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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;

  1. 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
  2. Venous Disorders Diagnosis and Treatment- Sigvaris accessed via http://www.sigvaris.com/sites/default/files/venous_disorders_brochure_en.pdf
  3. Venous Disorders Cynthia K Shortell MD accessed via https://web.duke.edu/surgery/vascular/Venous_disease_therapy_4-9-10.pdf
  4. Varicose Veins ; Diagnosis Management and Treatment Sylvia Zhang et al Medscape
  5. Pathogenesis of Varicose Veins European Journal of Vascular and Endovascular Surgery Volume 25, Issue 4, April 2003, Pages 319–324 J Golledge , FG Quigley
  6. CKS NHS Varicose veins accessed via http://cks.nice.org.uk/varicose-veins#!topicsummary
  7. Venous Insufficiency Robert Weiss MD , Chief Editor : William D James et al accessed via
http://emedicine.medscape.com/article/1085412-overview
  8. Stat Pearls NCBI Bookshelf Varicose Veins via https://www.ncbi.nlm.nih.gov/books/NBK470194/
  9. Varicose Veins Diagnosis and Treatment AFP via https://www.aafp.org/afp/2019/0601/p682.html

 

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