Varicose vein

Overview of Varicose vein

• Varicosity is the penalty for verticality against gravity.
• The blood has to flow from the lower limbs into the heart against gravity because of the upright posture of human beings.
• In many cases, varicose veins are asymptomatic.
• Raised intra-abdominal pressure also precipitates varicose veins, more commonly in females due to repeated pregnancy.
• The complications of varicose veins are responsible for hospitalization of the patient. [2]

Causes of Varicose vein

Varicosities are more common in lower limb because of erect posture and long column of blood has to be supported which can lead to weakness and incompetency of valves.

1.Primary varicosities due to i.e.:

• Congenital either incompetence or absence of valves.
• Weakness or wasting of muscles: defective connective tissue also smooth muscle in the venous wall.
• Stretching of deep fascia.
• Inheritance (family history) with FOXC2 gene.
• Klippel – Trenaunay syndrome.

2. Secondary varicosities i.e.:

• Recurrent thrombophlebitis,
• Occupational – standing for long hours (e.g. traffic police, guards).
• Obstruction to venous return like abdominal tumours, retroperitoneal fibrosis, lymphadenopathy.
• Pregnancy (due to progesterone hormone).
• AV malformations: Either Congenital or acquired.
• Iliac vein thrombosis. [1]

Risk factor of Varicose vein

• Height: Tall individuals suffer more
• Weight: Obesity may weaken vein wall
• Occupation: e.g. Hotel workers, police officers, shopkeepers, tailors
• Side: Left is comparatively affected more than the right
• Age and sex: Not very clear. [2]

Pathophysiology of Varicose vein

• Generally, Incompetence of venous valves causes stasis of blood.
• Furthermore, Chronic ambulatory venous hypertension causes defective microcirculation.
• So, RBC diffuses into tissue planes also lysis of RBC’s start.
• This leads to release of haemosiderin.
• It leads to Pigmentation, Dermatitis also Capillary endothelial
• Results in to Prevention of diffusion also exchange of nutrients causes severe
• Lastly, It leads to chronic venous ulceration.

Classification of Varicose vein

• Long saphenous vein varicosity.
• Short saphenous vein varicosity.
• Varicose veins due to perforator incompetence.
• Thread veins (or dermal flares/telangiectasias/spider
• veins are 0.5 – 1 mm in size): Are small varices in the skin usually around ankle which look like dilated,
• Red or purple network of veins.
• Reticular varices (1-3 mm in size): Are slightly larger
• Varices than thread veins located in subcutaneous region.
• Combinations of any of above.

Small varicose vein is < 3 mm in diameter.

Large varicose vein is > 3 mm in diameter. [1]

Sign & Symptoms of Varicose vein

Symptoms:

• Majority of the patients present with dilated veins in the leg.
• They are minimal to start with and at the end of the day they are sufficiently large because of the venous engorgement.
• Dragging pain in the leg or dull ache is due to heaviness.
• Night cramps occur due to change in the diameter of veins.
• Aching pain is relieved at night on taking rest or elevation of limbs.
• Sudden pain in the calf region with fever and Oedema on the ankle region suggests deep vein thrombosis.
• Patients can present with ulceration, eczema, dermatitis and bleeding.
• Symptoms of pruritus/itching and skin thickening. [2]

Signs:

Inspection (should be done in standing position)

• Dilated veins are present in the medial aspect of leg and the knee. Sometimes they are visible in the thigh also.
• Single dilated varix at SF junction is called saphenous varix. It is due to saccular dilatation of the upper end of long saphenous vein at the saphenous opening.
• Veins are tortuous and dilated.
• A localized, dilated segment of the vein, if present, is an indication of a blowout. It signifies underlying perforator.
• Ankle flare is a group of veins near the medial malleolus.
• Complications such as ulceration, bleeding, eczema and dermatitis may be present.
• Healed scar indicates previous ulceration.
• Look at the popliteal fossa region also.

Palpation

• First palpate along the whole length of vein. Look for tenderness. If present, it indicates thrombophlebitis.
• Vein which is thrombosed will feel as a firm/hard nodule. [2]

Clinical / Physical Examination For Varicose vein

1. Cough impulse test (Morrissey’s test):

• This test should be done in the standing position.
• The examiner keeps the finger at SF junction and asks the patient to cough.
• Fluid thrill, an impulse felt by the fingers, is indicative of ‘saphenofemoral incompetence’.

