Varicose veins

Dr Julian Spinks identifies the common presenting factors with varicose veins.

Varicose veins
Varicose veins

Varicose veins are widened and tortuous superficial veins in the legs. It is a condition that commonly presents in primary care.

The overall prevalence is high at around 40 per cent in men and 32 per cent in women, and this prevalence rises with age until it is 80 per cent over the age of 60. Despite the lower prevalence, women present for treatment more frequently than men.

A family history is common and a small number of patients may have absent iliac vein valves. It is also suggested that some patients may have congenital abnormalities of vein elasticity.

Other predisposing factors include obesity, prolonged standing, parity in women and previous DVT.

Most patients with varicose veins have no long-term sequalae, but complications can include superficial thrombo-phlebitis, oedema, varicose eczema, lipodermatoscler- osis, varicose ulcer and haemorrhage.

History
The most common reason for presentation is cosmetic disfigurement, particularly in women, whose clothing is more likely to leave the leg exposed.

Discomfort is frequently reported. The patient complains of aching or heaviness, sometimes associated with itching. This pain may not be linked to the varicosities. If the pain worsens after prolonged standing or towards the end of the day, or if it is relieved by leg elevation and support stockings, it is more likely that the pain is linked to varicose veins.

Leg swelling may be ascribed by the patient to the varicose veins but, while this can happen with more severe varicosities, other more common causes include gravitational oedema, DVT, infection and systemic disease.

Current or previous episodes of superficial thrombophlebitis, skin changes, ulceration and haemorrhage should be noted as these may have a bearing on future referral.

An important part of the history is to ascertain the reason for consultation. Is the patient only requiring diagnosis and reassurance, or are they expecting referral for treatment?

Examination
The patient should be examined standing up so that the veins are fully distended, and the whole leg should be inspected.

Sometimes only non-varicose 'spider veins', which are only of cosmetic significance, are present. Small distended veins at or below the ankle are also normal. The patient's skin should be examined for changes such as eczema, oedema, ulceration or lipodermatosclerosis.

The distribution of the varicosities may suggest the underlying venous defect. Varicosities along the length of the long saphenous vein suggest incompetence at the saphenofemoral (SF) junction.

Less commonly, the short saphenous vein is affected. Perforating vein incompetence can be palpated as a varix with an underlying fascial defect.

It may be possible to use tests to determine the site of incompetence. One is the Trendelenburg test, which involves elevating the leg and draining the veins, then applying a tourniquet below the SF junction. If the varicosities do not refill when the patient stands up, then the incompetence is at the SF junction. The tourniquet can be reapplied at lower levels until the level of incompetence is detected.

In practice, imaging studies are more reliable.

Investigations. Doppler tests and duplex scanning can accurately assess the site of venous incompetence. Indications include recurrent varicose veins, previous DVT, complex or unusual varicose veins or reflux in the poplitial fossa.

Treatment
Many patients only require reassurance, education and advice about conservative measures, including weight reduction, exercise and support hosiery.

Varicose eczema should not be treated with topical steroids as these contribute to skin atrophy. Leg elevation and support hosiery are recommended. Venous ulcers should be treated with compression bandaging.

Superficial thrombophlebitis should be treated with analgesia and does not require antibiotics.

NICE has recommended which patients should be referred for specialist assessment.

Surgical intervention includes conventional surgery, most commonly ligation at the SF junction with stripping of the long saphenous vein, and phlebectomy. An alternative is radio-frequency or laser ablation of the long saphenous vein. This can be done under local anaesthetic and causes less bruising. However, efficacy and cost-effectiveness are not fully proven.

Sclerotherapy is also a common treatment and involves the injection of sclerosant into varicosities followed by compression. This works well for small, below-knee varicosities but not for long saphenous vein disease.

A variant, foam sclerotherapy, may be more efficacious but remains the subject of research.

Dr Spinks is a GP in Strood, Kent

NICE REFERRAL GUIDELINES FOR VARICOSE VEINS
Immediate referral

  • Bleeding form a varicosity that has eroded the skin.

Urgent

  • A varicosity that has bled and is at risk of further bleeding.

Soon

  • An ulcer that is progressive or painful despite treatment.

Routine

  • Active or healed ulcer and/or progressive changes that may benefit from surgery.
  • Recurrent superficial thrombophlebitis.
  • Troublesome symptoms attributable to varicose veins and/or the patient or GP feels that the extent, site and size of the varicosities are having a severe impact on quality of life.

KEY POINTS

  • Predisposing factors include obesity, prolonged standing and previous CVT; a family history is also common.
  • The most common reason for presentation is cosmetic disfigurement, particularly in women.
  • The entire leg should be examined, with the patient standing up so that veins are fully distended.
  • Leg elevation and support hosiery are recommended for treatment, along with lifestyle changes such as weight management and exercise.

References

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