varicose veins

see also:

• deep venous thrombosis (DVT)
• vascular surgery

• varicose veins are dilated superficial leg veins with reduced ability to return venous flow to the heart against gravity when standing
• venous insufficiency occurs when the normal flow of blood from the superficial veins to the heart via the perforating deep veins in the lower limbs is impaired
• 60% have an incompetent sapheno-femoral junction, others have incompetent perforator vein valves
• perforating vein valvular failure or an incompetent sapheno-femoral junction allows higher pressure to enter the superficial venous system
• if severe, they cause chronic venous insufficiency and its sequelae

• affect up to 30% of adults, especially women who have twice the risk of men
• 21% of adult Europeans have C2 level while only 5.5% of Africans do ¹⁾
• C2 disease has a progression rate to venous ulceration within 6 years of 22% ²⁾
• it appears that pre-clinical venous reflux in young adults has a 30% risk of developing truncal VVs within 4yrs ³⁾

• varicose veins are caused by impaired function of the valves in the leg veins, especially those in the short perforator veins which connect the deep and superficial veins
  • valves do also exist even in veins with a diameter from 100 μm – 2 mm, and that these microvenous valves also can be incompetent secondarily
• the initial pathophysiology of valvular incompetence of the superficial venous system is thought to be inflammatory changes in the veins and valves
  • genetic factors
  • inflammatory processes
  • homocysteinaemia in some people
• acutely or chronically raised intra-venous pressures may result in further valve inflammation or in mechanical valve failure
  • gravitational pressure from prolonged standing - in adults, average venous pressure at the ankle when standing is 75-90mmHg, and higher in taller people
    • in those without incompetent venous valves, the pressure is reduced by exercise due to contraction of the calf muscle
  • pelvic vein reflux (PVR) - ovarian and internal iliac vein reflux appear to be a causative factor in some women and is greater at time of menses
  • chronic alcohol consumption due to the vasodilatation side effect
  • pregnancy
    • high progesterone levels cause chronic venous dilatation which combines with IVC compression by the gravid uterus to increase vulval varicosities, haemorrhoids, leg venous dilatation, stasis, varicose veins, and DVT risk
  • right heart failure
    • causes increased venous pressures and impaired venous returns
  • high impact and prolonged exercise such as long distance running or cycling can exacerbate pre-existing venous issues or contribute to the development of incompetent perforator veins - a key factor may be the increased diameter of veins as well as increased flows during such exercise which may impact valvular function
• in contrast, deep venous thrombosis (DVT) may cause acute physical damage to the deep venous valves as well as venous obstruction, and thus may cause increased superficial venous flows and varicose veins which in turn increase the risk of future DVTs

• genetic factors
• obesity
• chronic alcohol
• pregnancy
  • many women report that their varicosities progress rapidly in size and number during their first pregnancy
• jobs requiring prolonged standing appear to increase risk by 45%
• leg injury
• straining
• right heart failure
• deep venous thrombosis (DVT)

• visible and often tender veins:
  • spider veins (telangiectasia)
  • reticular veins (non-palpable subdermal veins 1–3 mm)
  • distorted, enlarged, palpable superficial veins
• chronic venous insufficiency in mod-severe cases:
  • inframalleolar ankle flare or corona phlebectatica is the most common initial manifestation of venous disease
  • venous dermatosis
  • venous leg ulcers
    • 0.1-4% of long standing ulcers may develop malignant transformation with development of carcinoma or sarcoma
  • risk of deep venous thrombosis (DVT) and superficial thrombophlebitis
    • NB. chronic low-level thrombosis within dilated veins may be sufficient to cause a raised D-Dimer pathology test with sonographic evidence of a DVT or superficial thrombophlebitis
  • heaviness in legs
    • occurs after prolonged standing, and eases on walking or elevation
  • restlessness of legs
  • leg oedema
    • usually pitting oedema but may be non-pitting if it is the result of subcutaneous fibrosis and repeated infections
    • usually spares the metatarsal area
  • muscle cramps in legs
  • cold hypersensitivity and feeling of ice cold feet ⁴⁾
  • poor healing in lower legs
  • lipodermatosclerosis (shrinking skin near the ankles)
  • venous claudication may occur if there is venous outflow obstruction – this causes a ‘bursting’ pain on walking.

Veins connecting the GSV and SSV are called “intersaphenous veins”.

• a particular intersaphenous vein is the Giacomini vein connecting the SSV in the popliteal fossa with the cephalad GSV. Duplex US has revealed the large variability of the superficial veins and therefore it is mandatory to rely on the so called “duplex anatomy” to plan any treatment.

Tributaries of the saphenous trunks and accessory veins are situated in the subcutaneous tissue with a very variable distribution and present as visible or palpable, usually tortuous VVs.

Perforating veins (PVs) are variable in arrangement and distribution, connecting the deep and superficial veins, with unidirectional valves assuring flow from superficial to deep veins, except in the foot. PVs form a complex subfascial network of interconnected veins.

Deep veins of the leg:

• the paired posterior tibial veins and the peroneal veins in the calf join to form the tibioperoneal trunk, which joins the anterior tibial veins
• large veins of the soleus and gastrocnemius muscles join these anterior tibial veins to form the popliteal vein (POPV). This ascends in the adductor canal becoming the femoral vein (FV), which joins the deep femoral vein (DFV) to form the common femoral vein (CFV) in the groin.

• consider referral for Doppler duplex USS to assess the venous system of the legs for patency and competency of the valves
• patients with CEAP levels C4-C6 should be referred to vascular surgeons for management
  • however, it is unlikely that patients with severe medical comorbidities or obesity will be offered surgical treatment, unless they have non-healing venous ulcers⁵⁾
• patients with CEAP levels less than C4 may want surgical referral in the private sector, mainly for cosmetic reasons
• consider below knee compressive stockings
  • as long as a patient has easily palpable foot pulses or an ankle-brachial index over 0.6, it is safe to fit Class 2 below-the-knee compression stockings.
• endoluminal therapies (sclerotherapy, endovenous laser therapy, radiofrequency ablation, etc) may be useful for some although at least 10% will develop new varicosities within 1 year
  • these generally should not be used if either:
    • veins are > 2cm diameter
    • overly tortuous veins
    • are very close to skin
• surgical management may include a combination of ligation, axial stripping, and stab phlebectomy