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Varicose veins
VASCULAR
Secondary varicose veins (5%) occur when the increased venous pressure in the superficial venous system is due to a disturbance in venous blood flow elsewhere, for example in: • pelvic thrombosis • extensive thrombosis of the veins in the leg • arterioveonus malformations (congenital or acquired as a result of a fracture).
Varicose veins Matthew Metcalfe Daryll Baker
Diagnosis Clinical features The clinical features of varicose veins are due to their symptoms or their complications.
Definitions
Varicose vein symptoms are associated with a low morbidity, but can affect quality of life. Treatment is therefore dependent on the patient’s perception of the disruption that they cause, that is: • aching (dull heaviness or fullness in the leg, relieved by elevation) • unsightly appearance • itching and throbbing • swelling of the ankle or leg.
Varicose veins (Figure 1) are abnormal tortuous dilated superficial veins that usually affect the legs. Reticular veins are prominent normal superficial veins that do not usually vary in thickness. Thread (spider) veins are fine, thin cutaneous veins that have a diameter of about 1 mm.
Epidemiology
Varicose vein complications may be associated with significant morbidity and therefore intervention is usually considered. Bleedingg can occur when a large varicosity is traumatised or spontaneously from the ankle; can be severe. Superficial thrombophlebitis is a sterile inflammation of the vein wall due to local thrombosis. Initially it presents as red, warm, very tender skin. Treatment is oral and topical NSAIDS and compression stockings. It eventually settles to leave a firm, non-tender cord (Figure 2). Causes of superficial thrombophlebitis include malignancy and connective tissue disorders. Venous hypertensive skin changes (Figure 3) occur mainly in the gaiter area, including: • lipodermatosclerosis (diffuse fibrosis of subcutaneous tissues accentuated by fat necrosis and chronic inflammatory changes); leads to areas of hard tissue in which veins form large, hollow grooves
Varicose veins and their complications account for 500,000 GP consultations per year in the UK; 10% of these will require hospital treatment. Fifty percent of subjects aged >50 years have signs of venous disease in their legs and 50% of these have true varicose veins. The incidence increases with increasing age and, although equally distributed between the sexes, more women than men present (ratio is 5:1). Varicose veins in the leg are more common in Caucasians than other races and are associated with: • a strong family history • obesity • pregnancy • the oral contraceptive pill • hormone replacement therapy (possible) • occupations that result in standing for long periods.
Aetiology Primary varicose veins (95%) are caused by an increase in venous pressure in the superficial veins of the leg due to damage to the venous valves between the deep and superficial venous systems. This increase may be at: • the sapheno-femoral junction between the long saphenous vein and the common femoral vein in the groin • the sapheno-popliteal junction between the short saphenous vein and the popliteal vein in the popliteal fossa • other sites (when they are known as perforators).
Matthew Metcalfe is a Clinical Research Registrar at the Royal Free Hospital, London, UK.
Large trunk varicose veins.
Daryll Baker is a Consultant Vascular Surgeon at the Royal Free Hospital, London, UK.
SURGERY 22:12
1
321
© 2004 The Medicine Publishing Company Ltd
VASCULAR
• pigmentation deposits of haemosiderin in the skin resulting from degraded extravasated erythrocytes • ulceration caused by chronic venous hypertension; as areas attempt to heal, the surrounding areas show a white scarring (atrophie blanche) • eczema (often without frank ulceration).
This is confirmed using MRI venography and plethesmography (occasionally). Indications The indications depend on patient wishes and symptoms. Varicose vein symptoms • The decision to operate is highly dependent on the impact of symptoms on quality of life. • All symptoms (apart from cosmetic improvement) can be managed by wearing graduated compression stockings (see below). • Varicose vein surgery (see below) will not remove thread or reticular veins; microsclerotherapy or cutaneous laser treatment can be undertaken. • Surgery is indicated only for current symptoms and not as prophylaxis against development or progression of symptoms. • Surgery requires general anaesthesia and has a risk of complications. Sclerotherapy for true varicose veins is not undertaken because the recurrence rate is high.
Investigations Investigations should be undertaken only if treatment is indicated. Investigations aim to answer three questions. • What is the site of incompetence between the deep and superficial venous systems? Identification is by the hand-held Doppler flowmeter or Duplex ultrasound. • Is the deep venous system patent? Removal of the superficial venous system when the deep system is not patent will markedly worsen venous hypertension. Identification is with Duplex ultrasound. • Are the pelvic and abdominal veins (the venous outflow) patent?
