Varicose veins - Hypertension and vascular diseases

Varicose veins

Definition

Distended and dilated lower limb superficial veins associated with incompetent valves within the perforating veins.

Incidence

Common

Age

Increases with age.

Sex

5F : 1M

Aetiology

Incompetent valves in perforating veins between the superficial and deep venous systems lead to reflux of blood from the deep system. This results in distension and tortuosity of the superficial veins. Familial predisposition, obesity, pregnancy and prolonged standing are established aetiological factors.

Pathophysiology

·        Primary varicose veins are common and show a familial tendency, which may either be due to intrinsic valve incompetence or loss of elasticity in the veins.

·        Secondary varicose veins develop after valve function has been disrupted by either disease (thrombosis) or occasionally trauma. The valves in the perforating veins are disrupted, so that blood refluxes from the

·        deep veins to the superficial veins.

Impaired venous return ‘chronic venous insufficiency’, leads to lower limb oedema, fibrosis around the small capillaries and veins, skin changes of eczema and ulceration. These changes are referred to as lipodermatosclerosis.

Clinical features

Patients complain of cosmetically unsightly veins and aching, heavy legs. There may be a family history or history of previous deep vein thrombosis.

Complications

Rupture is uncommon. The superficial veins are prone to thrombus formation due to stasis, causing tender, reddened, painful swollen veins (superficial throm-bophlebitis).

Investigations

The site of the incompetent valve can be identified by the Trendelenberg tourniquet test or by Doppler ultrasound.

Management

Elderly patients are managed conservatively with weight reduction, regular exercise and avoidance of constricting garments. Sclerotherapy and laser therapy can be used for small varices, but only surgery is effective if there is deeper valve incompetence. Surgery consists of three parts:

To interrupt incompetent connections between deep and superficial veins. The sapheno-femoral junction is visualised and the saphenous vein is ligated and divided.

To strip the main saphenous channels from which pressure is distributed, and the long saphenous vein is stripped out from knee to groin (omitted if a saphenous coronary bypass may be needed at a later date).

To eradicate varices by dissection or avulsion technique where the varices are winkled out through small incisions.