Varicose vein

Dilated, tortuous and elongated superficial veins of the limb are called Varicose veins

Types

Primary

Secondary

Due to congenital weakness in vein wall- defective

connective tissue and smooth

muscles

Pregnancy and

pelvic tumours proximal

obstruction to

blood flow

Due to muscular weakness or

congenital

absence of valves

Oral

contraceptive

pills- alter

viscosity of blood

Valves at

Sapheno- femoral junction

incompetent/

absent

Progesterone

dilates vessel wall

Absence of Valves at junction of

Superficial and deep veins

Congenital

arterio- venous fistula- increases blood flow

SYMPTOMS

Dilated veins in leg- usually getting sufficiently large by end of the day Dragging pain or dull ache- in leg due to heaviness

Usually relieved at night on taking rest or elevation of limbs

Night cramps- due to change in diameter of veins

At times, may present with ulceration, eczema, dermatitis and bleeding Also pruritis/ itching and skin thickening

If associated with sudden pain in calf with fever and edema of ankle- DVT. Signs

Inspection

Dilated, tortuous veins

A single dilated vein at Sapheno- femoral junction- Saphena Varix

Localised dilated segment of vein- indiaction of a blow out- site of underlying perforator

Ankle flare of group of veins near medial malleolus

Complications like ulcerations, bleeding, eczema and dermatitis Palpation

If tenderness- Thrombophlebitis

Tests :

Cough impulse / Morrissey’s test/ Fluid thrill- Saphenofemoral (SF) junction incompetence

Trendelenburg’s test- release pressure applied at SF junction

Sudden gush of blood from above downwards- Saphenofemoral junction incompetence

Slow filling of vein seen even on maintaining pressure at SF junction- Perforator Incompetence

Multiple tourniquet test- find exact site of perforator incompetence

Schwart’s test- palpable impulse on tapping the vein below- indicates a continuous column of blood in superficial vein

Modified Perthe’s- tourniquet at SF junction- patient asked to walk briskly- if severe pain- DVT

Treatment

Elastic compression stockings/ bandage and elevation of legs

Fundamental step

Usually 20- 30 mm Hg stocking pressure are sufficient

From ankle to below knee

To be worn during working hours (entire day)

Newer form “UNNA BOOTS”- special gauze bandage made of cotton and contains zinc oxide paste and calamine

Inner layer- roller gauze with calamine, zinc, glycerine

Middle layer- 4 inch wide continuous gauze compression

Outer layer- elastic wrap

Compression sclerotherapy (injection line of treatment)

Useful in varicose veins less than 3 mm in diameter

In below knee varicosity

Vein punctured with needle attached to syringe containing sclerosant agent causing aseptic thrombosis followed by fibrosis and shrinkage of vein

Then a tight elastic compression bandage is applied

Ultrasound guided foam sclerotherapy:

Foam sclerosant is used

Prepared by air mixing technique with sclerosant

Foam causes inflammation of vein wall- obliteration of venous lumen- vein occlusion

Advantage over compression sclerotherapy:

Foam displaces blood, so requires little quantity to be in touch with vein wall It is echogenic

If extravasated out of blood vessel, it is better tolerated.

Endovenous laser ablation (EVLA)

Minimally invasive out patient procedure using laser fibre to ablate varicose veins.

Catheter passed into great saphenous vein and positioned 1 cm distal to SF junction- followed by injecting tumescent anesthetic agent (which makes the wall firmer)

Then laser fibre is introduced till catheter tip and energy laser fired and compression bandage applied.

Radiofrequency ablation (RFA)

Using a bipolar catheter at a temperature of 85- 120⁰ C with 2- 4 W Procedure same as in EVLA