Varicose Veins

Kelvin Maikana
Contents
• Background
• Pathophysiology
• Etiology
• Epidemiology
• History
• Examination
• Investigations
• Treatment
Definition
• Dilated, elongated, tortuous, palpable superficial veins as a result of
venous hypertension
Sites where varicosities can occur
• Long saphenous varicosity
• Short saphenous varicosity
• Oesophageal varices and fundal varices
• Haemorrhoids
• Varicocoele
• Vulval varix and ovarian varix
• Varicosities are more common in lower limb because of erect posture
and long column of blood has to be supported which can lead to
weakness and incompetency of valves
Anatomy
• Superficial system
• Perforators
• Deep system of veins
Superficial venous system
• Long saphenous vein (LSV)
• starts in the foot from the tributaries of dorsal venous arch
• ascends in front of medial malleolus
• ascends in the thigh and ends at the saphenofemoral junction (SF) by joining
the femoral vein, which is 4 cm below and lateral to the pubic tubercle
• it has 15 to 20 valves
• absence of valves results in varicose veins
• Short saphenous vein
• 1 valve
Superficial venous system
Tributaries
• Near the termination
• Superficial circumflex iliac vein
• Superficial epigastric vein
• Superficial external pudenda) vein
• In the lower thigh
• Lateral superficial femoral vein
• Medial superficial femoral vein
• Transverse suprapatellar vein
• Transverse infrapatellar vein
• In the leg
• Anterior vein of the leg
• 2. Posterior arch vein
Tributaries
Superficial system features
• saphenous means easily seen
• they are a low pressure and poorly supported system
• They have numerous valves
• normal blood flow is from superficial to deep system of veins.
Perforators
• connect long saphenous vein with deep system of veins
• Leg perforators
• Lowest-below and behind the medial malleolus
• Middle-10 cm above the tip of the medial malleolus
• Upper-15 cm above the medial malleolus
• Knee perforator
• just below the knee
• Thigh perforator
• palm-breadth above the knee
• A knowledge of perforators forms the basis of multiple tourniquet test
Perforators
Deep venous system
• this comprises the femoral and the popliteal veins, veins or venae
comitantes
• a high pressure system, well-supported by powerful muscles
• connected to superficial veins by means of perforators
• it is the powerful calf muscle contraction that returns the blood to the
heart
• deep veins are also provided with valves
Deep venous system
Physiology
• Calf muscle pump
• alternate contraction and relaxation of the muscles of the leg
• Competent valves (unidirectional) in the leg
• when these valves are absent or weak, perforator incompetence develops
• Venous patency
• Vis-a-tergo of the circulation
• the pressure transmitted from the arterial tree passes the capillary bed to the
venous side
• Negative intrathoracic pressure
• Venae comitantes
Pathophysiology
• Fibrin cuff theory
• White cell trapping theory
Fibrin cuff theory
• elevated venous pressures in the lower limb
• increase in the size of the capillary bed
• widening of the interstitial pores
• allows leakage through the capillary pores of fibrinogen
• which polymerizes to fibrin and fibrin then forms a cuff around the
capillaries
• fibrin deposition, tissue death, scarring occurs together-
lipodermatosclerosis
Fibrin cuff theory
White cell trapping theory
• inappropriate activation of trapped leucocytes
• release of proteolytic enzymes which cause cell destruction and
ulceration
Secondary valvular failure
• venous reflux → venous wall dilatation → effects
• weakening of the venous endothelial wall and valves occur due to
raised venous wall tension by
• shearing stress pressures of blood flow
• increased matrix metalloproteinases (MMPs) activity on endothelium and
smooth muscle cells reducing structural integrity of venous wall with
decreased elastin content in the media of the vein
• changes in normal venous constriction and relaxation properties
• recurrent inflammation
Etiology
• Primary
• Secondary
Primary varicosities
• Congenital incompetence or absence of valves
• Weakness or wasting of muscles—defective connective tissue and smooth
muscle in the venous wall
• Stretching of deep fascia
• Inheritance (family history) with FOXC2 gene
• Klippel-Trenaunay syndrome
• Characterised by nevus flammeus (portwine stain), venous malformations, lymphatic
malformations and soft tissue hypertrophy of the affected limb
• Can also have large arteriovenous malformations
• Avalvulia
• Parkes-Weber syndrome
Primary varicosities
• Very often, the valve at the saphenofemoral (SF) junction is
incompetent/absent
• The valves can also be absent where the superficial veins join the
deep veins
Secondary varicosities
• Recurrent thrombophlebitis
• Occupational—standing for long hours (traffic police, guards,
sportsman)
• Obstruction to venous return like abdominal tumour, retroperitoneal
fibrosis, lymphadenopathy, ascites
• Pregnancy (due to progesterone hormone), obesity, chronic
constipation.
