasing age
• Pregnancy, especially multiple pregnancies
• Occupations requiring prolonged standing, restrictive clothing (e.g., very tight girdles)
• Obesity
• History of phlebitis
• Family history
Genetics
Familial, dominant, X-linked
PATHOPHYSIOLOGY
• Varicose veins are caused by venous insufficiency from faulty valves in 1 or more perforator veins in the lower leg, causing secondary incompetence at the saphenofemoral junction (valvular reflux).
• Valvular dysfunction causing venous reflux and subsequently venous hypertension
• Failed valves allow blood to flow in the reverse direction (away from the heart) from deep to superficial and from proximal to distal veins.
• Deep thrombophlebitis
• Increased venous pressure from any cause
• Congenital valvular incompetence
• Trauma (should consider AV fistula: Listen for bruit)
• In many individuals, no cause or precipitating factor found
• Presumed to be due to a loss in vein wall elasticity with failure of the valve leaflets to coapt (1)[C]
ASSOCIATED CONDITIONS
• Stasis dermatitis
• Stasis ulcer, venous ulcer (large varicose veins may lead to skin changes and eventual ulceration (2)


DIAGNOSIS
SIGNS AND SYMPTOMS
History
Symptoms range from minor annoyance or cosmetic problem to a lifestyle-limiting problem.
• Localized symptoms
- Sometimes asymptomatic or minimal symptoms
- Pain
- Burning
- Itching
• Generalized symptoms
- Leg muscular cramp, aching
- Leg fatigue or swelling
• Pain if varicose ulcer develops
• Symptoms often worse at the end of the day, especially with prolonged standing
• Women are more prone to symptoms due to hormonal influences: Symptoms worse during menses (3)[B]
• There is no direct correlation with the severity of the varicose veins and the severity of symptoms.
Physical Exam
• Inspect lower extremities with patient standing. Varicose veins in the proximal femoral ring and distal portion of the legs may not be visible when the patient is supine.
• Varicose veins are
- Dilatated, tortuose superficial veins, chiefly in the lower extremities
- Dark purple or blue in color and are raised above the surface of the skin.
- Often twisted and bulging and can look like cords.
- Most commonly found on the posterior or medial lower extremity
• Edema of affected limb may be present.
• Skin changes may include
- Eczema
- Hyperpigmentation
- Lipodermatosclerosis
• Spider veins (idiopathic telangiectases)
- Fine intracutaneous angiectasis
- May be extensive/unsightly
• Documentation to help with differential diagnosis should include
- The extent and location of varicose veins
- Description of the skin including hair distribution
- Neurological-especially sensory and motor
- Periferial arterial vasculature-pulses
- Musculoskeletal system to document associated rheumatologic or orthopedic issues
TESTS
Special tests
• Trendelenburg test (4): Test for varicose veins. Patient lies on his back and raises his leg to empty the veins. A tourniquet is applied just below the saphenous opening. The patient is then stood up and the tourniquet removed in 60 seconds. Normally the vein should fill from below within 35 seconds with the tourniquet in situ. Earlier filling indicates incompetence of a communicating vein. If on release the veins fill rapidly from above it is due to incompetent sapheno-femoral valves.
• Perthes test (5): A clinical test for assessing the patency of the deep femoral veins, used in preparations for operation for varicose veins. With the patient standing and veins filled, a tourniquet is placed around the mid-thigh, and the patient walks for 5 minutes. If the saphenous veins collapse below the tourniquet, the deep veins are patent and the communicating veins are competent; if unchanged, both saphenous and communicating veins are incompetent, and if the veins increase in prominence and pain occurs the deep veins are occluded.
Imaging
• Duplex ultrasound-formal noninvasive imaging of the venous system with duplex ultrasound will confirm the etiology, anatomy, and pathophysiology of segmental venous reflux.
• Duplex scanning, venous Doppler study, photoplethysmography, light-reflection rheography, air plethysmography, and other vascular testing should be reserved for those patients who have venous symptoms and/or large (>4 mm in diameter) vessels or large numbers of spider telangiectasia indicating venous hypertension.