Complications of varicose veins: surgery should be considered in this group, but they are usually an older age group and often have comorbidity, which increases the anaesthetic risk. Hence, graduated compression stockings may be an alternative. For patients with ulceration, varicose vein surgery should be considered especially if the deep venous system is not diseased (Figure 4). Surgery should be avoided in patients with varicose veins that arise from unusual causes (e.g. venous malformations). Treatment Graduated compression stockings can cover the entire thigh or below the knee, both levels will relive symptoms. The degree of compression selected depends on the symptoms and compliance. Compliance can be difficult because they must be worn continuously when not in bed. Patients with arthritis have difficulty in putting them on, and others find them unsightly. The stockings must be replaced every six months.
2 Established superficial thrombophlebitis that is no longer painful, but remains as a firm cord and from which haemosiderin pigmentation has eluted to stain the skin.
2 Superficial thrombophlebitis.
SURGERY 22:12
3 Varicose veins associated with venous hypertensive skin changes in the gaiter area. Venous eczema and haemosiderin pigmentation are seen; the subcutaneous tissue is beginning to thicken into lipodermatosclerosis. The prominent varicosity seen centrally is likely to be a perforating vessel.
4 Female with an occluded inferior cava. Venous return is ensured only by dilated varicosed superficial abdominal veins.
322
© 2004 The Medicine Publishing Company Ltd
VASCULAR
Surgery is performed usually under general anaesthesia (as a day case or overnight stay). An incision over the site of deep to superficial venous system incompetence (usually the groin or popliteal fossa) is made and the superficial vein divided. For saphenofemoral junction incompetence, the long saphenous vein is stripped from the groin to the knee, which reduces the recurrence rate. Several new developments to replace stripping the long saphenous vein have been made (Figure 5), but most have not been subject to randomized clinical trials. For example, the long saphenous vein can be ablated by inducing in situ thrombosis by heat produced from a laser or radiofrequency catheter passed up along the vein. Alternatively, ablation of the vein can be achieved by passing foam into it. An advantage of these techniques is that the procedure can be done under local anaesthesia and a groin incision is avoided.
6 Thread veins.
Phlebectomies are undertaken by making small incisions over the varicose vein. The varicosity is avulsed using a crochet hookshaped instrument and the leg is bandaged postoperatively. If there are marked skin changes around the ankle and perforator veins have been identified in this region by duplex scanning, these vessels are divided by passing a scope under the fascia deep to the altered skin area. This skin is undisturbed and healing is not adversely affected (as it would have been if skin had been cut).
patients. Sural nerve damage during ligation of the short saphenous vein in the popliteal fossa may also produce neuropraxia. Recurrence – there is a 20% chance of developing further varicose veins within five years. Postoperative care: graduated compression stockings or bandages are worn day and night for 7–10 days; thereafter they are worn only during the day for one month. Oral analgesics are given and the patient should sit with his feet elevated (so that heels are higher than hips). A walk of a few hundred yards three times a day is advised; the patient should return to work and driving within ten days of surgery. Swimming and cycling are allowed after the dressings have been removed.
Complications of surgery Bleeding – a small amount of blood may ooze from the wounds during the first 12 hours. This usually stops spontaneously, especially if the wound is pressed for ten minutes. Bruising is variable, but clears within three weeks. Large wound haematomas are rare. Healing fibrosis can produce firmness under the operation scars or in the line of the removed veins. A wound infection must be excluded if there is associated swelling, redness and tenderness. Wound infections – although the wound is often erythematous at one week, the prevalence of a true wound infection is about 1%. Neuropraxia – numbness over phlebectomy sites is common and temporary. True permanent neuropraxia over the skin supplied by the saphenous nerve (which is damaged while stripping the long saphenous vein or during a phlebectomy) may occur in 5–10% of
Reticular and thread veins Reticular and thread veins (Figure 6) look unsightly. They do not produce the symptoms of varicose veins, but often co-exist with them. Most women have such vessels on their legs, with visability dependent on skin colour. Treatment Treatment is undertaken after true varicose veins have been managed. Sclerotherapy is used to treat reticular veins and larger thread veins. After a good draw back of blood has confirmed intravenous positioning, a sclerosing agent (e.g. sodium tetradecyl sulphate, polidocanol, hypertonic saline, chromated glycine) is injected (via a fine-gauge hypodermic needle) into the vein. Complications include haemosiderin skin staining at the site of sclerotherapy, and small local ulceration (also due to the sclerosant passing into surrounding tissues). Allergic reactions to the sclerosant are rare; the development of further veins is likely. Laser therapy is used to treat thread veins <1 mm in diameter. Pulses of laser (595–600 nm) cause the blood in the vein to coagulate. The vessel is then gradually degraded and the veins cleared. The process takes 3–4 months.
5 New techniques of ablating the long saphenous vein are being developed. In this case, the long saphenous vein is cannulated and a laser probe is passed up to the saphenofemoral junction. The laser is then slowly withdrawn and the heat from this causes the vein to thrombose and occlude.
