Varicose veins
Varicose veins are characterized by visible dark-blue or purple veins, leg swelling, and persistent leg aching. To ensure proper identification, differentials include distinguishing varicose veins from conditions like deep vein thrombosis and arterial insufficiency. Effective management strategies encompass lifestyle adjustments like regular exercise and leg elevation, alongside wearing compression stockings and avoiding prolonged standing. For more severe cases, medical interventions like sclerotherapy, endo-venous ablation, or surgical procedures may be considered.
Diagnostic Techniques:
| Diagnostic Technique | Purpose | Procedure |
|---|---|---|
| Brodie-Trendelenburg Test | Differentiate between deep and superficial reflux | Patient lies down, leg elevated, tourniquet applied, observe veins after standing. Varicose vein dilate immediately is suggestive of deep (or combined) venous insufficiency Varicose veins filling > 20 seconds indicates superficial venous insufficiency. |
| Plethysmography | Measure components of CVI pathophysiology including reflux, obstruction, and muscle pump dysfunction | Measures venous volume, venous refilling times, maximum venous outflow, segmental venous capacitance, and ejection fraction. |
| Computed Tomography (CT) and Magnetic Resonance Venography (MR) | Evaluate venous disease, especially focal or complex lesions at proximal veins | Requires appropriate timing for optimal imaging, limited use due to lack of functional information. |
| Venous Duplex Ultrasonography (DUS) | Most common and useful diagnostic technique for CVI, provides etiological and anatomical information | Combines B-mode imaging and spectral Doppler to detect venous obstruction and reflux in superficial and deep veins. Provides visualizations of venous flow patterns. |
| Intravascular Ultrasound (IVUS) | Superior to conventional venography for morphologic diagnosis of iliac venous outflow obstruction | Provides accurate placement of venous stents, gaining acceptance in percutaneous intervention for chronic venous iliofemoral disease. |
Venous Reflux:
| Term | Definition |
|---|---|
| Venous Reflux | Reverse flow of blood in a vein, typically due to malfunctioning valves, allowing blood to flow in the wrong direction. |
| Detection Position | Reverse Trendelenburg Position is commonly used for detecting venous reflux. |
| Diagnostic Maneuvers | - Valsalva Maneuver: Increases intra-abdominal pressure, evaluating flow characteristics and valve functions. - Augmentation: Compressing the calf to increase flow moving centrally. |
| Duration of Reflux | Brisk venous reflux is considered normal. Pathologic reflux is defined as: - Femoral or Popliteal Veins: > 1.0 second - Saphenous Systems: > 0.5 second - Perforators: > 0.35 second |
| Correlation with Symptoms | The duration of reflux does not always correlate with clinical symptoms or severity of the disease. |
Management Options:
| Therapy Type | Description |
|---|---|
| Conservative Management | 1. Initial treatment for all patients with signs and/or symptoms of Chronic Venous Insufficiency (CVI). 2. Mainstay is the use of compression stockings. 3. Encourages risk modification such as weight reduction, regular walking exercise, and smoking cessation. |
| Compression Stockings | 1. Provide graded external compression (Graduated compression stockings preferred) to the leg, counteracting venous hypertension. 2. Knee-length stockings better tolerated, especially by elderly patients. 3. Recommended pressure: - 20-30 mmHg for varicose veins (C2-C3), - 30-40 mmHg for advanced venous skin change or an ulcer (C4-C6), - 40-50 mmHg for recurrent ulcers. 4. Primary therapeutic modality for healing venous ulcers. 5. Non compliance due to: - Application difficulty (frailty or arthritis), - Physical constraints (obesity, contact dermatitis, tender, fragile, or weepy skin), and - Coexisting arterial insufficiency |
| Medical Therapy | 1. Venoactive drugs like - saponins (e.g., horse chestnut seed extract), - flavonoids (e.g., rutosides, diosmin, hesperidin), - micronized purified flavonoid fraction (MPFF), and - other plant extracts can be considered for symptomatic varicose veins, ankle swelling, and venous ulcers. 2. Evidence for global use is insufficient. |
| Pentoxifylline (400 mg orally three times a day) | 1. Targets inflammatory cytokine release, leukocyte activation, and platelet aggregation. 2. Used in combination with compression to improve healing rates of venous ulcers. 3. Higher dose more effective but may cause gastrointestinal upset. 4. Role in patient management is unclear. |
| Surgical Therapy | 1. Open surgical therapy involves high ligation and stripping of the Great Saphenous Vein (GSV) along with excision of large varicose veins. 2. Indicated for specific cases. 3. Complications include DVT, bleeding, hematoma, infection, and nerve injury. 4. Endo-venous ablation therapy has largely replaced this classic approach. |
| Stab Phlebectomy | 1. Involves removal or avulsion of varicose veins through small stab wounds or puncture holes. 2. Can be performed in conjunction with saphenous vein ablation. |
| Sclerotherapy | 1. Least invasive technique using chemical irritants to close unwanted veins. 2. Adverse events can occur with sclerotherapy. |
| Endovenous Thermal Ablation | 1. Involves either Endovenous Laser Ablation (EVLA) or Radiofrequency Ablation (RFA). Both guided by ultrasound. 3. Causes local thermal injury to the vein wall, leading to thrombosis and fibrosis. 2. Frequently used for GSV reflux, replacing surgical procedures due to reduced convalescence and pain. |
| Tumescent Anesthesia: 1. Required for endovenous thermal ablation. 2. Involves delivering high-volume but low-dose anesthetic to the perivenous area along the GSV. 3. Reduces pain, provides hemostasis, prevents burn and nerve damage, and enhances heat transmission. |
|
| Stent Implantation, Bypass Surgery, Valvuloplasty | 1. Considered for patients with chronic occlusions of the iliac vein with advanced CVI symptoms unresponsive to other therapies. 2. Surgical reconstruction of valves involves tightening or transfer procedures. |
2. Sclerotherapy: Treatment of Varicose and Telangiectatic Leg Veins 6th edition