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