Varicose veins

Varicose veins are tortuous, dilated veins of the superficial venous system.

Pathophysiology

• Incompetent valves in perforating veins cause retrograde blood flow from the deep to superficial veins of the leg
• This results in increased pressure and dilation of the superficial veins

Clinical features

Symptoms

• Most are asymptomatic except for aesthetic problems but patient may have pain, cramps, heaviness, tingling and restless legs

Signs

• Oedema
• Varicose eczema
• Venous ulcers
• Haemosiderin deposits
• Phlebitis
• Lipodermatosclerosis (subcutaneous fibrosis due to chronic inflammation and fat necrosis)
• Atrophie blanche (white scarring around healing ulcer)

Investigations

• Colour flow duplex ultrasound

Management

• Indications for vascular referral
  • Bleeding
  • Symptoms (e.g. pain, aching, discomfort, swelling, heaviness and itching)
  • Venous eczema/pigmentation,
  • Superficial vein thrombosis
  • Venous ulceration
• Management options
  • Conservative: avoid prolonged standing, graduated compression stockings (if no peripheral arterial disease), regular walking, weight loss
  • Endothermal ablation: radiofrequency ablation or endovenous laser ablation
  • Ultrasound‑guided foam sclerotherapy: sclerosant injected at multiple sites in varicosities
  • Surgical stripping

Reference: NICE ‘CG168 Varicose veins: diagnosis and management’ 2013

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