Varicose veins are excessively dilated, tortuous superficial leg veins, with resultant pooling of blood. Varicose veins, in addition to phlebothrombosis and thrombophlebitis, make up at least 90% of significant venous disease (1).

 

Introduction

In normal veins in the leg, blood that is collected from the capillaries and superficial veins must be directed upwards, against the pull of gravity, in order to empty into the right atrium via the vena cavae. Apart from the muscular pump mechanism in the leg, which helps direct venous blood flow upwards, backflow of blood is usually prevented by one way valves. These valves are crucial components to preventing the development of varicose veins.

Anatomically speaking, blood from superficial veins are drained via perforator veins, which eventually drain into deeper veins underlying the fascia. Should a valve defect occur, the deep veins can usually withstand the imposed high pressures, caused by pooling of the blood. However, superficial veins are weaker and are thin-walled. Therefore, they succumb to the high pressures, which causes them to become dilated and tortuous. Hence, varicose veins form. 

 

 

Normal Vein vs. Varicose Vein

Classification of Chronic Venous Disease

Chronic venous disease, which includes varicose veins, can be classified into different categories and stages. Developed by the Committee of the American Venous Forum, the CEAP classification is an important method of assessing the severity and determining the course of treatment provided to the patient. The CEAP classification categorizes limbs with venous disease according to clinical signs (C), cause (E), location (A) and pathophysiology (P). Since cause, location and pathophysiology can be deduced through patient history and physical examination, the clinical signs category is the most important and widely used in everyday practice:

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Aetiology

1.   Simple orthostatic oedema:

Even in essentially normal superficial veins, varicose veins can arise due to sitting or standing in one position for extended periods of time.  In turn, the venous pressure in these veins are elevated markedly which can cause plasma fluid to leak into the interstitium.  

 

2.   Defective valve in sapheno-femoral junction:

Reflux through this valve directly increases pressure within the superficial venous system of the leg.

 

3.   Valvular insufficiency in perforating veins:

This is mainly due to the development of increased intraluminal pressure secondary to valvular insufficiency. Perforating veins link the high pressure deep venous system with the low pressure superficial veins. If valves in these veins are incompetent, high pressures are transmitted to the superficial veins. 

 

4.   A defect in the muscle pump system:

Thrombophlebitis leading to vessel wall/valve damage and reflux:

·         Stasis

·         Previous DVT (Deep Vein Thrombosis)

 

Direct mechanical damage to the vein and valves:

·         Trauma

·         Hereditary

·         Pregnancy

·         Obesity

 

5.   Pregnancy and women

This female disposition is thought to be a result of cyclical hormonal changes (oestrogen and progesterone). These changes lead to muscular and connective tissue dilatation, affecting the lower limb venous system. In pregnancy, direct compression of the IVC (inferior vena cava) by the foetus can lead to increased pressure and reflux.

 

6.   Family history:

A family history of varicose veins increases the individual's chances of also developing this disease.  This is due to the hereditary nature of acquiring weak venous valves, which contributes to the pathogenesis briefly discussed above.

 

Clinical Features

Risk Factors

  • Pregnant women
  • Old age
  • Family history
  • A sedentary lifestyle
  • Obesity
  • Prolonged standing

 

Signs and Symptoms

  • Visibly enlarged veins
  • Aching, worse on standing
  • Mild swelling of the ankles
  • Discomfort and restlessness
  • Pigmentation or discolouration of the surrounding skin
  • Itching
Varicose vein - long saphenous vein

 

 

Complications

  • Phlebitis, caused by chronic inflammation of the vein
  • Leg ulcers caused by venous insufficiency
  • Peripheral oedema
  • Rupture of the varicosity
  • Dermatitis if it is chronic and severe
  • Gangrene, in the disease's most severest form
  • Right heart failure

 

     

     

    Differential Diagnosis

    • Claudication
    • Superficial thrombophlebitis
    • Peripheral neuropathy
    • Cellulitis
    • Deep vein thrombosis

     

      History Taking and Physical Examination

      Investigations

      Not all patients will undergo investigation. In some centres diagnosis is made and surgery is performed based on a thorough patient history as well as a physical examination.  However some investigations include:

       

      • Colour Duplex ultrasound allowing accurate mapping of veins and venous blood flow in the leg prior to surgery.

