Varicose veins are abnormal tortuous dilated superficial veins seen mostly on the legs. Reticular veins are prominent normal superficial veins, which do not usually vary in thickness. Thread or spider veins are fine thin cutaneous veins of a millimetre or so diameter.
Incidence: 50% of those over 50 years of age have signs of venous disease on their legs50% of these have true varicose veins
Age range: increases with increasing age
Sex ratio: Distribution is equal, but more women than men present (5:1)
Race: Caucasians have a higher incidence than other races
Associations: Family history, obesity, pregnancy, oral contraceptive pill, possibly HRT; occupations which result in standing for long periods may worsen varicose vein symptoms
Varicose veins and their complications account for 500,000 general practitioner consultationsper year. 10% of these will receive hospital treatment.
- Primary varicose veins (95%) are caused by an increase in venous pressure in the superficial leg veins. This is due to damage to the venous valves between the deep and superficial venous systems. This may be at the saphenofemoral junction between the long saphenous vein and the common femoral vein in the groin; at the sapheno-popliteal junction between the short saphenous vein and the popliteal vein in the popliteal fossa; or at other sites when they are known as perforators.
- Secondary varicose veins (5%) occur when the increased venous pressure in the superficial venous system is due to a disturbance in venous blood flow elsewhere, for example in pelvic and extensive leg vein thrombosis, and arterioveonus malformations (either congenital or acquired as a result of a fracture)
- The clinical features of varicose veins fall into two groups.
- Group I symptoms
These are associated with a low morbidity, but can affect the patient’s quality of life. Treatment is therefore dependent on the patient’s perception of disruption caused.
- Aching – dull heaviness or fullness in the leg, relieved by leg elevation
- Cosmetically unsightly
- Itching and throbbing
- Swelling of ankles or leg
- Group II complications
These symptoms can be associated with significant morbidity and therefore intervention is indicated.
- Superficial thrombophlebitis (see other chapter)
- Venus skin changes – venous hypertension causes an increase in capillary pressure and eventually leads to skin and subcutaneous tissue changes usually at the ankle. The main skin changes are:
- induration (lipodermatosclerosis) – diffuse fibrosis of subcutaneous tissues accentuated by fat necrosis and chronic inflammatory changes leads to areas of hard tissue in which veins form large hollow grooves
- pigmentation – deposits of haemosiderin in the skin from degraded extravasated erythrocytes
- ulceration – caused by chronic venous hypertension. As areas attempt to heal the surrounding areas show a white scarring – “atrophie blanche”.
- eczema – often occurs without frank ulceration.
Investigations should be undertaken only if treatment is indicated. Investigations aim to answer three questions:
- What is the site of incompetence between the deep and superficial venous systems? This can usually be identified using the hand held Doppler or a Duplex ultrasound
- Is the deep venous system patent? Removal of the superficial venous system when the deep system is not patent will markedly worsen venous hypertension. Identify with Duplex ultrasound
- Are the pelvic and abdominal veins (the venous outflow) patent? This is confirmed using MRIor venography.
- Treatment options.
- No intervention
- Graduated compression stockings
- Treatment depends on the patient and their symptoms
- Group I symptoms,
- The decision to operate depends very much on the impact of symptoms on quality of life
- All symptoms (apart from cosmetic improvement) can be managed by wearing graduated compression stockings
- Varicose vein surgery will not remove thread or reticular veins. Other forms of treatment are needed (see below).
- Surgery is only indicated for symptoms the patient has now and not as prophylaxis against development or progression of symptoms.
- Surgery often requires a general anaesthetic and has a risk of complications.
- Group I symptoms,
- Group II complications
- serious consideration to surgery should be given.
- This group of patients, however are usually of an older age group and often have co-morbidity which increases their anaesthetic risk. In these patients graduated compression stockings may be an alternative.
- For those patients with varicose veins, which arise from unusual causes such as arteriovenous malformations, surgery is usually best avoided.
- The Surgery
- There are methods of removing varicose veins.
- Saphenous vein stripping
- Endovenous ablation
- Foam sclerotherapy.
- Potential complications of surgery
- A little blood may ooze from the wounds during the first 12 hours. This usually stops spontaneously, especially if the wound is pressed for ten minutes.
- Bruising is variable, but common and will cleared within 3 weeks
- Large wound haematomas are rare.
- Healing fibrosis can produce firmness under the operation scars or in the line of the treated veins. If there is associated swelling, redness and tenderness, a wound infection needs to be excluded.
- Wound infections
- Neuropraxia – some numbness over phlebectomy sites is common and temporary. True permanent neuropraxia may occur over the skin supplied by the saphenous nerve, which is damaged while stripping the long saphenous vein or during a phlebectomy. Sural nerve damaged during a short saphenous vein ligation in the popliteal fossa also produces neuropraxia.
- Recurrence – there is a one in five chance of developing further varicose veins within five years.
- Post-op care includes:
- graduated compression stockings or bandages are warn day and night for seven to ten days and thereafter only during the day for a month
- simple oral analgesics
- sitting with the feet elevated so that heels are higher than hips to aid drainage of excess fluid from the tissues and assist healing.
- Patients are advised to take a short walk of a few hundred yards three times a day
- return to work and driving within 2 weeks of surgery; swimming and cycling are allowed after the dressings have been removed.