Venous disease: how should varicose veins be treated

Describe the major methods for treating varicose veins and the evidence to support them (high
ligation, stripping and avulsions; sclerotherapy; lasar therapy, others)

Varicose Veins. Q1. What two significant venous abnormalities are visible on this picture? Q2. How
should this patient be investigated? Q3. What are the complications if the venous hypertension
goes untreated. Q4 What is the mainstay of threatment for this condition.

Varicose vein

 They are dilated, elongated, tortuous, subcutaneous veins 3mm or greater in diameter
with demonstratable reflux due to incompetent valves in the deep, superficial or
perforator systems

Aetiology
 Primary – venousincompetence or obstruction
 Increasing age, HRT, prolonged standing, pregnancy, obesity
 Secondary – DVT, maligat pelvic tumours with vneous compression, congenital anomalies, AV
fistulae

Path
 Due to incompetent venous valves, more blood in the veins leading to (HTN), reflux and total
dilation. Over time they become swollen and varicose.
 The clinical effects are due to prolonged high pressures in the veins
 Only genetic and past Hx of DVT have been showed to be causes
 Some patients have loss of elastic tissue in the vein wall causing progressive valve incompetence


Epi
 Increasing rate in older people
 More common in females
 Increasing BMI and height
 Pregnancy
 Fx
 Inconclusive – smokers, constipated, prolonged standing

Classification
 CEAP classification is most used
 Clinical


  Each of these are further classified as whether they are symptomatic (S) or
asymptomatic (A)
 Aetiology
 C – congenital
 P- primary
 S – secondary (ie. post thrombotic)
 N – nil cause found
 Anatomy
 S – superficial
 P – perforator vein
 D – deep veins
 N – nil location
 Pathophys
 R – reflux
 O – obstruction
 R,o – reflux and obstruction
 N – nil found

Clin
 Aching and heaviness, increasing throughout the day or with prolonged standing
 Relieved by elevation or compression
 Ankle swelling
 Inframalleolar ankle flare or corona phlebectatica is the most common initial manifestation of
venous disesase class 1
 Isolated calf varicosities are commonly noted with prolonged standing or during menses
 With progression, people note appearance in the proximal limnb
 Can progress rapidly in size and number during first pregnancy (CEAP 2)
 Oedema, sparing the metatarsal area
 Limb heaviness or ahce eases on walking or elevation
 Claudication is for arterial disease and worsens with exertion
 Pain and tenderness on the course of the vein
 Skin pigment change (class 4)
 Ulcer formation
 Telangiectasia
 Reticular veins (subdermal non-palpable)
 Skin pigmentation
 Ulcer
 Angle vneous flar

 itching
 Indications for Ix
 bleeding
 superficial thrombopletbitis
 dermatitis
 lipodermatosclerosis
 ulceration
 tortous dilated subcutaneous veins
 confined to the long and lesser saphenous systems in 60 and 20% of cases
 medial thigh and calf varicosities suggest long saphenous incompetence
 posterior lateral calf suggest short saphenous
 anterior lateral thigh and calf indicate isolated impotence of the proximal anterolateral long
saphenous tributary
 other signs
 telangiectasia
 reticular veins are dilated
 atrophie blanche – white atrophic skin frequently surrounded by dilated capillaries and
hyperpigmentation around the ankes
 corona plebactasia – fan shaped patterns of small intradermal veins on the medial or lateral
aspects of the ankle or foot – ankle flares
 pigmentation – brown due to haemosiderin most on the gaiter area. Can be associated with
ulcer and phlebitits
 dermatitis that is blistering, weeping or scaling
 dependent pitting oedema due to increase fluid in skin and subcut tissue. Present
throughout the day and relieved by elevation and compression. Confined to the ankes but
can extend
 lipodermatosclerosis – localised chronic inflammation and fibrosis of the skin and sub cut
tissue of the leg
 ulcer
 saphena varix – large groin varicosity which presents as usually painless lump, emergent
when standing and disappearing when recumebt. Thrill when palpating during cough
 Ix
 Prev: tourniquet test
 Duplex US prior to any intervention
 Reduce recurrence risk
 Allows assessment regarding endovenous intervention
 Patency and competency of both the superficial and deep system
 Clinical acumen with continuous wave Doppler only if duplex US not available (miss 30% of
connections)
Forward and reverse
flow produces a biphasic signal which is indicative of blood refluxing
through incompetent valves. A biphasic signal following a calf
squeeze performed with the Doppler probe over the saphenofemoral
junction suggests the presence of junctional incompetence.
A biphasic signal over the saphenopopliteal junction or lesser
saphenous vein is not an accurate method of establishing incompetence
of the lesser saphenous vein as its termination is variable
and it is difficult to separate lesser saphenous incompetence from
 popliteal valvular incompetence

