Varicose Veins

The term varicose derives from the Latin 'varix', which means twisted. A varicose vein is usually tortuous and dilated.
Under normal circumstances, blood collected from superficial venous capillaries is directed upward and inward via one-way valves into superficial veins. These in turn drain via perforator veins, which pass through muscle fascia into deeper veins buried under the fascia. Leakage in a valve causes retrograde flow back into the vein. Unlike deep veins which are thick-walled and confined by fascia, superficial veins cannot withstand high pressure, and eventually become dilated and tortuous. The failure of one valve puts pressure on its neighbours and may result in retrograde flow, and hence varicosity, of the entire local superficial venous network.¹

The superficial veins in the legs are normally involved, as these are most likely to come under hydrostatic pressure due to gravity.
Other pathological processes may also be involved, such as an inherent weakness of the vein wall. The influence of genetics has been confirmed by twin studies,² and the genes involved are beginning to be identified.³

Pregnancy brings its own problems, with hormonal factors increasing the pliability of the venous walls and the valves themselves. In later pregnancy, there is expansion of the circulating blood volume, and this is compounded by pressure on the inferior vena cava from the growing uterus.
Another mechanism that sometimes come into play is obstruction to venous outflow. This can be either intravascular as in deep vein thrombosis, or extravascular from trauma or compression from surrounding structures such as tumours or a cirrhotic liver.

Varicose veins are extremely common. In America, one branch of the Framingham study found that the incidence was 2.6% in women and 2.0% in men.⁴ A Belgian systematic review found the prevalence in Western populations to be about 25% in women and 10% in men. A study conducted in London of people aged 35 to 70 concluded that the prevalence of varicose veins in men and women was 17% and 31% respectively.⁵

The Framingham study also confirmed that having more than two or more pregnancies was an independent risk factor, as was obesity (but only in women).⁶ Several studies have confirmed that varicose veins are more common with increasing age.⁷

History

Patients with cosmetic concerns present less often than they used to, but are still occasionally seen with asymptomatic but unsightly tortuous veins or thread veins.
Commonly, patients will present with chronic sequelae such as itching, discomfort and heaviness of the legs, night cramps, oedema, burning sensations, parasthesiae, exercise intolerance, or restless legs. Subjective symptoms are usually more severe in the early stages of the condition, less severe in middle stages, and worse in latter years. The pain associated with larger varicose veins is usually described as a dull ache that is worse after prolonged standing. Aggravating factors may include pregnancy, exogenous hormones, menstruation, and occasionally sexual intercourse.
Apart from the presenting symptoms, the history should include:

• History of previous venous problems, any visible abnormal veins, any history of varicosities in pregnancy
• Any risk factors such as family history of varicose veins, a job which involves prolonged standing, past history of trauma
• History of oedema, date of onset, any risk factors, any variation throughout day, degree of induration, and location
• History of an previous hospital assessments or treatment
• History of any previous episodes of superficial or deep vein thrombosis or thrombophlebitis
• History of any cardiovascular co-morbidity

Examination^1,8

A complete examination should include a general assessment of the patient's cardiovascular status, and abdominal examination to exclude secondary causes such as tumours which could be causing external venous compression.
To map the areas of varicosity, examine the patient standing in the first instance. To confirm that a swelling is a varicose vein, gently press over the area. The vein will empty and then refill.
Attempt to identify which vein the varicosities drain into. Varicosities of the short saphenous vein are normally seen below the knee and are distributed posterolaterally. Long saphenous vein varicosities may run the whole length of the leg, and are distributed more medially.
Inspect the skin for changes suggestive of chronic venous insufficiency. These may include ulcers, lipodermatitis, pigmentation, telangiectasia or eczema.
Finally, identify the saphenofemoral junction. To do this, ask the patient to lie down and identify the femoral artery pulse. The junction is located medial to this, about two fingers' breadths below the inguinal ligament.
Once you have finished the inspection, ask the patient to lie down and identify the saphenofemoral junction. One good way to do this is by locating the femoral artery which lies between the anterior superior iliac spine and the pubic tubercle by feeling for the pulse. The vein is medial to the artery and the saphenofemoral junction about two fingers' breadths below the inguinal ligament.
Ask the patient to stand and tap the varicosity lower down the leg. A fluid thrill felt at the level of the valve indicates that it is incompetent.
Two tests have classically been used to assess valvular competency (Trendelenberg's test) and deep venous patency (Perthes' test). They have been superseded to a large extent by other non-invasive investigations (see below) but may still be relevant in a primary care setting.⁹