SURGERY 22:12
323
© 2004 The Medicine Publishing Company Ltd
Secondary varicose veins (5%) occur when the increased venous pressure in the superficial venous system is due to a disturbance in venous blood flow elsewhere, for example in: • pelvic thrombosis • extensive thrombosis of the veins in the leg • arterioveonus malformations (congenital or acquired as a result of a fracture).
Varicose veins Matthew Metcalfe Daryll Baker
Diagnosis Clinical features The clinical features of varicose veins are due to their symptoms or their complications.
Definitions
Varicose vein symptoms are associated with a low morbidity, but can affect quality of life. Treatment is therefore dependent on the patient’s perception of the disruption that they cause, that is: • aching (dull heaviness or fullness in the leg, relieved by elevation) • unsightly appearance • itching and throbbing • swelling of the ankle or leg.
Varicose veins (Figure 1) are abnormal tortuous dilated superficial veins that usually affect the legs. Reticular veins are prominent normal superficial veins that do not usually vary in thickness. Thread (spider) veins are fine, thin cutaneous veins that have a diameter of about 1 mm.
Epidemiology
Varicose vein complications may be associated with significant morbidity and therefore intervention is usually considered. Bleedingg can occur when a large varicosity is traumatised or spontaneously from the ankle; can be severe. Superficial thrombophlebitis is a sterile inflammation of the vein wall due to local thrombosis. Initially it presents as red, warm, very tender skin. Treatment is oral and topical NSAIDS and compression stockings. It eventually settles to leave a firm, non-tender cord (Figure 2). Causes of superficial thrombophlebitis include malignancy and connective tissue disorders. Venous hypertensive skin changes (Figure 3) occur mainly in the gaiter area, including: • lipodermatosclerosis (diffuse fibrosis of subcutaneous tissues accentuated by fat necrosis and chronic inflammatory changes); leads to areas of hard tissue in which veins form large, hollow grooves
Varicose veins and their complications account for 500,000 GP consultations per year in the UK; 10% of these will require hospital treatment. Fifty percent of subjects aged >50 years have signs of venous disease in their legs and 50% of these have true varicose veins. The incidence increases with increasing age and, although equally distributed between the sexes, more women than men present (ratio is 5:1). Varicose veins in the leg are more common in Caucasians than other races and are associated with: • a strong family history • obesity • pregnancy • the oral contraceptive pill • hormone replacement therapy (possible) • occupations that result in standing for long periods.
Aetiology Primary varicose veins (95%) are caused by an increase in venous pressure in the superficial veins of the leg due to damage to the venous valves between the deep and superficial venous systems. This increase may be at: • the sapheno-femoral junction between the long saphenous vein and the common femoral vein in the groin • the sapheno-popliteal junction between the short saphenous vein and the popliteal vein in the popliteal fossa • other sites (when they are known as perforators).
Matthew Metcalfe is a Clinical Research Registrar at the Royal Free Hospital, London, UK.
Large trunk varicose veins.
Daryll Baker is a Consultant Vascular Surgeon at the Royal Free Hospital, London, UK.
SURGERY 22:12
1
321
© 2004 The Medicine Publishing Company Ltd
VASCULAR
• pigmentation deposits of haemosiderin in the skin resulting from degraded extravasated erythrocytes • ulceration caused by chronic venous hypertension; as areas attempt to heal, the surrounding areas show a white scarring (atrophie blanche) • eczema (often without frank ulceration).
This is confirmed using MRI venography and plethesmography (occasionally). Indications The indications depend on patient wishes and symptoms. Varicose vein symptoms • The decision to operate is highly dependent on the impact of symptoms on quality of life. • All symptoms (apart from cosmetic improvement) can be managed by wearing graduated compression stockings (see below). • Varicose vein surgery (see below) will not remove thread or reticular veins; microsclerotherapy or cutaneous laser treatment can be undertaken. • Surgery is indicated only for current symptoms and not as prophylaxis against development or progression of symptoms. • Surgery requires general anaesthesia and has a risk of complications. Sclerotherapy for true varicose veins is not undertaken because the recurrence rate is high.
Investigations Investigations should be undertaken only if treatment is indicated. Investigations aim to answer three questions. • What is the site of incompetence between the deep and superficial venous systems? Identification is by the hand-held Doppler flowmeter or Duplex ultrasound. • Is the deep venous system patent? Removal of the superficial venous system when the deep system is not patent will markedly worsen venous hypertension. Identification is with Duplex ultrasound. • Are the pelvic and abdominal veins (the venous outflow) patent?