• AV malformations—congenital or acquired
• Iliac vein thrombosis
• Tricuspid valve incompetence
Factors which predispose to varicose veins
• Height: Tall individuals suffer more
• Weight: Obesity may weaken vein wall
• Occupation: Hotel workers, policemen, shopkeepers, tailors
• Side: Left is affected more than the right
• Age and sex: Female
History
• Majority of the patients present with dilated veins in the leg
• Dragging pain in the leg or dull ache is due to heaviness
• Night cramps occur due to change in the diameter of veins
• Aching pain is relieved at night on taking rest or elevation of limbs
• Sudden pain in the calf region with fever and oedema of the ankle
region suggests deep vein thrombosis
• Some patients with DVT may be asymptomatic
• Patients can present with ulceration, eczema, dermatitis and bleeding
• Symptoms of pruritus/itching and skin thickening
• Pain due to varicose veins is relieved on exercise
Inspection (should be done in standing
position)
• Dilated veins are present in the medial aspect of leg and the knee
• Single dilated varix at SF junction is called saphena varix. It is due to
saccular dilatation of the upper end of long saphenous vein at the
saphenous opening
• Veins are tortuous and dilated
• A localised, dilated segment of the vein, if present, is an indication of a
blow out
• Ankle flare is a group of veins near the medial malleolus
• Complications such as ulceration, bleeding, eczema and dermatitis may be
present
• Healed scar indicates previous ulceration
• Look at the popliteal fossa region also
Palpation
• palpate along the whole length of vein
• look for tenderness, if present, it indicates thrombophlebitis
• a vein which is thrombosed will feel as a firm/hard nodule
Tests for varicose veins
• Cough impulse test: SF incompetence
• Trendelenburg I: SF incompetence
• Trendelenburg II: Perforator incompetence
• Multiple tourniquet test: Site of perforator incompetence
• Schwartz test: Superficial column of blood
• Modified Perthes' test: Deep vein thrombosis
• Fegan's test: To locate the perforators in the deep fascia
Cough impulse test (Morrissey's test)
• in the standing position
• examiner keeps the finger at SF junction and asks the patient to
cough
• fluid thrill, an impulse felt by the fingers, is indicative of
'saphenofemoral incompetence'
Trendelenburg test
• patient is asked to lie on the couch in the supine position
• leg is elevated above the level of heart and the vein emptied
• SF junction is occluded with the help of the thumb (or a tourniquet) and
the patient is asked to stand
• Trendelenburg I:
• Release the thumb or tourniquet immediately. Rapid gush of blood from above
downwards indicates saphenofemoral incompetence
• Trendelenburg II:
• The pressure at the SF junction is maintained without releasing the thumb or
tourniquet. The patient is then asked to stand. Slow filling of the long saphenous is
seen. It is due to per/orator incompetence (retrograde flow of blood)
Multiple Tourniquet test
• to find out exact site of perforators
• patient is asked to lie supine on the couch
• the vein is emptied by elevation.
• 3-5 tourniquets (multiple) can be applied
• mainly ankle, knee and thigh perforators
• 1st Tourniquet: At the level of saphenofemoral junction(SF junction).
• 2nd Tourniquet: At the level of middle of the thigh, to occlude perforator in
the Hunter's canal.
• 3rd Tourniquet: Just below the knee.