       

      • Colour-flow imaging, in which doppler sounds are translated into coloured images that allows enhanced vision as well as interpretation of the affected vein. This method of investigation enables the clinician to accurately see valve leakages from some varicose veins.

       

      • The most common and convenient technique used is by Doppler imaging. A hand held Doppler is used to distinguish between a vein which has anterograde flow (flow that is in the correct upwards direction) and one that has a valve defect allowing retrograde flow (flow that is in the incorrect downwards direction). After a patient history and physical examination, the Doppler test should be used to confirm any suspicions concerning a potential varicose vein diagnosis.

       

        Management

        There are many ways to manage this disease. However, this depends on the severity of symptoms and patient choice:

         

        Conservative

        The patient puts up with the discomfort, alleviating the symptoms by resting and facilitating the healing process by elevation of the affected limb. Exacerbating factors as well as secondary complications, such as obesity, oedema and right heart failure, must be managed accordingly in order to relieve the patient's symptoms. Ulcers that have formed, as a result of variceal rupturing, must be kept clean to avoid infection and aid the healing process.

         

        Compression Stocking Support

        Compression stockings function by applying pressure over the affected area in a gradual way (pressure is greatest at the ankle than at the thigh), which helps blood flow upwards in the varicosed vein. Advantages include a non-invasive and painless alternative to surgery. On the other hand, compression stockings must be worn all the time in order for them to have any benefits. Therefore, patients often experience intolerable discomfort.

         

        Medical

        Injection of a sclerosing substance (hypertonic saline or sodium tetradecyl sulfate) into the varicosities causing endothelial damage, sclerosis and degradation of the vein. This solution degrades the endothelium of the vein, which causes the varicosed vein to swell. The vein then undergoes fibrosis and may eventually fade from view. This is only effective in mild cases. Sclerotherapy is done while the patient is standing – an elastic band is wrapped around the legs after the procedure. These injections do not work as effectively as surgery and have many side effects.

         

        Surgical

        • Vein-Stripping

        The surgeon makes a cut at the bottom (ankle end) and the top (groin end) of the varicose vein. A thin, plastic tube-like instrument is placed into the vein and tied around it. When the tube is pulled out, it pulls the vein from out under the skin. Small surgical cuts can also be made over individual veins to remove them. Bandages and stockings are worn afterwards. Occassionally, additional injections may be needed to get rid of any residual veins not dealt with by surgery.

         

        • Endovenous Ablation therapy

        This therapy uses heat to destroy vein tissue. A thin catheter (or tube) is inserted into the vein through a tiny skin incision under local anaesthetic. Then, using laser or radiowave (radiofrequency) energy, the vein is heated and cauterized closing off the vein. This procedure is less invasive than vein stripping with equal or better outcomes. Patients have significantly less pain and a quicker recovery.

         

        • Avulsion

        Surgical incisons or cuts are made over various regions of the leg where the varicose veins are. Then, forceps are used to extract the vein out of the leg.

         

        Prognosis

        If left untreated, varicose veins become even more dilated and tortuous. Eventually, the veins become lacerated and haemorrhagic. Even worse, gangrene may ensue, which would require amputation of the affected limb. Even though success rates are very high with surgical treatment, a ten year recurrence rate of 70% has been reported (2). An explanation as to why varicose veins can recur is due to the fact that venous branches can re-grow. These new branches can penetrate the scar tissue, as a result of the surgery, to connect with healthy superficial veins. 

         

        References

        1. Mitchell RN, Schoen FJ. Blood vessels. In: Kumar V et. al, editors. Robbins and cotran pathologic basis of disease. 8th ed. Philadelphia: Saunders Elsevier; 2010. p. 487-528.

        2. Winterborn RJ, Earnshaw JJ. Crossectomy and great saphenous vein stripping. J Cardiovasc Surg (Torino). 2006 Feb;47(1):19-33. [abstract].

        * Please note that this table has been adapted from (http://herkules.oulu.fi/isbn9514267230/html/i634880.html). Accessed 02/03/11. 

        Kind Permission for the clinical photograph of the leg with varicose veins has been obtained from Dr. David West. 

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