2. Trendelenburg test:

• This test is done in 2 parts.

Method:

• The patient is asked to lie on the couch in the supine position.
• The leg is elevated above the level of heart and the vein emptied.
• SF junction is occluded with the help of the thumb (or a tourniquet) and the patient is asked to stand.

Trendelenburg I i.e.:

• Release the thumb or tourniquet immediately.
• Rapid gush of blood from above downwards indicates saphenofemoral incompetence.

Trendelenburg II i.e.:

• The pressure at the SF junction is maintained without releasing the thumb or tourniquet.
• The patient is then asked to stand.
• Slow filling of the long saphenous is seen. It is due to per/orator incompetence (retrograde flow of blood).

3. Multiple Tourniquet test:

• It is done to find out exact site of perforators

Method i.e.:

• The patient is asked to lie supine on the couch.
• The vein is emptied by elevation.
• As the name suggest 3-5 tourniquets (multiple) can be applied.
• However, more tourniquets are applied, the exact localization c the perforators can be made out but it is not practical.
• There are mainly ankle, knee and thigh perforatons.
• Hence, four tourniquets can be applied at various level as mentioned below.
• 1st Tourniquet: At the level of saphenofemoral junction (SF junction).
• 2nd Tourniquet: At the level of middle of the thigh, t, occlude perforator in the Hunter’s canal.
• 3rd Tourniquet: Just below the knee.
• 4th Tourniquet: Palm breadth (lower third of the leg above medial malleolus/ankle.
• Ask the patient to stand and observe appearance of veins

Inference i.e.:

• Appearance of veins between first and second tourniquets indicates incompetence of thigh perforators between second and third indicates incompetence of knee, perforators and below the fourth tourniquet indicates incompetence of ankle perforators.
• Most commonly, below knee and ankle perforators are incompetent.
• On releasing the tourniquets one by one from be upwards, sudden retrograde filling of the veins occurs.

4. Schwartz test:

• It is done with the patient in the standing position.
• Place the fingers of the left hand over a dilated segment of the vein and with the right index finger tap the vein below.
• A palpable impulse suggests a superficial column of blood in the vein and it also suggests incompetence of the valves in between the segment of the vein.

5. Modified Perthes’ test:

• It done to rule out deep vein thrombosis.
• The patient ask to stand, the tourniquet is applied at SF junction and he ask to have a brisk walk.

Inference i.e.:

• If the patient complains of severe pain in calf region or if superficial veins become more prominent, it is an indication of deep vein thrombosis and is a contraindication for surgery.

6. Fegan’s method (test):

• It done to detect the site of perforators.
• The patient ask to stand. The varicosity is marked with methylene blue and he is asked to lie down.
• The leg elevate to empty the vein and the vein palpate throughout its course.
• The defects in the deep fascia have a circular, buttonhole consistency. [2]

Investigation of Varicose vein

Hand held Doppler i.e.:

• It is the first, mm1mum level investigation to do before treating a patient with venous disease.
• When the blood flows, the wave emits a signal – the Doppler signal.
• If there is SF incompetence, fo1ward and backward flow can detect.
• Biphasic signal: Gently squeeze calf muscles and the flow can assess by Doppler probe in the SF junction.
• It can also pick up accessory long saphenous vein in the groin.
• It is not an investigation to identify the perforators.

Duplex ultrasound imaging i.e.:

• In this investigation high resolution B-mode ultrasound imaging and Doppler ultrasound use.
• It helps in getting images of veins, measure flow in all lower limb veins.
• Origin of venous ulcers and varicose veins can also assess.

Venography i.e.:

• Both ascending and descending venography can done in a case of deep vein thrombosis.
• It is an invasive procedure and risk of spreading infection and septicemia is present.
• Duplex ultrasonography has largely replaced this investigation (rarely done now).
• Varicography refers to injecting contrast into surface veins (indicated in recurrent varicose veins).
• It can follow by sclerosant injections.