Trendelenberg test

The Trendelenburg test can sometimes distinguish patients with superficial venous reflux from those with incompetent deep venous valves. The patient should lie flat with the leg elevated, allowing the veins to empty. A tourniquet is applied to the thigh at the saphenous opening. If the valve is competent, the vein should fill from below. If the valve is incompetent, the vein will fill from above on removing the tourniquet. This can repeated at various levels, until the location of an incompetent vale is located.

Perthes' manoeuvre

Perthes' manoeuvre is used to distinguish antegrade flow from retrograde flow in superficial varicosities. Antegrade flow is an indicator of collateral flow around a deep venous obstruction. A tourniquet is applied to a varicose leg in such a way that the superficial veins are compressed without pressure being applied to the deep vessels. The patient is then asked to repeatedly stand on tip-toe, activating the calf muscles. Normally this would empty the varicosities, but in the presence of deep vein obstruction they would paradoxically become congested.

• Cellulitis
• Osler-Weber-Rendu Syndrome (telangiectasia, recurrent epistaxis, and a positive family history - also known as hereditary hemorrhagic telangiectasia)
• Superficial phlebitis
• Deep vein thrombosis

Imaging

Hand-held doppler

This non-invasive test is a more accurate means of assessing whether a vein is dilated but carrying blood in an antegrade direction or whether it is a true varicosity with retrograde flow.¹⁰The Doppler probe is positioned directly along the axis of of vein at 45 degrees, and the vein is tapped gently. A strong Doppler signal confirms that the probe is correctly positioned. Compression of the limb below the probe will produce a sound indicating flow in the direction of the valve. In incompetent veins, a signal is also produced when the pressure is released, indicating retrograde flow. This can be repeated at several levels until no retrograde flow is detected. All veins suspected by inspection or palpation of being varicose should be tested in this manner. If no veins are obviously dilated, simply record whether any retrograde flow can be detected along the length of the long and short along the short saphenous veins.¹

Duplex ultrasound

This uses a combination of Doppler and conventional ultrasound and gives a more accurate assessment than Doppler alone. It is used in patients with significant varices, although some authorities maintain that it should be used in all patients as a screening procedure.¹¹

Colour-flow imaging

This is sometimes called triplex ultrasonography and is a further refinement in which Doppler information is translated into colour images. It is a highly sensitive technique which can demonstrate minor valve leakages and incompetence in small perforator veins.¹²

Physiological tests of venous function¹

These may be helpful as an adjunct to imaging in complex cases.
Venous refilling time - the time necessary for the lower leg to fill with blood after it has been maximally emptied by the calf-muscle pump.
Maximum venous outflow - this is the time taken for a leg distended by a tourniquet to empty and is a measure of possible venous obstruction.
Muscle pump ejection fraction - this is used to detect failure of the muscle-pump to expel blood from the lower leg.

Deep vein thrombosis,¹³ any condition causing calf muscle pump failure (e.g. neuromuscular disease, muscle wasting conditions).¹⁴

Various classification systems have been used, the original being the CEAP classification (Clinical picture, the Etiology, the Anatomic distribution and the Pathophysiology) devised by the Consensus Committee of the American Venous Forum. This included such features as the number and extent of varicosities, the presence of skin changes, and the disabling effect of any symptoms. The original system was published in 1994¹⁵ and updated a decade later.¹⁶

It is important to determine why the patient is presenting for treatment. One third of patient have symptoms unrelated to varicose veins, or may simply be seeking advice about possible complications or deterioration.¹⁷

Lifestyle changes

The evidence base addressing the issue of lifestyle changes such as weight loss and exercise is limited, but they are most likely to be of benefit in preventing the initial development of varicosities and their complications, rather than reversing the disease process once it is established (see Prevention).