Complications of varicose veins: surgery should be considered in this group, but they are usually an older age group and often have comorbidity, which increases the anaesthetic risk. Hence, graduated compression stockings may be an alternative. For patients with ulceration, varicose vein surgery should be considered especially if the deep venous system is not diseased (Figure 4). Surgery should be avoided in patients with varicose veins that arise from unusual causes (e.g. venous malformations). Treatment Graduated compression stockings can cover the entire thigh or below the knee, both levels will relive symptoms. The degree of compression selected depends on the symptoms and compliance. Compliance can be difficult because they must be worn continuously when not in bed. Patients with arthritis have difficulty in putting them on, and others find them unsightly. The stockings must be replaced every six months.
2 Established superficial thrombophlebitis that is no longer painful, but remains as a firm cord and from which haemosiderin pigmentation has eluted to stain the skin.
2 Superficial thrombophlebitis.
SURGERY 22:12
3 Varicose veins associated with venous hypertensive skin changes in the gaiter area. Venous eczema and haemosiderin pigmentation are seen; the subcutaneous tissue is beginning to thicken into lipodermatosclerosis. The prominent varicosity seen centrally is likely to be a perforating vessel.
4 Female with an occluded inferior cava. Venous return is ensured only by dilated varicosed superficial abdominal veins.
322
© 2004 The Medicine Publishing Company Ltd
VASCULAR
Surgery is performed usually under general anaesthesia (as a day case or overnight stay). An incision over the site of deep to superficial venous system incompetence (usually the groin or popliteal fossa) is made and the superficial vein divided. For saphenofemoral junction incompetence, the long saphenous vein is stripped from the groin to the knee, which reduces the recurrence rate. Several new developments to replace stripping the long saphenous vein have been made (Figure 5), but most have not been subject to randomized clinical trials. For example, the long saphenous vein can be ablated by inducing in situ thrombosis by heat produced from a laser or radiofrequency catheter passed up along the vein. Alternatively, ablation of the vein can be achieved by passing foam into it. An advantage of these techniques is that the procedure can be done under local anaesthesia and a groin incision is avoided.
6 Thread veins.
Phlebectomies are undertaken by making small incisions over the varicose vein. The varicosity is avulsed using a crochet hookshaped instrument and the leg is bandaged postoperatively. If there are marked skin changes around the ankle and perforator veins have been identified in this region by duplex scanning, these vessels are divided by passing a scope under the fascia deep to the altered skin area. This skin is undisturbed and healing is not adversely affected (as it would have been if skin had been cut).
patients. Sural nerve damage during ligation of the short saphenous vein in the popliteal fossa may also produce neuropraxia. Recurrence – there is a 20% chance of developing further varicose veins within five years. Postoperative care: graduated compression stockings or bandages are worn day and night for 7–10 days; thereafter they are worn only during the day for one month. Oral analgesics are given and the patient should sit with his feet elevated (so that heels are higher than hips). A walk of a few hundred yards three times a day is advised; the patient should return to work and driving within ten days of surgery. Swimming and cycling are allowed after the dressings have been removed.
Complications of surgery Bleeding – a small amount of blood may ooze from the wounds during the first 12 hours. This usually stops spontaneously, especially if the wound is pressed for ten minutes. Bruising is variable, but clears within three weeks. Large wound haematomas are rare. Healing fibrosis can produce firmness under the operation scars or in the line of the removed veins. A wound infection must be excluded if there is associated swelling, redness and tenderness. Wound infections – although the wound is often erythematous at one week, the prevalence of a true wound infection is about 1%. Neuropraxia – numbness over phlebectomy sites is common and temporary. True permanent neuropraxia over the skin supplied by the saphenous nerve (which is damaged while stripping the long saphenous vein or during a phlebectomy) may occur in 5–10% of
Reticular and thread veins Reticular and thread veins (Figure 6) look unsightly. They do not produce the symptoms of varicose veins, but often co-exist with them. Most women have such vessels on their legs, with visability dependent on skin colour. Treatment Treatment is undertaken after true varicose veins have been managed. Sclerotherapy is used to treat reticular veins and larger thread veins. After a good draw back of blood has confirmed intravenous positioning, a sclerosing agent (e.g. sodium tetradecyl sulphate, polidocanol, hypertonic saline, chromated glycine) is injected (via a fine-gauge hypodermic needle) into the vein. Complications include haemosiderin skin staining at the site of sclerotherapy, and small local ulceration (also due to the sclerosant passing into surrounding tissues). Allergic reactions to the sclerosant are rare; the development of further veins is likely. Laser therapy is used to treat thread veins <1 mm in diameter. Pulses of laser (595–600 nm) cause the blood in the vein to coagulate. The vessel is then gradually degraded and the veins cleared. The process takes 3–4 months.
5 New techniques of ablating the long saphenous vein are being developed. In this case, the long saphenous vein is cannulated and a laser probe is passed up to the saphenofemoral junction. The laser is then slowly withdrawn and the heat from this causes the vein to thrombose and occlude.
SURGERY 22:12
323
© 2004 The Medicine Publishing Company Ltd