Pathological Findings
• Elongation and tortuosity of veins
• Medial fibrosis of veins
• Disappearance or atrophy of valves
DIFFERENTIAL DIAGNOSIS
• Nerve root compression
• Arthritis
• Peripheral neuritis
• Telangiectasia: Smaller, visible blood vessels that are permanently dilated
• Deep vein thrombosis
TREATMENT
Patients with unsightly varicose veins seek treatment for cosmetic reasons.
GENERAL MEASURES
• Appropriate health care: Outpatient
• Conservative methods
- Frequent rest periods with legs elevated
- Lightweight, elastic compression hosiery. Best put on before getting out of bed
- Graduated compressing stockings are considered 1st-line therapy.
- Avoid girdles and other restrictive clothing.
- If stasis ulcers present, use warm, wet dressings
SURGERY
• Challenge to balance a cosmetically acceptable result with a low incidence of recurrence and complications
• Surgery is indicated if there is pain, recurrent phlebitis, skin changes/ulceration, or for cosmetic improvement for severe cases.
• Minimally invasive techniques include (6)[C]
- Radiofrequency ablation (RFA)
- Endovenous laser therapy (EVLT)
- Transilluminated power phlebectomy (TIPP)
- Foam sclerotherapy is more powerful than a liquid sclerosant. (7)[A]
- Ambulatory phlebectomy-has a lower risk of recurrence than with sclerotherapy. (7)[A]
• Traditional surgical methods include
- Ligation and stripping of the varicose vein (Sclerotherapy: Sclerosing solution is injected into varicosities causing vein walls to swell, adhere, and scar. 50-90% improvement expected [American Academy of Dermatology])
- Stab avulsion phlebectomy
• For extensive fibrosis: Excision of the entire area, followed by skin graft, may be necessary.
• Surgical treatment of clinically symptomatic varicose veins involves treatment of the saphenous vein reflux as well as the varicosities.
PROGNOSIS
• Usual course: Chronic
• Favorable with appropriate treatment
• Quality of surgical treatment is less satisfactory if significant deep venous reflux, history of ulceration, or congenital arteriovenous malformation exists. (6)
COMPLICATIONS
• Petechial hemorrhages
• Chronic edema
• Superimposed infection
• Varicose ulcers
• Pigmentation
• Eczema
• Recurrence after surgical treatment
• Scarring or nerve damage from stripping technique
PATIENT MONITORING
Until surgery or conservative therapy brings maximal benefit
REFERENCES
1. Clarke GH, Vasdekis SN, Hobbs JT, Nicolaides AN. Venous wall function in the pathogenesis of varicose veins. Surgery. 1992;111(4):402-408.
2. Hanrahan LM, et al. Distribution of valvular incompetence in patients with venous stasis ulceration. J Vasc Surg. 1991;13(6):805-811.
3. Fegan WG, Lambe R, Henry M. Steroid hormones and varicose veins. Lancet. 1967;2:1070-1071.
4. Trendelenburg F. Uber die Unterbindung der Vena saphena magna bei Unterschenkelvaricen. [Brun's] Beitrage zur klinischen Chirurgie,1891;7:195-210.
5. Perthes GC. Uber die Operation der Unterschenkelvarizen nach Trendelenburg. Deutsche medizinische Wochenschrift. Berlin,1895;16:253-257.
6. Teruya TH, Ballard JL. New approaches for the treatment of varicose veins. Surg Clin North Am. 2004;84(5):1397-1417.
7. Sadick NS. Advances in the treatment of varicose veins: Ambulatory phlebectomy, foam sclerotherapy, endovascular laser, and radiofrequency closure. Dermatol Clin. 2005;23(3):443-455.
ADDITIONAL READING
• Callam MJ. Epidemiology of varicose veins. Br J Surg. 1994;81:167-173.
• Ellis H, Taylor P. Varicose Veins. 3rd ed. London: Greenwich Medical Media; 1999.
MISCELLANEOUS
See also: Hemorrhoids; Dermatitis, Stasis