Compression stockings

These are widely used.¹⁸ However, the evidence base supporting their effectiveness is inconclusive.¹⁹ They are likely to be of benefit in patients whose main symptoms are aching and oedema, and they can also be used diagnostically to assess whether symptoms are due to varicosities or some other cause.¹⁷

Surgical treatment

Avulsion

In this process, small incisions are made over each varicosity, and that part of the vein is excised using a vein hook or forceps.

Stripping

A wire, plastic or metal rod is passed through the lumen of the saphenous vein and pulled until the entire vein is stripped out of the leg. Inversion stripping is a refinement of this method in which the vein is turned in on itself during removal.
Evidence suggests that the incidence of recurrence after avulsion is significantly reduced if the procedure is combined with stripping of the long saphenous vein.²⁰
Partial stripping to the knee may cause less neurological trauma than stripping to the ankle, and preserves venous tissue that may subsequently be required for vein grafting techniques (e.g. CABG).²¹
Inversion stripping caused significantly less pain than after one week in one randomised trial.²²

Powered phlebectomy

This Involves infiltrating subcutaneous tissue with a saline solution containing local anaesthetic (lidocaine) and dilute adrenaline. A mechanical device with a fast rotating blade and attached suction device is then used to destroy and remove the vein. One randomised trial showed no difference in post-operative symptoms compared to conventional surgery, but less incisions were involved significant improvement in operating time. This technique may therefore have a role to play in the treatment of extensive varicosities.²³

Radiofrequency ablation

This involves sealing the lumen of the long saphenous vein by delivering radiofrequency energy via a catheter under ultrasound guidance. Comparative evidence supporting the advantages of this technique is lacking.²²

Endovenous laser therapy

This works by delivering high intensity laser through a sheathed wire guided into the vein. It is a relatively new technique but the results are so far encouraging. The incidence of complications is low and the two year recurrence rate is 7% which is as good as or better than other currently employed treatments.²⁴

Injection sclerotherapy

Once used as first-line treatment for new varicosities, this is now being employed less frequently due concerns about skin staining and ulceration.¹⁷ Some randomised trials also suggest that sclerotherapy may have a higher recurrence than surgery, but the data needs further evaluation.²⁵ Randomised trials suggest that injection using a mixture of sodium tetradecyl sulphate and polidocanol resulted in improved symptoms (night cramps, pains, fatigue, and heaviness) and reduction in oedema compared to either sclerosant alone.²⁶
Using the sclerosant in foam rather than liquid form gives better results initially, but does not seem to affect recurrence rates in the long term.²⁷

Complications directly relating to varicose veins include haemorrhage and thrombophlebitis.
Complications relating to the increased pressure arising from chronic venous incompetence (venous hypertension) include venous ulcers, oedema, skin pigmentation, varicose eczema, atrophie blanche (smooth white areas of atrophic scar tissue with telangiectasia) and lipodermatosclerosis (areas of induration arising from fibrosis of subcutaneous fat).
Potential complications of treatment include deep vein thrombosis and pulmonary embolus, parasthesiae from injury to the sural nerve or the saphenous nerve, and the development of haematomas. Skin burns have been known to occur if radiofrequency catheters are placed too near the skin.

Untreated, varicose veins tend to become larger over time, and patients with significant reflux are prone to develop chronic venous ulceration.²⁸
Long-term studies of the outcome of surgical treatment have been less than encouraging with a ten-year recurrence rate of approximately 70%. It remains to be seen whether newer techniques such as radiofrequency ablation and laser treatment can improve upon this figure.²⁹

Certain factors such as genetic predisposition, gender, and increasing age are unavoidable. The Framingham data suggests that weight control, adequate physical exercise, avoidance of smoking, avoidance of sedentary activities and control of hypertension may all be significant in preventing the development of varicose veins.⁴