in all cases of biphasic lesser saphenous signal a duplex scan should be done

--

Duplex US
 it si the main Ix
 venous flow can be augmented by calf squeeze
 it can establish
 what saphenous junctions are incompetent and locations
 extent of reflux and the diametres
 number, location and diameter of incompetent performing vein
 other relevant veins that demonstrate reflux
 the source of all superficial vairces if not from the veins already described
 the competence and evidence of previous venous thrombosis in the deep venous system

varicographs
 detailed mapping

descendingiV venograpgy

MR venography – if from pelvic vein

Management
If asymptomatic, reassurance
When to refer
 telenctasia or retinal veins (C2)
 with bleeding, superficial thrombophlebitis, or impact on QoL
 any c3-6 disease CEAP 3 or greater
 all patients with venous eczema or ulceration, evidence of insufficiency, thrombophlebitis,
bleeding or severe discomfort should be referred to vascular


compression
 relies on graduated external external pressure to improve deep venous return
 they improve sx but it is not popular with patients with poor compliance rate and long term
tolerance
 there is no evidence to suggest that compression hosiery prevents the occurrence or progression
of varicose veins
 can lead to pressure necrosis, tourniquet effect
 as long as ankle brachial index >0.6 or easily palpable foot pulse, otherwise further treatment is
necessary

US guided sclerotherapy
 injection of detergent directly into the superficial vein which destroys the lipid membranes of
endothelial cells causing them to shed and leading to thrombosis, fibrosis and obliteration
(sclerosis)
 It is important to cannulate all the veins prior to injecting the first as injection quickly spreads
and makes further cannulation difficult
 The leg is elevated to empty the veins
 Injection continued until the foam is seen at the site of junctional incompetence
 Acts by destroying the venous endothelium
 Hypertonic saline, sodium tetradecyl sulphate and polidocanol
 Need to wear elastic bandage
 Only 10-12mL per session
 Compression then applied and left for 7-10days
 Recurrence rate and the need for reintervention are high
 Foam is better than liquid therapy
 Other complications include phlebitis, pigmentation, headache, visucal disturbance, chest
tightness, cough
 Short recovey time
 More cases of superficial phlebitis

1:3 or 1:4 ratio mixture of sclerosant and
air is drawn into one syringe, and is then oscillated vigorously
between the two syringes about 10 or 20 times (Figure 57.17).
 The foam produced in this way is stable for about 2 minutes so it
 sodium tetradecyl sulphate

endovenous laser ablation

 laser fibre into the lumen of an incompetent truncal vein with subsequent thermal ablation of
the vein
 only treats junctional and truncal incompetence
 manage varicosities managed by phlebectomy or sclerotherapy
 highest cost per treatment

radiofrequency ablation
 bipolar catheters to generate thermal energy to ablate the vein
 associated with less pain and bruising compared to lasar
 complications: phlebitis, VTE, skin burns
 faster recovery than laser or surgery or endovenous laser
 more superficial phlevitis
 highest cost per treatmetn

surgery
 the principles are to ligate the point of junctional incompetence and to remove the refluxing
trunk and dilated tributaries
 gold standard, now there is a trend away from it
 combined ligation, stripping and stab phlebectomy
 risks of infection, nerve injury and recurrence
 saphenofemoral ligation and long saphenous stripping
striping is the removal of all or part of the greater and short saphenous vein

larger veins are best treated by surgical excision usting the stab avulsion. Make 2mm incision directly
over branh varicose vein and the vein is avulsed with no attempts to ligate it
  they are common and present in 10% of the general population
 Dilated and tortous veins
 Telangiectasia
 Fine reticular varicosities
 RF: obesity, female, inactivity, Fx
 Primary – due to intrinsic venous wall abnormalities
 Secondary – deep or superficial venous insufficiency
 Cosmetic
 Aching
 Heaviness
 Pruritus
 Early fatigue of affected leg
 Worsening of sx with prolonged standing and sitting, relieved by elevation above the
heart
 Mild oedema
 Severe signs
 Thrombophlebitis, hyperpigmentation, lipodermatosclerosis, ulceration, bleeding

Mx
 Compression stockings – wide range of pressures and lengths. Important to cover the sx varices
 Cosmetic, s worsening or unrelieved despite compression therapy or those that have
lipodermatosclerosis or venous ulcer reasons can lead to intervention

http://www.racgp.org.au/afp/2013/june/varicose-veins/