Varicose Veins

Varicose veins are defined as dilated, usually

tortuous, subcutaneous veins 3 mm in diameter
measured in the upright position with
demonstrable reflux.

Epidemiology
The adult prevalence of visible varicose veins is 25
30 percent in women and 15 per cent in men.
Factors affecting prevalence include:
gender: the vast majority of studies report a
higher prevalence in women than men
age: the prevalence of varicose veins increases
with age. In the Edinburgh Vein Study, the
prevalence of trunk varicosities in the age groups
1824 years, 2534 years, 3544 years, 4557
years and 5564 years was 11.5, 14.6, 28.8, 41.9
and 55.7 percent, respectively;

ethnicity: does seem to influence the prevalence of

varicose veins;
body mass and height: increasing body mass index
and height may be associated with a higher
prevalence of varicose veins;
pregnancy: appears to increase the risk of varicose
veins;
family history: evidence supports familial
susceptibility to varicose veins;
occupation and lifestyle factors: there is
inconclusive evidence regarding increased
prevalence of varicose veins in smokers, patients
who suffer constipation and occupations which
involve prolonged standing.

Classification
The CEAP (clinical etiology anatomy
pathophysiology) classifi cation for chronic venous
disorders is widely utilised.
Clinical classifi cation
C0: no signs of venous disease
C1: telangectasia or reticular veins
C2: varicose veins
C3: oedema
C4a: pigmentation or eczema
C4b: lipodermatosclerosis or atrophie blanche
C5: healed venous ulcer
C6: active venous ulcer
Each clinical class is further characterised by a subscript
depending upon whether the patient is symptomatic (S)
or asymptomatic (A) e.g. C2S.

Etiologic classifi cation

Ec: congenital
Ep: primary
Es: secondary (post-thrombotic)
En: no venous cause identifi ed
Anatomical classification
As: superficial veins
Ap: perforator veins
Ad: deep veins
An: no venous location identified

Pathophysiological classification
Pr: reflux
Po: obstruction
Pr,o: reflux and obstruction
Pn: no venous pathophysiology identifiable

Clinical features
Symptoms
The most common symptoms being aching or
heaviness, which increases throughout the day or
with prolonged standing and is relieved by elevation
or compression hosiery; ankle swelling and itching
while complications (bleeding, superficial
thrombophlebitis, eczema, lipodermatosclerosis and
ulceration) represent important indications for
investigation and intervention

Sign
The presence of tortuous dilated subcutaneous veins
are usually clinically obvious.
The distribution of varicosities may indicate which
superficial system is defective; medial thigh and calf
varicosities suggest long saphenous incompetence
(Figure 57.3a), posterolateral calf varicosities are
suggestive of short saphenous incompetence (Figure
57.3b), whereas anterolateral thigh and calf
varicosities may indicate isolated incompetence of
the proximal anterolateral long saphenous tributary
(Figure 57.3c).

Other signs commonly found include:

Telangectasia, which are essentially a confluence
of dilated intradermal venules <1 mm in diameter.
These may be mild or severe (Figure 57.4).
Synonyms include spider veins, thread veins and
hyphen webs.
Reticular veins are dilated, subdermal veins, 13
mm in diameter. The presence of telangectasia and
reticular veins are of dubious significance, are not
necessarily associated with major varicose veins and
are purely a cosmetic problem.

In saphena varix (Figure 57.5), there is a large groin

varicosity which presents as a (usually painless)
lump, emergent when standing and disappearing
when recumbent. Gentle palpation over the varix
during coughing may elicit a thrill.
Atrophie blanche (Figure 57.6) is localised white
atrophic skin frequently surrounded by dilated
capillaries and hyperpigmentation, usually seen
around the ankle.

Corona phlebectasia are fan-shaped patterns of

small intradermal veins on the medial or lateral
aspects of the ankle or foot. Synonyms include
malleolar or ankle flares.
Pigmentation (Figure 57.7) is usually a brown
discolouration (because of haemosiderin deposition)
of the skin, most frequently affecting the gaiter area,
and may be associated with phlebitis and ulceration.

Eczema (Figure 57.8a); this is an erythematous

dermatitis which may progress to blistering, weeping
or scaling eruption of the skin, not to be confused
with contact dermatitis (Figure 57.8b).
Dependent pitting oedema as a result of increase in
volume of fluid in skin and subcutaneous tissue
characteristically increases throughout the day, and
is relieved by elevation and compression
hosiery/bandaging. The oedema is usually confined
to the ankle area but may extend to the foot and
rest of the leg.

Lipodermatosclerosis (Figure 57.9) is a localised

chronic inflammation and fibrosis of the skin and
subcutaneous tissues of the leg, a sign of severe
chronic venous disease.
Ulceration (Figure 57.10) is a full thickness
epidermal defect, most frequently affecting the
gaiter area.

Investigation
Tourniquet tests have now largely been abandoned.
There is good evidence to support the policy of
duplex ultrasound scanning for all patients with
varicose veins prior to any intervention. This policy
facilitates a more accurate surgical approach,
reduces the incidence of varicose vein recurrence,
and allows assessment regarding suitability for
endovenous intervention

Hand-held continuous wave Doppler emits a sound

when blood flows past the transmitting and
receiving crystals. A uniphasic signal indicates flow
in one direction. Forward and reverse flow produces
a biphasic signal which is indicative of blood
refluxing through incompetent valves.

Duplex ultrasound
imaging
The aim of the duplex scan in patients with varicose
veins is to establish:
which saphenous junctions are incompetent and
their locations;
the extent of reflux in the saphenous veins and
their diameters;
the number, location and diameter of incompetent
perforating veins;

Management
Patients who have asymptomatic varicose veins can
simply be reassured. Indications for referral to a
vascular surgeon include C2 disease associated with
bleeding, superficial thrombophlebitis or symptoms
which are impairing quality of life, or C36 disease.

Compression hosiery
Ultrasound-guided foam sclerotherapy
Endovenous laser ablation (EVLA)
Radiofrequency ablation (RFA)

Surgery
Saphenofemoral ligation and long saphenous
stripping
Saphenopopliteal junction ligation and lesser
saphenous stripping
Perforator ligation
Phlebectomies