This document provides a summary of varicose veins including: - Incidence rates that are higher in women and industrialized countries - Risk factors such as family history, pregnancy, prolonged standing, and obesity - Presentation with dilated, tortuous veins and possible complications like eczema or ulcers - Examination techniques including looking for varicose veins while standing and using tests like cough impulse and Doppler ultrasound - Treatment options ranging from compression stockings and sclerotherapy to surgical procedures like vein stripping

1. Sarantos Kaptanis [email_address] Airedale General Hospital Department of Surgery Teaching Session 27 August 2009

2. “ In A Surgeon's Gown (Good) Physicians May Make Some Progress” Incidence Age Sex Geography Genetics Predisposing factors Macroscopic appearance Microscopic appearance Spread Prognosis: mortality and complications

3. 25-50% of adult women 15-30% of adult men Is it an industrialized country disease? UK: 45 000 hospital admissions per year Patrick H. Carpentier, Hildegard R. Maricq, Christine Biro, Claire O. Poncot-Makinen, Alain Franco, Prevalence, risk factors, and clinical patterns of chronic venous disorders of lower limbs: A population-based study in France, Journal of Vascular Surgery, Volume 40, Issue 4, October 2004, Pages 650-659, ISSN 0741-5214, DOI: 10.1016/j.jvs.2004.07.025. Coon WW, Willis PW III, Keller JB. Venous thromboembolism and other venous disease in the Tecumseh community health study. Circulation 1973; 48: 839–846. Franks PJ, Wright DD, Moffatt CJ, Stirling J, Fletcher AE, Bulpitt CJ et al. Prevalence of venous disease: a community study in west London. Eur J Surg 1992; 158: 143–147. Bradbury A, Evans C, Allan P, Lee A, Ruckley CV, Fowkes FG. What are the symptoms of varicose veins? Edinburgh vein study cross sectional population survey. BMJ 1999; 318: 353–356

4. Family history of varicose veins (current hypothesis: autosomal dominant with variable penetrance mode of genetic transmission) History of thromboembolic disease Number of pregnancies Activity (prolonged sitting or standing) Unskilled work Exercise less than once a week Height Obesity Cornu-Thenard A, Boivin P, Baud MM, et al: Importance of the familial factor in varicose disease: Clinical study of 134 families. J Derm Surg Oncol 20:318-326, 1994 Patrick H. Carpentier, Hildegard R. Maricq, Christine Biro, Claire O. Poncot-Makinen, Alain Franco, Prevalence, risk factors, and clinical patterns of chronic venous disorders of lower limbs: A population-based study in France, Journal of Vascular Surgery, Volume 40, Issue 4, October 2004, Pages 650-659, ISSN 0741-5214, DOI: 10.1016/j.jvs.2004.07.025.

5. Dilated, tortuous, elongated superficial veins – Possible venous eczema – possible venous ulcers Venous eczema Images: Mr Neeraj Bhasin

6. Anatomy of the venous system of the leg Deep veins Posterior tibial Anterior tibial Peroneal Soleal Gastrocnemius Popliteal Femoral Iliac Superficial veins Long saphenous (LSV) Short saphenous (SSV)

8. It was previously thought that axial destruction of venous valves led to transmission of ambulatory venous hypertension, causing reflux and varix formation. However, Labropoulos and associates reported that the most common location for initial varicose vein formation was in the below-knee great saphenous vein (GSV) and its tributaries, followed by the above-knee GSV, and the saphenofemoral junction. Their study clearly indicates that vein wall degeneration with subsequent varix formation can occur in any segment of the superficial and deep systems at any time and suggests a genetic component to the disease. Labropoulos N, Giannoukas AD, Delis K, et al: Where does the venous reflux start? J Vasc Surg 26:736-742, 1997.

9. Asymptomatic Unsightly cutaneous veins Itching Corona phlebectatica (ankle/malleolar flare) Lipodermatosclerosis Atrophie blanche Varicose eczema Edema Hemorrhage Chronic ulceration

11. Presenting Complaint: Varicosities, abdominal/groin lump – saphena varix Symptoms Localized discomfort in the leg, Pain, Swelling, Venous claudication, Itching “ Risk” factors Female, age, ethnicity, occupation, pregnancy, obesity, smoking ASK about history of abdominal complaints/cancer, DVT, previous & other venous complaints

12. General OSCE tips: ICEPP I ntroduce – be polite and friendly C onsent to examination E xpose (adequately!) P osition (standing initially) P ain – ask before examining the patient Wash hands before examining the patient Cover and thank patient, present findings

13. Look at the legs whilst patient is standing Examine around the medial malleolus ‘gaiter area’ VVV LAPS V aricose veins – distribution (LSV, SSV) V enous ulcers/eczema V enous stars L ipodermatosclerosis A trophy blanche P itting oedema S cars

