Venous Disease of the Lower Limb

An overview of venous disease that affects the lower limb - including venous ulcers and varicose veins.

 

Lecture by

Video Duration: 11 minutes

  • Varicose Veins
    Created by Tom Goldsmith
    General
    Epidemiology

    Dilated, often palpable subcutaneous veins with reversed blood flow. (As defined by the Vascular Society of Great Britain and Ireland)

    Common; Edinburgh Vein Study demonstrated trunk varices in one third of adults aged 18-64.

    Female: Male ratio 1.5-3.5:1, and incidence increases with age.

    Pathology

    Incompetence of valves between the deep and superficial venous systems of the lower limb result in superficial veins becoming dilated with reversed blood flow from the deep vessels into which they usually drain

    Top three causes

    Obesity and a low fibre diet are associated with the development of varicose veins.

    Genetic component probable

    Occupation and increased parity have been suggested as notable factors, but there a lack of good evidence for this.

    Clinical Features
    Symptoms

    Uncomplicated Varicose Veins

    Often cosmetic complaints are included in the presentation. Various symotoms include pain, itching, tingling a feeling of heaviness

    Complicated Vericose Veins

    As above, plus complaints of varicose eczema, and more severe pain

    Signs

    Varicose veins will be demonstrable by the patient.

    To prove complicated varicose veins, look for lipodermatosclerosis, venous ulcers or corona phlebetatica (dilated vessels of the medial malleolar region; early sign of complicated varicose veins which can haemorrhage or cause ulceration), oedema (although consider alternative causes) and venous eczema.

    Tourniquet test is infrequently used in practice but makes for good clinical examination material!

    Investigations
    Cultures

    None

    Bloods

    None

    Imaging

    None

    Scopic/Biopsy

    None

    Functional

    Duplex utrasonography can be used to demonstrate anatomy if a patient is being considered for surgical intervention.

    Treatment
    Conservative

    Reassurance for asymptomatic varicose veins is important; in these patients, bleeding, ulceration and thrombosis is unlikely

    Medical

    Compression Hosiery (could be considered conservative)

    !! Surgical management is recommended over and above compression hosiery by NICE (CG168) unless the patient is unsuitable for surgical management !!

    Results are dependant on compliance, which is very often poor

    Good for patients not suitable for surgery, including pregnant women with symptomatic varicose veins


    Surgical

    (In order of preference according to NICE)

    1. Endothermal ablation or laser treatment
    2. Ultrasound-guided foam sclerotherapy (sclerosing agent injected at multiple sites along the vein's length to obliterate patency)
    3. Surgical intervention (no particular order)
      • Ligation of sapheno-femoral or sapheno-popliteal junction
      • Avulsion of varicose veins with "stab incisions" (small parts of the offending vein removed along its length with small incisions closed with a single steri-strip)
      • Vein Stripping; reducing in popularity (entire vein removed by passing an endovascular instrument along its length which strips the vessel from the leg as it is passed)