VARICOSE VEINS
Part 1: Symptoms and diagnosis.
Varicose veins are enlarged dilated tortuous veins in the legs. The essential abnormality of varicose veins is the failure or incompetence of the valves within the veins. Incompetent valves allow reflux of blood under pressure, either from gravity or from the calf muscle pump, and so cause the veins to distend and become varicose. Varicose veins are commoner in women, often run in families and are made worse by obesity and pregnancy.
Varicose
Veins Symptoms
Simple varicose veins
Many patients seek advice because they do not like the appearance of the veins in their legs. However, primary uncomplicated varicose veins can lead to symptoms of aching and tiredness in the leg or a feeling of heaviness of the leg. Veins are often more distended by the end of the day when symptoms may be worse. Standing for a long time can exacerbate symptoms in varicose vein sufferers. Simple varicose veins are usually not a cause of swollen legs.
Dermal thread veins
These have an unfortunate cosmetic appearance and cause some patients considerable distress. They do not give rise to other symptoms.
Thrombophlebitis
Patients with varicose veins are at risk of thrombophlebitis, which is a painful inflammation of the vein and can require time off work and even bed rest in severe cases. Rest, analgesia and antiinflammatory treatment is required.
Hemorrhage
Varicose veins can bleed following surprisingly minor traumas. The haemorrhage can be spectacular.
Elevation of the leg, local pressure and a bandage will stop the bleed. Some definitive treatment such as surgery or injection sclerotherapy may be needed. Venous insufficiency
This is a general term for patients with venous reflux, usually in the deep system, sufficient to cause skin changes. Initially the skin may be
pruritic, then a venous flare may appear at the ankle, followed by pigmentation, lipodermatosclerosis with a thickened plaque of sub dermal fibrosis in the gaiter area and eventually ulceration.
Varicose
Veins Diagnosis
Clinical
The key to diagnosis is to identify the main source of venous reflux into the varicose veins. This is usually saphenofemoral reflux into the long saphenous vein in the groin. Other sites lower down the long saphenous vein may also be the source of incompetence. The saphenopopliteal junction behind the knee may be incompetent and fill the short saphenous vein and its tributaries in the calf. The distribution of the varicose veins in the leg gives a good clue as to which system is involved. Tourniquet testing will help identify the primary site of the valvular incompetence. A hand held Doppler probe can be used in clinic to confirm reflux.
Duplex scan
This scan uses ultrasound and combines B-mode imaging with Doppler. It should be used for all patients with recurrent veins for which an operation is planned, as the anatomy will have been affected by previous surgery. Patients suspected of having a short saphenous problem or incompetent perforating veins should also undergo scanning. Simple varicose veins associated with the long saphenous system probably do not need scanning. Who should be
referred to a vascular surgeon?
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Patients with obvious varicose veins and symptoms.
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Patients with skin changes (varicose eczema or
lipodermatosclerosis).
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Patients with venous ulcers Please note: At the request of the health authority, patients with thread veins cannot be given treatment on the NHS as this is considered to be a cosmetic problem. Treatment is however available in the private sector.
A typical venous duplex ultrasound report. Note that all deep and truncal veins of the right leg have been scanned. In this case, the long saphenous vein is shown to be grossly incompetent.
More
information on Varicose Veins
Treatment.
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