Varicose veins develop due to incompetence of the one-way valves in the veins, allowing retrograde blood flow and pooling in the superficial veins. This causes the superficial veins to dilate and become tortuous. Risk factors include family history, older age, pregnancy, and history of deep vein thrombosis. Diagnosis is based on history and physical exam, with duplex ultrasonography used to detect reflux and evaluate venous anatomy. Treatment options include compression therapy, sclerotherapy, thermal ablation, and surgery to ligate or strip the refluxing vein.

1. VARICOSE VEINS

2. VARICOSE VEINS
• Varicose veins are tortuous dilated segments of
vein associated with valvular incompetence.
• They arise from incompetent valves, which permit
blood flow from the deep venous system to the
superficial venous system
• This results in venous hypertension and dilatation of
the superficial venous system
• Usually affects the saphenous vein and its branches

3. Types
• 1.) Greater saphenous varicose veins
• 2.) Lesser saphenous varicose veins
• 3.) Genital area varicose vein
• 4.) Reticular type and Web type (spider veins) varicose vein

4. CAUSES
• Most varicose veins are idiopathic.
• Secondary causes arise from mechanisms of venous outflow
obstruction which can either be:
Intravascular (e.g. a deep vein thrombosis)
Extravascular (e.g. pelvic masses, including tumours, fibroids and pregnancy)
• Progesterone and oestrogen are also believed to have vasodilatory
properties which can predispose to or worsen already existing varicose veins.

5. Risk Factors
• Family history of varicose veins (90% risk if both parents
are affected)
• Older age (especially 40 years and above)
• Pregnancy (higher parity equals higher risk)
• Female sex
• History of deep vein thrombosis (DVT)

6. • Varicose veins develop due to the incompetence
of the one-way valves, leading to the leakage,
retrograde flow and consequently, pooling of
blood in the superficial venous system.
• Additionally, the weaker, thinner walls of the
superficial veins (as opposed to the stronger and
thicker walls of the deep veins) make them more
prone to the effects of the high-pressure build-
up of blood leading to distension of the
venous walls and tortuosity of the affected
venous segment.
• This manifests as bulging of the skin over the
affected vein
PATHOPHYSIOLOGY

7. CLINICAL FEATURES
Varicose veins are commonly asymptomatic or initially just a cosmetic concern with patients worrying
about the visible and often palpable tortuous veins in their legs.
Typical (usually chronic) symptoms that can develop with worsening varicose veins include:
•Pain (often described as a dull ache or burning of the skin)
•Leg fatigue, discomfort, or worsening pain after prolonged standing (with
associated relief after leg elevation)
•Leg cramps (usually nocturnal)
•Restless legs
•Skin discolouration over the affected areas (haemosiderin deposition)
•Heaviness of the legs
Less common symptoms include:
•Itching after prolonged standing (venous eczema)
•Ankle oedema
•Lipodermatosclerosis

8. PHYSICAL EXAMINATION
• A thoroughperipheralvenousexaminationshouldbeperformed.
• The varicositiesshould beassessedwiththe patientstandingatfirstandthen withthem lyingdown.
• Varicosesegments usuallycompriseareasofthe greatandshortsaphenousveins andthe full lengths ofbothveins shouldbe
assessedfromthefront,thesides andfrombehind.
INSPECTION
Assessthesize,location,andextension ofthe dilatedveins.
Lookforassociatedsigns andcomplications:
•Chronicvenous insufficiency:ulceration(bothactiveandhealed),eczema, haemosiderindeposition,lipodermatosclerosisand
atrophieblanche.
•Complications:bleeding andsuperficialvein thrombosis

9. PALPATION
• Gently pressover thedistendedvein. The vein shouldemptythenrefill afterabriefperiodoftime,but thrombosed
varicosities will be firmandpossiblytender.
• Assessforbumpsandbulgesthatmight correspondwithvaricoseveins, keeping noteofthe size,shape,length, andlocation of
the veins:
•Pressthecalfgently tofeel forcalftenderness.
•Makesureto carefullyexaminetheintegrity oftheskin in the‘gaiter’areaandfeel forsigns ofchronic venous insufficiency,
especially venous ulcers.
Tocompletethe physicalexamination,it is imperativeto assessthe patient’scardiovascularhealthandtocarryoutan abdominal
examinationtoexcludesecondarycauses suchas pelvic orabdominaltumoursorotherfactorsthatcouldbecausing distal
venous obstruction.

