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

This information below covers the diagnosing and managing of varicose veins. It aims to ensure that healthcare professionals like yourself know when to refer people on to one of our specialists 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 approximately 90% of the venous return. The superficial venous system is used for the remaining venous return and heat dissipation. In the superficial system the two main trunks are the Great Saphenous Vein (GSV) which goes from the groin to the ankle  and the Short Saphenous vein (SSV) which runs along the calf. These empty into the deep venous system at the Saphenofemerol Junction (SFJ) and Saphenopopliteal Junction (SPJ) respectively.

To allow blood to return from the lower limbs against gravity there exists a one-way valvular system along 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 varicose veins. Due to the retrograde flow within these veins, a low pressure becomes a high pressure system, which is known as chronic venous hypertension. As a result there is  leakage of intravascular fluid into the surrounding tissue to cause oedema, reduced oxygenation of local tissue and inflammation. This can manifest as swelling, aching, cramping, pain and restless legs.  The skin becomes compromised and poor healing, skin pigmentation, venous eczema and venous ulceration can occur. Sometimes the varicose vein itself can become thrombosed and present as a hot swollen and tender area.  

Chronic venous hypertension causes significant morbidity and decreases the patients quality of life. Treating the varicose veins early before permanent skin damage occurs 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, occupations involving long periods of standing obesity, family history and a past medical history of deep vein thrombosis.

Symptoms of Varicose Veins and Chronic Venous Hypertension

Symptoms classically involve:

  • Aching, throbbing, pain
  • Night cramps
  • 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.
  • Skin ulceration
  • Superficial venous thrombosis or thrombophlebitis

Investigations

All patients must have comprehensive lower limb venous mapping with duplex ultrasound. The purpose of this investigation is  to map the pattern of venous reflux for the individual patient. This involves finding where the reflux begins, what veins are involved and determining the size of the refluxing veins. 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

Compression stockings will improve venous return, reduce oedema and improve the skin somewhat. However, they will need to be class 2 compression and worn daily to be have effect.

Endovenous Thermal Ablation

The two main method of endovenous thermal ablation include radio frequency ablation and laser ablation. Both are an ultrasound guided percutaneous procedure under local anaesthetic  and is a walk in and walk out procedure.  Depending on the patient’s pattern of venous disease the radiofrequency catheter or laser is introduced to the vein at the thigh or lower leg. Tumescent anesthesia is injected to surround 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 substance into the vein to cause controlled endothelial damage to the internal vein wall. The damage causes endofibrosis and resolution 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 introduction of the injected foamed  sclerosant into refluxing veins. Foamed sclerotherapy increases surface area of contact and duration of contact between the sclerosant and the endothelial cells of the vein. This improves targeted endothelial damage to improve clinical outcomes and reduces total volume of sclerosant required to minimise 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 involve 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 friendly and professional and welcome your patient referrals. Our providers are covered by most 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

Consider routine referral of patients with varicose veins who meet the criteria above. The referral letter and patients medical record need to clearly state how the criteria is met. 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 though our appointment form.