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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
  • Risks: age, female > male, previous DVT, obesity, pregnancy

Clinical features

Symptoms

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

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)
  • Saphena varix: dilation of the saphenous vein at its confluence with the femoral vein (transmits a cough impulse)

Investigations

  • Colour flow duplex ultrasound

Management

  • Refer if: bleeding, pain, ulceration, thrombophlebitis, severe impact on quality of life
  • Management options
    • Conservative: avoid prolonged standing, graduated compression stockings (if no peripheral arterial disease), regular walking, weight loss
    • Injection sclerotherapy: sclerosant injected at multiple sites in varicosities
    • Phlebectomy: stab avulsion or mechanical avulsion
    • Endovenous laser ablation
    • Radiofrequency ablation
    • Surgical stripping
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