10. Trendelenburg test: examines the function of
superficial and perforating venous valves
Procedure
1. The patient should be in a supine position with
their legs elevated.
2. A tourniquet is applied to compress the
superficial veins
3. The leg is lowered (patient should stand).
Interpretation
Normal: No filling of the superficial veins as
blood flows from the superficial to the perforating
veins.
Trendelenburg I positive: If stasis is present,
there is rapid filling from the deep to superficial
venous system (insufficient perforating veins)
Trendelenburg II positive: After stasis removal,
there is rapid filling within the superficial venous
system (insufficient superficial venous valves)
Perthes test: assesses deep venous patency
Indication: examine operability before varicose
vein surgery
Procedure
1. The patient should be in a standing position.
A tourniquet is applied to compress the
superficial vein (mainly the great saphenous
vein).
2. The patient should walk for several minutes.
Interpretation
Normal: no filling of varices
Positive: excessive filling of the varices (blood is
unable to flow through the obstructed deep veins)

12. Varicose veins and chronic venous insufficiency are diagnosed based on history and clinical
findings.
Test of choice: duplex ultrasonography
• Presence of venous reflux confirms diagnosis of CVI
• Examine patency of deep vein
• Examine sufficiency of superficial and perforating veins
Magnetic resonance venography (MRV)
• Better sensitivity and specificity
• Typically used in complicated cases, when
duplex ultrasonography is inconclusive
• Visualizes venous anatomy and depicts venous
reflux and/or obstruction
Venous plethysmography:
• noninvasive measurement of the velocity
of venous recovery (while exercising) via infrared light
DIAGNOSIS

13. TREATMENT
Conservative measures
Indications
• Superficial disease with no correctable cause of reflux
• Postoperative period
Measures
• Compression therapy with compression stockings
• Frequent elevation of the legs
• Physical therapy, manual lymphatic drainage
• Avoid long periods of standing and sitting (with bent legs) and heat

14. •Vein ligation, stripping, and avulsion –
making an incision in the groin and
identifying the responsible, refluxing vein,
before tying it off and stripping it away. The
surgeon must be aware of surrounding
arterial and nervous structures, such as the
saphenous and sural nerves.
.
•Thermal ablation – which involves heating
the vein from inside (via radiofrequency or
laser catheters), causing irreversible damage to
the vein which closes it off. This is done
under ultrasound guidance and also may be
performed under local (or general)
anaesthetic.

15. Foam sclerotherapy – injecting a sclerosing (irritating) agent directly
into the varicosed veins, causing an inflammatory response that closes
off the vein. This is done under ultrasound guidance to ensure the foam
does not enter the deep venous system, however this method only
requires a local anaesthetic

16. COMPLICATIONS
• Haemorrhage
• Eczema and dermatitis
• Periostitis causing thickening of periosteum
• Venous ulcer, marjolin’s ulcer
• Lipodermatosclerosis
• Deep vein thrombosis
• Thrombophlebitis
• calcification

17. REFERENCE
• https://teachmesurgery.com/vascular/venous/varicose-veins/
• https://geekymedics.com/varicose-veins/
• https://scvascular.com.au/services/varicose-veins/endovenous-thermal-ablation/
• https://my.clevelandclinic.org/health/treatments/16965-venous-disease-
endovenous-thermal-ablation
• https://www.webmd.com/skin-problems-and-treatments/understanding-varicose-
veins-basics