• 4th Tourniquet: Palm breadth (lower third of the leg above medial
malleolus/ankle)
Multiple Tourniquet test
Multiple Tourniquet test
• Ask the patient to stand and observe appearance of veins
• Most commonly, below knee and ankle perforators are incompetent
• On releasing the tourniquets one by one from below upwards,
sudden retrograde filling of the veins occurs
Schwartz test
• patient in the standing position
• Place the fingers of the left hand over a dilated segment of the vein
• with the right index finger tap the vein below
• A palpable impulse suggests a superficial column of blood in the vein
and it also suggests incompetence of the valves in between the
segment of the vein
Modified Perthes' test
• to rule out deep vein thrombosis
• patient is asked to stand, the tourniquet is applied at SF junction and
he is asked to have a brisk walk
• If the patient complains of severe pain in calf region or if superficial
veins become more prominent, it is an indication of deep vein
thrombosis and is a contraindication for surgery
Fegan's method (test)
• done to detect the site of perforators
• patient is asked to stand
• Varicosity is marked with methylene blue and he is asked to lie down
• leg is elevated to empty the vein and the vein is palpated throughout
its course
• defects in the deep fascia have a circular, buttonhole consistency
• All clinical/phlebological tests mentioned above have been
superseded
• by Doppler test. doppler test is considered to be a clinical method
Examination of varicose ulcer
• inspection and palpation
Evidence of deep vein thrombosis
• Homan's test and Moses’ test (vide infra) must be done in chronic
DVT
Examination of the abdomen
• To rule out pelvic tumours.
• Look for inferior vena caval obstruction in the form of dilated veins in
the lateral abdominal wall
CEAP
Clinical discussion
• Which system is involved? Medial or lateral
• Is SF junction incompetent?
• Is there perforator incompetence?
• Which group of perforators are incompetent?
• Is there deep vein thrombosis?
• Is there any abdominal mass?
• Is it unilateral or bilateral?
Chronic venous insufficiency (CVI)
• a syndrome resulting from continuous chronic venous
hypertension/ambulatory venous hypertension [AVP] (>80 mmHg venous
pressure at ankle) in the erect posture either on standing or exercise
• CVI consists of postural discomfort, varicose veins, oedema, pigmentation,
induration, dermatitis, lipodermatosclerosis and ulceration
• patients may be having superficial vein incompetence (30%) with or
without perforator incompetence or deep vein incompetence (30%) or
having previous DVT with complete obliteration or partial recanalisation
with incompetence called as post-thrombotic syndrome (30%)
Investigations
• Venous Doppler
• by hearing the changes in sound, venous flow, venous patency, venous reflux can be very well identified
• Duplex scan
• It is a highly reliable U/S Doppler imaging technique (here high resolution B mode ultrasound imaging and Doppler ultrasound is used)
• Venography
• was very common investigation done before Doppler period
• Plethysmography
• noninvasive method which measures volume changes in the leg
• gives functional information on venous volume changes and calf muscle pump insufficiency
• Ambulatory venous pressure (AVP)
• Patients with AVP more than 80 mmHg has got 80% chances of venous ulcer formation
• Arm-foot venous pressure
• Foot pressure is not more than 4 mmHg above the arm pressure
• Varicography

• Here nonionic, iso-osmolar, nonthrombogenic contrast is injected

• directly into the variceal vein to get a detailed anatomical mapping
Investigations
• Ultrasound abdomen, peripheral smear, platelet count, other relevant
investigations are done depending on the cause of the varicose veins
• If venous ulcer is present, then the discharge is collected for culture
and sensitivity, biopsy from ulcer edge is taken to rule out Marjolin’s
ulcer
• Plain X-ray of the part is taken to look for periostitis
Treatment
• Conservative
• Elastic crepe bandage application
• Elevation of the limb
• Pneumatic compression method
• Reduce AVP
• Injection—sclerotherapy
• Fegan’s technique
• Foam sclerotherapy by Tessari
• Microsclerotherapy
• Surgery
• Trendelenburg's operation
• Stripping of vein
• Subfascial ligation of Cockett and Dodd
• Subfascial endoscopic perforator surgery (SEPS)
Treatment
Treatment
Treatment
Complications
• Eczema and dermatitis
• Lipodermatosclerosis
• Haemorrhage
• Thrombophlebitis
• Venous ulcer
• Calcification
• Periostitis
• Equinovarus deformity