Plethysmography i.e.:

• They base on measurement of volume changes in the leg.
• By placing a light-emitting diode above medial malleolus and patient performing tiptoe movements, venous recovery time can measure.
• This call phot plethysmography (PPT). [2]

Differential Diagnosis of Varicose vein

• Lymphoedema
• A-V malformation
• Orthostatic Oedema
• Renal and cardiac disease
• Hepatic causes
• Vasculitis
• Metabolic diseases like gout, myxedema, and morbid obesity
• Chronic infections like tuberculosis, syphilis. [1]

Treatment of Varicose vein

Elastic compression stockings:

• Elastic compression bandage and elevation of leg.
• It forming the fundamental steps in treating varicose veins.
• This can advise in asymptomatic cases of varicose veins and 1r secondary varicose veins.
• Usually, 20-30 mmHg stockings are sufficient.
• It should worn from ankle to below knee.
• It should worn during working hours (entire day).
• Should remove while lying down but legs should be kept elevated.
• Unna boot i.e.: It is a three-layered dressing.
• Inner layer i.e.: It contains roller gauze bandage impregnated with calamine, zinc, glycerine, etc. with graded compression.
• Middle layer i.e.: 4″ wide continuous gauze dressing
• Outer layer i.e.: Elastic wrap with graded compression.
• Pneumatic compression devices not commonly used.

Injection line of treatment (compression sclerotherapy)

Indications

• Basically, Below knee varicosity.
• Moreover, Recurrent varicosity after surgery.
• Varicose veins mark in the standing position.
• The veins puncture with a needle attached to a syringe containing sclerosant agent also the patient ask to lie down.
• 3% sodium tetradecyl sulphate or 1-2 ml of ethanolamine oleate or hypertonic saline inject into the column of vein.
• Aseptic thrombosis occurs also when fibrosis occurs, the vein shrinks.
• Tight elastic compression bandage apply.
• Success of sclerotherapy depends upon effective sclerosant, injection into an empty vein and compression followed especially by exercise.

Ultrasound-guided foam sclerotherapy.

• It is popular in a few centers in the UK only.
• Foam sclerosant C (Polidocanol) use. It prepare specifically by air mixing technique with sclerosant.
• It inject into veins (superficial) under ultrasound guidance.
• LSV should compress in the upper thigh to prevent foam from entering into femoral vein.
• Elevate the leg to prevent foam from entering into calf veins.

Endovenous laser ablation (EVLA) Introduction:

• It is a minimally invasive, outpatient procedure using laser fibre to ablate varicose veins.
• This gives excellent cosmetic and functional results.

Radiofrequency ablation (RFA):

• It is also a minimally invasive technique of ablation of the veins by using a two minds catheter at a temperature of 85- 1200C, using a power of2-4 W.
• The position of the patient, accurate marking of the veins, tumescent anaesthesia, are similar to that of EVLA.
• However, the vein cannulate with a 7F sheath and catheter is not positioning within 2 cm of the SF junction.
• Segment of the vein over 7 cm long can ablate.
• Complications include thrombophlebitis, pain, skin bums

Surgery:

• Trendelenburg’s operation:
• An inguinal incision made, long saphenous vein identified and the 3 tributaries ligate.
• Long saphenous vein ligate close to the femoral vein juxta femoral flush ligation.
• Sub fascial ligation of Cockett and Dodd
• In this operation, the perforators identify deep to deep fascia and ligate subfascially.
• This indicate in cases of perforator incompetence with saphenofemoral competence.
• This can also done using an endoscope.
• Sub fascial endoscopic perforator surgery (SEPS) :
• Small port incisions make in the skin of calf region, deepened through the fascia.
• Carbon dioxide insufflation done.
• A balloon expander may also use to distend the sub fascial plane.
• 2-6 perforators identify and ligate.
• The procedure is simple, quick with least morbidity and is becoming popular.
• Indicated for below knee perforators. [2]

Prevention of Varicose vein

• Patients with normal deep veins should offer treatment to obliterate any sites of saphenous or perforator reflux.
• Elastic stockings should prescribe for all patients with evidence of post-thrombotic deep vein damage and these remain an alternative treatment for patients with superficial venous disease who decline intervention. [3]

Diet & Regimen of Varicose vein

• Take rest with leg elevated above heart level.
• Apply compression stockings.
• Should lose weight. [2]