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Varicose veins: diagnosis and management
Skin Institute
February 25, 2019

The information below covers the diagnosis and management of varicose veins. It aims to help healthcare professionals like yourself know about how and when to refer patients on to one of our specialist team for assessment and/or treatment.

Aetiology of Varicose Veins

There are two venous systems in the lower leg – the deep venous system which lies within the muscle and the superficial venous system which is positioned on top of the muscle.

The deep venous system carries 90+% of the venous return from the leg. The superficial venous system is used for the remaining venous return, as well as vascular storage and heat dissipation. In the superficial system the two main trunks are the Great Saphenous Vein (GSV) which runs from the ankle to the groin up the medial side of the leg, and the Short Saphenous vein (SSV) which runs in the midline posteriorly up the calf. These veins empty into the deep venous system at the Saphenofemerol Junction (SFJ) in the groin, and Saphenopopliteal Junction (SPJ) behind the knee, respectively.

The blood pressure in the veins is significantly less than in the arteries, and not enough to return blood from the foot to the heart in the standing or sitting position. In order for blood to return from the lower limbs against gravity there are multiple one-way valves throughout the length of the vein. Varicose veins result when there is failure of these valves and blood backflows down into the superficial venous system and its branches. These veins subsequently become dilated and tortuous and, if close to the skin, can be seen as visible lumpy varicose veins, but are not always visible. Due to the retrograde flow within these veins, a low pressure becomes a high pressure system, known as chronic venous hypertension. As a result there is reduced oxygenation of local tissues, there is often leakage of intravascular fluid into the surrounding tissue to cause oedema and there can be inflammation. These manifest in a variety of symptoms such as swelling, aching, cramping, pain and restless legs.  The skin can also become compromised with poor healing, skin pigmentation, venous eczema and venous ulceration. Sometimes the varicose vein can become thrombosed and present as a hot inflamed and tender area.  This superficial venous thrombosis (SVT) has a real risk of progressing to a DVT.

Chronic venous hypertension therefore causes significant morbidity and significantly decreases a patient’s quality of life. Treating the varicose veins early before permanent skin damage or thrombosis occur is important.

Epidemiology

Varicose veins are a global problem that have an increasing incidence with age. It is more common in women.  Varicose veins occur in 8% of women aged 20-29, 41% of women aged 50-59 and 72% of women aged 70-79. In men varicose veins occur in 1% aged 30-39, 24% aged 40-49 and 43% aged 70-79.

Risk factors for developing varicose veins include pregnancy, family history, occupations involving long periods of standing, obesity and a past medical history of deep vein thrombosis.

Symptoms of Varicose Veins and Chronic Venous Hypertension

Symptoms classically include:

  • Aching, throbbing, pain
  • Night cramps or restless legs
  • Swelling – made worse with standing, flying or in the heat
  • Skin pigmentation changes: Hyperpigmentation from haemosiderin deposition or hypopigmentation due to fibrosis
  • Itching
  • Dermatitis
  • Haemorrhage – varicose veins can bleed easily when scratched or cut.
  • Poor healing of leg wounds
  • Skin ulceration
  • Superficial venous thrombosis or thrombophlebitis

Investigations

It is essential that all patients have a comprehensive lower limb venous mapping with duplex ultrasound. The purpose of this investigation is to map the pattern of venous reflux for each individual patient. This involves determining where the reflux begins, which veins are involved, where they run and all their associated interconnections. The deep venous system is also checked for reflux or obstruction. With this information we can then proceed to formulating an individualised treatment plan.

Management options for Varicose Veins and Chronic Venous Hypertension

Compression Stockings

Conservative treatment may be appropriate for some patients, ie pregnant patients or those just about to travel. Compression stockings will improve venous return, thus improving many of the symptoms, reducing oedema, improving the skin health and reducing thrombosis risk. However, this will need to be class 2 compression and will need to be worn every day to be effective. In the previous era of surgical intervention many elderly patients also fell into this conservative category, but now with modern non surgical techniques age is often not a barrier to treatment.

Endovenous Thermal Ablation 

The two main methods of endovenous thermal ablation are radio frequency ablation and laser ablation. Both are ultrasound guided percutaneous procedures under local anaesthetic and are walk in, walk out with no sedation required and very little downtime.  Depending on the patient’s pattern of venous disease, based on the mapping, the radiofrequency catheter or laser is introduced into the vein at the thigh or lower leg. Tumescent anaesthesia is injected around the vein to be treated, to protect the surrounding tissue and make the procedure painless for the patient. Subsequently, the radio frequency catheter or laser is slowly withdrawn whilst emitting heat to cauterize the faulty vein.

Sclerotherapy 

Sclerotherapy is the introduction of a chemical into the vein to cause controlled endothelial damage to the internal vein wall. The damage causes endofibrosis and subsequent resorption of the varicose vein. The most common sclerosants used are Sodium tetradecyl sulphate (STS) and Polidocanol (POL).  UIltrasound guided sclerotherapy (UGS) uses real time ultrasonography for targeted injection of the foamed sclerosant into refluxing veins. Foaming the sclerosant helps evacuate the blood from the varicose veins, increasing both the surface area and duration of contact between the sclerosant and the endothelial cells of the vein. This increases the endothelial damage whilst reducing the total volume of sclerosant used, thus improving clinical outcomes and minimising unwanted side effects.

Microsclerotherpy is used for spider veins of the skin (telangiectasias). This process involves liquid sclerosant injected under direct visual guidance.

Post treatment management

After both endovenous thermal ablation and ultrasound guided sclerotherapy patients are fitted with compression stockings and advised on post treatment instructions. This will include daily walking to reduce the small risk of a DVT. The patients will be followed up in a few weeks and again several times over the following year. Commonly patients will receive a mixture of endovenous thermal ablation and ultrasound guided sclerotherapy over the course of a year to completely treat their varicose vein disease.

With 24 years of looking after New Zealanders’ skin and vein health, at Skin Institute we provide specialised healthcare. At Skin Institute, our expert team is extremely experienced, professional and friendly, and we welcome your patient referrals. Between our providers we are covered by all insurance companies and we are an Affiliated Provider to Southern Cross Health Society for contracted skin cancer and varicose vein treatments where medical necessity criteria apply*.

*Where medical criteria are met in accordance with your insurance policy.

 


Referral process

Please consider referral of any patients who may have symptoms or signs of varicose veins disease. Large lumpy varicose veins are not always necessarily seen and so if you have any suspicion, we are happy to consult and map any patients. We welcome all your referrals via phone 0800 SKIN DR (754637), fax or letter to your nearest clinic, or via Healthlink (skininst). Alternatively, your patient can request an appointment directly by telephone or though our appointment form.