Varicose Veins
Varicose veins are dilated often palpable subcutanous veins with reversed blood flow. Most commonly found in legs ( NICE 2014 )
Dilated , tortuous or lengthened superficial veins affecting the lower limbs. They occur in the distribution of ○ Long saphenous vein ○ Short ( small ) saphenous vein Varicose veins are present in up to 10-20 % of men and 25-33 % women Common during pregnancy ( around 40 % of pregnant women )
Tingling Itching Pain , pruritis Skin rashes Fatigue Heavy feeling in legs Cosmetic embaressment.Burning sensation Restless legs Night cramps Edema Paraesthesia
Pathophysiology-Number of theories have been suggested Venous hypertension in diseased veins Venous endothelium and smooth muscle abnormality → vein wall dilatation with secondary valvular incompetence Valve incompetence →Reflux of blood and ↑ ed pressure in the vein distally
Complications –Inflammation and throbosis of superficial veins ( thrombophlebitis ) Deep vein thrombosis Skin thickening Skin staining ( lipodermatosclerosis ) Haemorrhage from a superficial varicosity Ulceration ( around 70 % of lower limb ulcers are due to venous disease )
Classification –CEAP ( Clinical , Anatomical and Pathophysiological ) Classification for Chronic Venous Disorders C0 No signs of venous disorder C1 Spider veins and reticular varices ▬ Spider veins ; Intradermal venulae < 1 mm ▬ Reticular varices : subdermal < 3 mm C2 Varicose Veins – subcutaneous > 3mm C3 Oedema – Fluid retention C4 Skin changes ▬ C4 a – pigmentation , purpura , eczema ▬ C4 b – hypodermatitis , lipodermosclerosis , white atrophy C5 Healed ulcer C6 Open ulcer
Types Superficial Veins Great saphenous vein Small saphenous vein Tributaries.Deep Veins-run along arteries Anterior tibial Posterior tibial Peroneal Politeal Deep femoral Superficial femoral Iliac.Perforating or communicating veins
Assessment –Check bothersome symptoms General history and examination Check for complications ○ Skin changes – pigmentation , venous eczema or lipodermatosclerosis ○ Venous leg ulcers – most commonly seen in ankle area ○ Thrombophlebitis – tender inflamed varicose veins overlying redness and heat-feels firm owing to thrombus within the vein.
Management –Varicose vein bleeding → seek adv /admit to vascular services If not bleeding - ○ Reassure that complications are uncommon ○ Pregnant women -limited treatment options ▬ Compression stockings improve symptoms ▬ Improve considerably after pregnancy Lifestyle modifications- if appropriate ○ Weight loss ○ Light to moderate physical activity ○ Avoid aggrevating factors eg sitting or standing for long periods ○ Elevate the legs Advise to seek further help if ○ Veins are hard or painful ( thrombophlebitis ) ○ Skin changes ○ Ulcer risk- break in skin lasts longer than 2 weeks ○ Bleeding
Primary or recurrent varicose veins which are symptomatic Lower limb skin changes Superficial vein thrombosis ( hard painful veins ) and suspected venous incompetence Venous leg ulcer (which has not healed within 2 weeks- refer within 2 weeks ) Healed venous leg ulcer
Doppler / Duplex sonography to establish diagnosis
Surgery →surgical removal ( or stripping ) or ligation ( tying off ) of the vein Foam sclerotherapy – inj of an irritant into the vein → stimulates an inflammatory response resulting in closing of vein Endothermal methods ( Radiofrequency and laser ablation ) heat the inside of vein- causes it to close of
Offer compression stocking if referral is declined or is not indicated Assess dexterity Assess peripheral circulation ○ Measure ABPI ○ ABPI may not be needed if – foot pulse easily palpable , person has no symptoms of arterial disease and strong compression is not being applied ABPI ○ < 0.5 → Arterial dis likely avoid compression stockings ○ 0.5 to 0.8 → use class 1 – light compression ( arterial dis is likely ) ○ 0.8 to 1.3 →compression stockings are safe to wear ○ > 1.3 →may be due to calcified and incompressible arteries -avoid and consider specialist opinion Strength ○ Varicose veins- class 1 or 2 ○ Venous eczema – class 1 or 2 ○ Lipodermatosclerosis , atrophie blanche , healed venous leg ulcer – class 2 or class 3 if poor response to 2 ○ Post DVT ( prevention of post-thrombotic syndrome ) – class 3 or class 2 if these are poorly tolerated ○ Superficial thrombophlebitis – class 1 or 2 ( doubtfull usefullness ) Choosing length ○ Below knee -preferred choice in most people ○ Consider thigh- length if severe varicose veins or swelling extends above the knee Open or Closed Toe ○ Individual preference ○ Open toe for ▬ arthritis or clawed toes ▬ fungal infection of toes ▬ wish to wear a sock over stocking ▬ long foot size compared to calf size Should be taken off at bed time and put back 1st thing in the morning Replace every 3-6 months Review the patient every 3-6 months Doppler should be repeated every 6-12 months or earlier if clinically indicated
LINKS AND RESOURCES
PATIENT INFORMATION
Circulation foundation – printable colour leaflet https://www.circulationfoundation.org.uk/system/files/Circulation_Foundation_Varicose_Veins_General_Info_Leaflet.pdf
Vascular Society on varicose veins https://www.vascularsociety.org.uk/patients/conditions/3/varicose_veins
A comprehensive patient resource from National Heart Lung and Blood Institute https://www.nhlbi.nih.gov/health-topics/varicose-veins
A good review of treatment from British Society of Interventional Radiology https://www.bsir.org/patients/varicose-veins/
A detailed article for the patient from BUPA https://www.bupa.co.uk/health-information/heart-blood-circulation/varicose-veins
Society for Vascular Nursing Patient Education: varicose veins Do’s and Dont’s https://svnnet.org/wp-content/uploads/2015/09/SVN-Varicose-Veins-Education.pdf
A video and other reading on varicose veins from the Society of Vascular Surgery https://vascular.org/patient-resources/vascular-conditions/varicose-veins
INFORMATION FOR CLINICIANS
NICE guidance Varicose Veins Diagnosis and Management 2013 https://www.nice.org.uk/guidance/cg168
A quick 1 page useful visual for the non-specialist from NHS Greater Glasgow and Clyde https://www.nhsggc.org.uk/media/246488/varicose-vein-management.pdf
The care of patients with varicose veins and associated chronic venous diseases: Clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum Gloviczki, Peter et al. Journal of Vascular Surgery, Volume 53, Issue 5, 2S – 48S ( Abstract- check for access ) https://www.jvascsurg.org/article/S0741-5214(11)00327-2/abstract
European Society for Vascular Surgery ( ESVS ) Management of Chronic Venous Disease 2015 https://www.ejves.com/article/S1078-5884(15)00097-0/pdf
Revised Venous Clinical Severity Score https://www.veinforum.org/wp-content/uploads/2019/05/Revised-VCSS-AVF.pdf
Australian Family Physician A synopsis of current international guidelines and new modalities for the treatment of varicose veins Volume 46, No.4, 2017 Pages 229-233 https://www.racgp.org.au/afp/2017/april/a-synopsis-of-current-international-guidelines-and-new-modalities-for-the-treatment-of-varicose-veins/
An open-access article A multicenter review of epidemiology and management of varicose veins for national guidance 2016 https://www.sciencedirect.com/science/article/pii/S2049080116300425
References;
- Diagnosis and management of Varicose Veins in legs KCE Reports 164 C accessed via https://kce.fgov.be/sites/default/files/ page_documents/kce_164c_varicose_veins.pdf
- Venous Disorders Diagnosis and Treatment- Sigvaris accessed via http://www.sigvaris.com/sites/default/files/venous_disorders_brochure_en.pdf
- Venous Disorders Cynthia K Shortell MD accessed via https://web.duke.edu/surgery/vascular/Venous_disease_therapy_4-9-10.pdf
- Varicose Veins ; Diagnosis Management and Treatment Sylvia Zhang et al Medscape
- Pathogenesis of Varicose Veins European Journal of Vascular and Endovascular Surgery Volume 25, Issue 4, April 2003, Pages 319–324 J Golledge , FG Quigley
- CKS NHS Varicose veins accessed via http://cks.nice.org.uk/varicose-veins#!topicsummary
- Venous Insufficiency Robert Weiss MD , Chief Editor : William D James et al accessed via http://emedicine.medscape.com/article/1085412-overview
- Stat Pearls NCBI Bookshelf Varicose Veins via https://www.ncbi.nlm.nih.gov/books/NBK470194/
- Varicose Veins Diagnosis and Treatment AFP via https://www.aafp.org/afp/2019/0601/p682.html