14. Venous ulcers/eczema Venous stars (spider veins) Atrophy blanche Ulceration: active and healed Leaves a white patch Pitting oedema

15. Lipodermatosclerosis Literally "scarring of the skin and fat“ A slow process that occurs over a number of years and has 2 phases: Acute Venous pooling ->chronic venous hypertension RBC forced into surrounding tissue Haemoglobin broken down into brown haemosiderin Chronic Chronic haemosiderin formation leads to fibrin deposition Skin becomes thickened and shiny Skin around ankle constricts and the inverted champagne-bottle shape is seen

16. Temperature Feel with back of hand, should be warm If cold, arterial disease may co-exist Palpate the vein Feel the course of the vein Cough impulse Locate the saphenofemoral junction (SFJ) Feel for the smooth swelling and palpable thrill of a saphena varix (cause of groin lump) If present, cough test +ve Tap Test Place finger at any point along the varicose vein Tap the vein proximally (above the finger) Incompetent valves allow the transmission of a fluid thrill to the finger below Direction Test Empty a short section of the vein (place one finger on the vein and slide another finger firmly upwards). If the valves are incompetent, the vein will refill when you release the top finger. Auscultation Over a large group of veins may indicate a bruit Rare – indicates an underlying arteriovenous malformation

17. 1. The Trendelenburg test Used to assess the competence of SFJ Patient lies flat Elevate the leg and gently empty the veins Palpate the SFJ and ask the patient to stand whilst maintaining pressure Findings: If the veins do not refill-> SFJ is incompetent If the veins do refill ->SFJ may or may not be incompetent, presence of distal incompetent perforators

18. 2. Tourniquet test Uses a tourniquet to control the junction rather than fingers Advantage of moving the tourniquet lower (mid-thigh region) Test is unreliable below the knee 3. Perthes Test Empty the vein as above, place a tourniquet around the thigh, stand the patient up. Ask them to rapidly stand up and down on their toes – filling of the veins indicated deep venous incompetence. This is a painful and rarely used test.

19. Use a Doppler ultrasound Examine the abdomen for masses (+ DRE) to ascertain whether the varicose veins are primary or secondary Complete a peripheral vascular exam for arterial supply of the lower limb, including ABPI

20. Conservative/Medical Graded compression bandaging, Compression hosiery Paste Gauze (Unna) Boots Diuretics? Zinc? Phlebotrophic/Hemorheologic agents? Aspirin/NSAIDs etc Robert B. Rutherford (editor). Vascular surgery 6th ed. 2005. Elsevier Saunders. ISBN 0-7216-0299-1 (set) J. A. Michaels, J. E. Brazier, W. B. Campbell, J. B.MacIntyre, S. J. Palfreyman and J. Ratcliffe. Randomized clinical trial comparing surgery with conservative treatment for uncomplicated varicose veins. British Journal of Surgery 2006; 93: 175–181 Surgical Ankle-to-groin saphenous vein stripping (with stab avulsion) Segmental saphenous vein stripping (with stab avulsion) Saphenous vein ligation: high, low, or both Saphenous vein ligation and sclerotherapy Saphenous vein ligation (with stab avulsion) Stab avulsion of varices without saphenous vein stripping (phlebectomy) Endoluminal occlusion of the saphenous vein by radiofrequency (RF) or laser energy

22. Images: Mr Neeraj Bhasin

23. Day case procedure Oral paracetamol as analgesia Elastic bandaging for 2-3 days Mobilization: Walking for 2-3 miles daily (ideally for 5 minutes every hour) Compression stockings? J.P. Houtermans-Auckel a, E. van Rossum b, J.A.W. Teijink c, A.A.H.R. Dahlmans a, E.F.B. Eussen a, S.P.A. Nicolaı¨a, R.J.Th.J. Welten. To Wear or not to Wear Compression Stockings after Varicose Vein Stripping: A Randomised Controlled Trial. Eur J Vasc Endovasc Surg (2009) 38, 387-391

24. Major complications following VV surgery are relatively rare Up to 20% morbidity Infection Hematoma Pain Nerve damage Saphenous nerve (LSV surgery) Sural, peroneal nerve (SSV surgery) Lymphatic leak - Venous thrombosis - Vascular injury Recurrence W. B. Campbell, F. France & H.M. Goodwin, Medicolegal claims in vascular surgery. Annals of the Royal College of Surgeons of England, 84 (2002), 181–4. W.G. Tennant, Medicolegal action following treatment for varicose veins. British Journal of Surgery, 8 (1996), 291–2.

25. Any Questions?