Varicose Veins Investigation and Management

Investigation

Doppler/Duplex Scan

• Evaluates blood flow and directional cues (red = away from heart, blue = toward heart).
• Detects reflux: superficial vein reflux is considered if retrograde flow lasts more than 0.5 seconds.

Management

Adjunctive Management

• Compression Garments:

  • Class III (25-35 mmHg) recommended.
  • Challenges include low compliance and limited pressure due to concurrent arterial disease (reduced Ankle-Brachial Pressure Index).

• Horse Chestnut Seed Extract:

  • Safe for chronic venous hypertension; alleviates symptoms and reduces leg swelling.

Tests

• Trendelenburg Test: Assesses venous incompetence; gradual filling indicates incompetent perforators, while rapid filling points to superficial femoral junction (SFJ) incompetence.
• Fegan's Method: Involves palpating the vein and marking areas of reflux to identify incompetent perforators.
• Morrisey's Cough Impulse: Cough impulse at SFJ indicates incompetency.
• Multiple Tourniquet Test: Used to localize incompetent perforators by observing dilatation between tourniquets.
• Modified Perthes Test: Rules out Deep Vein Thrombosis (DVT) based on pain and swelling response when walking post-tourniquet application.

Types of Varicose Veins

• Primary Varicose Veins: Caused by defective valves.
• Secondary Varicose Veins: Often due to deep vein thrombosis (DVT) or tumors.
• Risk Factors: Prolonged standing, gender (more common in females), family history, pregnancy.

Pathophysiology

• Normal Physiology: Venous return is aided by gravity, thoracic pressure changes during inspiration, muscle compression, and exercise.
• Pathology: Increased pressure in superficial veins with exercise leads to ambulatory venous hypertension.

Clinical Features

• Dilated Veins:
  • Varicose veins >3mm diameter; reticular veins 1-3mm; thread veins ≤1mm.
• Symptoms: Dull, aching pain, and pigmentation due to hemosiderin deposits.

Anatomy of Superficial Veins

• Great Saphenous Vein (GSV): Originates from the medial end of the dorsal venous arch; closely associated with the saphenous nerve; drains into the sapheno-femoral junction.
• Short Saphenous Vein (SSV): Emerges from the dorsal venous arch and drains into the sapheno-popliteal junction.

Perforator Veins

• Connect superficial and deep venous systems; approximately 100-150 perforators exist.
• Notable perforators include:
  • Hunterian (Thigh)
  • Dodd's (Above knee)
  • Boyd's (Below knee)
  • Cockett's (Above medial malleolus)

CEAP Classification

• Clinical: Ranges from no visible veins (Co) to active venous ulcers (C6).
• Etiological: Categories include congenital, primary, secondary (post-thrombotic).
• Anatomical: Classifies based on vein location - superficial, perforator, deep.
• Pathophysiological: Involves reflux, obstruction, or a combination.

Clinical Tests

• SFJ incompetence: Trendelenburg test, Morrisey's cough impulse.
• Perforator incompetence: Trendelenburg, multiple tourniquet test, Fegan's method.
• DVT assessment: Modified Perthes test.

Treatment Modalities

• Endovenous Laser Therapy (EVLT): Utilizes a 1470 nm laser; generates heat to close veins; demands catheter withdrawal for vein collapse.
• Radiofrequency Ablation (RFA): Operates at 120°C for 20 seconds; easier learning curve as continuous pull-back isn't needed.
• Dodd and Cockett Procedure: Involves multiple ligation of incompetent perforators.
• Sub-fascial Endoscopic Perforator Surgery (SEPS): Enables ligation of multiple perforators via a single incision.
• Foam Sclerotherapy: Sclerosants create an inflammatory response to collapse veins; can involve sodium tetradecyl sulfate, polidocanol, etc.

Complications of Varicose Vein Surgery

• Common complications include infection, bruising, recurrence, bleeding, and nerve injuries (most frequent being to the saphenous and sural nerves).
• Risk of marjolin's ulcer from long-standing venous ulcers.

Venous Ulcers

• Typical Sites: Primarily found in the gaiter area (above medial malleolus), also above lateral malleolus.
• Characteristics: Shallow, sloping edges, pale granulation tissue; not healing, with pigmented margins.

Management of Venous Ulcers

• Limb elevation, education on care, and the use of compression stockings (grade III).
• Surgical interventions and the administration of pentoxyphylline to enhance microvascular perfusion.

Associated Syndromes

• Klippel-Trenaunay Syndrome: Absent deep veins with varicose vein development; typically non-surgical management.
• Parkes-Weber Syndrome: Multiple arteriovenous fistulas leading to limb hypertrophy and potential cardiac failure.

This quiz covers the assessment techniques for varicose veins, including Doppler and Duplex scans, along with management strategies like compression garments. Test your knowledge on the flow direction, reflux characteristics, and adjunctive management options for dealing with varicose veins.