Editing Varicose veins

Subcutaneous veins in the lower extremities which are dilated to >=3mm in diameter in the upright position.

* Can occur in axial superficial veins (GSV and SSV) or their tributaries.

== Pathophysiology ==

* Thought to represent primary venous disease - may develop due to structural weakening of the vein wall, which can be focal or diffuse.
* Most likely the result of underlying morphologic or biochemical abnormalities - but exact nature is not understood.
* Valvular incompetence in the superficial veins is usually present, but not clear if this is inciting or sequelae of other venous disease
* Progressive disease - regression does not occur except after delivery of baby
* Varicosities over medial leg are generally related to the great saphenous vein or its perforating branches
* Varicosities over posterior calf are in the distribution of the small saphenous vein
* Also review location with respect to the named perforators (see Anatomy tab)

== Symptoms ==

* Lower extremity pain and swelling, especially after prolonged standing
* Feeling of heaviness in legs

== Examination: ==

* Examine in the standing position
* Note location of all varicosities
** In obese patients, may be palpable but not visible
* Ankle flare
* Corona phlebactica
* Lipodermatosclerosis
** Venous hypertension -> increased leucocytes -> proinflammatory state -> increased collagen production and deposition
** Leakage of fibrinogen and formation of fibrin cuffs around vessels also contributes to perfusion deficits
* Often see telangiectasias (dilated intradermal venules about 1mm in size) and reticular veins (non-palpable subdermal veins 1-3mm)
* Trendelenburg test ('tourniquet test' if using a tourniquet instead of manual compression): 
** Used to locate the site of incompetent valves
** Patient supine, with leg lifted by examiner to empty the varicosities
** Manual compression used to occlude proximal great saphenous vein, then the patient stands upright. 
*** If the veins don't fill, the SFJ was the problem
*** If the veins still fill, there are other incompetent valves.
** Repeat the test at different levels to isolate the incompetent valves
* Perthes test
** Used to differentiate between insufficiency from deep, superficial and perforator systems
** Tourniquet on mid-thigh while the patient ambulates, leading to markedly distended varicosities.
** Varicosities are less distended: no deep venous insufficiency
** Remain distended, or more distended: likely deep venous system problem

== Complications ==

* Superficial thrombophlebitis
* Acute bleeding
* Eczema
* Skin ulceration
** Venous ulcers associated with chronic venous insufficiency
*** Location of ulcers may be related to location of incompetence - relationship between lateral malleolus ulcers and SSV reflux
** Non-operative
*** Compression
*** Elevation
*** Skin care

== Indications for public VV treatment in Australia: ==

* Symptomatic VV with CEAP classification of C3 or greater
** Chronic leg oedema
** Chronic dermatitis/eczema
** Bleeding
** Leg ulcers or infections
** Superficial thrombophlebitis
* VV in a patient <16yo
* Excluded: cosmetic veins and spider veins are NOT able to be done in public

== Treatment options ==

* No treatment
* Conservative (compression)
** Generally done as a trial first step for patients in CEAP2-4 (20-30mm Hg) or CEAP6 (30-40mm Hg)
** ESCHAR trial - compression is comparable to compression plus ligation + stripping of the GSV in CEAP6 disease, but ulcer recurrence is much lower with surgery
* Surgery
** Rationale and treatment approach:
*** Goal is to close refluxing superficial veins
*** Treat most proximal point of reflux first - ''most'' (50-70% of patients) have SFJ incompetence, and one study found 85% with VV have GSV reflux and 20% SSV
*** Remove diseased segments but leave normal functioning veins behind - not necessary to treat normal or atretic sections of GSV
*** Use the least invasive technique possible - start with RFA and step up if necessary
*** Need to remove as many superficial varicosities as possible - if left behind, even after GSV ligation +/- stripping, they can drain by alternate pathways and persist.
*** GSV disease: RCTs have shown benefit to surgery over conservative management. Early post-operative advantage in pain for endovenous ablation, but no long-term difference.
**** Indications for GSV surgery as opposed to EVA:
***** Superficial saphenous tributary (risks skin burns unless 1cm between vein and skin)
***** GSV dilation or aneurysmal venous segments >2.5cm (the probe won't ablate properly because it won't contact the vein walls)
***** Chronic thrombophlebitis (prevents advancement of catheter)
***** Excessive tortuosity (can't advance)
***** Acute superficial thrombophlebitis (EVA contraindicated in any vein with acute thrombus)
*** SSV disease: EVA is probably effective, but concern persists over potential for thermal injury to popliteal neurovascular structures.
*** Reticular veins/telangiectasias: sclerotherapy - controversial whether this treatment should happen simultaneously with primary VV treatment
** Endovenous
***
*** RFA:
**** Segmental ablation - catheter contacts vein wall and delivers radiofrequency energy, resulting in destruction of endothelium, contraction of vein wall collagen, and thrombus formation. Eventually fibrosis occurs, resulting in a durable ablation.
**** Contraindications:
***** SVT
***** DVT
***** Venous aneurysm
***** ABI < 0.9
***** Pacemaker - needs assessment by cardiologist prior
**** Results
***** 74% had improved CEAP at 36 months
***** 93% had continued occlusion of treated truncal veins at 3 years
*** Sclerotherapy
**** Introduction of a chemical into a vein to induce endothelial damage that results in thrombosis and eventually fibrosis.
**** Indications
***** Most often used to treat smaller vessels such as reticular veins and telangiectasias
**** Relative contraindications
***** Asthma
***** Late complications of diabetes
***** Hypercoagulable state
***** Leg oedema
***** Advanced PAD
***** Bad CKD
**** Absolute contraindications
***** Known allergy
***** Acute cellulitis
***** Acute respiratory or skin disease
***** Severe systemic disease
***** Phlebitis migrans
***** Acute superficial thrombophlebitis
***** Pregnancy
***** Hyperthyroidism
***** Bedridden status
** Surgical



[[Category:Vascular]]