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Varicose Veins — Comprehensive Clinical Overview

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Definition

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Anatomy — The Venous System of the Lower Limb

1. Deep veins — femoral, popliteal, tibial; enclosed in fascia and muscle
2. Superficial veins — Great Saphenous Vein (GSV) and Small Saphenous Vein (SSV) with their tributaries
3. Perforating (communicating) veins — connect the two systems; have valves that normally only allow flow from superficial → deep

• Calf muscle contraction generates up to 300 cm H₂O pressure, pumping blood proximally through the deep veins
• Valves prevent retrograde flow
• During relaxation, blood flows from the superficial system through perforators into deep veins (superficial system = "atrium"; deep veins = "ventricle")
• Standing still creates hydrostatic pressure of ~70–80 cm H₂O at the foot

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Pathophysiology

1. Saphenofemoral junction (SFJ) incompetence → retrograde flow from common femoral → GSV → progressive dilation → distal valve failure → cascade incompetence of entire saphenous system
2. Perforator incompetence → during calf contraction, blood flows from deep system backward into the superficial system (instead of the reverse) → venous hypertension → sustained dilation → stasis dermatitis, pigmentation, lipodermatosclerosis, ulceration

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Classification

By vessel size (Sadick classification):

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Risk Factors

• Female sex
• Obesity
• Family history (strong genetic component)
• Prolonged standing or inactivity
• Pregnancy (increased intra-abdominal pressure + progesterone-induced vein wall relaxation)
• Previous DVT or thrombophlebitis
• Age

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Causes of Unilateral Varicose Veins

1. Deep Vein Thrombosis (DVT) — most important

• Previous DVT causes valve destruction in the deep system → post-thrombotic syndrome
• Deep venous occlusion forces collateral drainage through the superficial system → secondary varicosities
• Look for: history of immobilisation, thrombophilia, prior leg swelling, asymmetric oedema

2. Iliac Vein or IVC Compression/Obstruction

• May-Thurner syndrome: Left common iliac vein compression by the right common iliac artery → unilateral left leg varicosities
• Pelvic masses (fibroid uterus, ovarian cysts, lymph nodes, retroperitoneal tumours) compressing iliac vein
• Pregnancy — particularly asymmetric if uterus rotates

3. Arteriovenous Fistula (AVF)

• Congenital or acquired (post-trauma, post-surgical)
• High-pressure arterial flow enters the venous system → venous hypertension → varicosities
• Clinical clue: warm limb, thrill/bruit, dilated pulsatile veins, leg length discrepancy

4. Congenital Venous Anomalies

• Klippel-Trénaunay syndrome: triad of port wine stain, varicosities, and limb hypertrophy — typically unilateral
• Involves posterolateral tributary veins and anterolateral superficial thigh veins
• Associated with absence of deep venous system (surgical stripping contraindicated)

5. Pelvic Congestion Syndrome

• Ovarian vein incompetence / pelvic varicosities draining to the thigh
• Typical pattern: posterior thigh varicosities — a key clinical sign pointing to a pelvic venous source
• Common in multiparous women

6. Inferior Vena Cava (IVC) Obstruction

• Thrombosis, tumour invasion (renal cell carcinoma), external compression
• Bilateral initially but can present unilaterally depending on level and collateral pathways

7. Trauma or Previous Surgery

• Post-surgical ligation of deep veins or previous stripping procedures
• Limb trauma causing AVF or deep vein damage

8. Tumour Infiltrating Pelvic/Inguinal Lymph Nodes

• Lymphatic-venous communications allow recurrence of varicosities after treatment

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History — Key Points to Elicit

Presenting Complaint

• Site, distribution, and onset of varicosities
• Cosmetic concern only, or symptomatic?

Symptoms

• Aching, heaviness, dragging in the leg (worse after prolonged standing, relieved by elevation)
• Itching or burning over varicosities
• Ankle swelling (especially evening)
• Restless legs or cramps at night
• Skin changes — pigmentation, eczema, ulceration

Aggravating / Relieving Factors

• Worse with prolonged standing/sitting → better with leg elevation (classic)
• Worse in hot weather, premenstrually

Complications to Ask About

• Thrombophlebitis — localised redness, tenderness, hard cord
• Bleeding — spontaneous or traumatic bleeding from varicosity
• Venous ulceration — around the medial malleolus
• Lipodermatosclerosis — woody induration and pigmentation of gaiter area

Relevant Past History

• Previous DVT, PE, or thrombophlebitis
• Unilateral only: previous hip/knee surgery, trauma, pelvic surgery, malignancy
• Pregnancies — how many, which legs affected
• Previous treatment for varicosities (sclerotherapy, stripping)

Family History

• Varicose veins (strong hereditary component)
• Thrombophilia

Drug/Social History

• OCP / HRT (venous thrombosis risk)
• Occupation — prolonged standing (nurse, teacher, surgeon)
• BMI

Systems Review (for secondary causes)

• Pelvic pain, dyspareunia → pelvic congestion
• Weight loss, haematuria → malignancy / RCC / IVC thrombosis
• Skin birthmark, limb length discrepancy → Klippel-Trénaunay

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Examination

General Inspection

• Distribution: unilateral vs bilateral; GSV distribution (medial) vs SSV distribution (posterior/lateral calf)
• Assess entire limb for skin changes

Look

Feel

• Temperature — warm over varicosities; very warm limb may suggest AVF
• Tenderness — localised tenderness over vein (thrombophlebitis)
• Oedema — pitting vs non-pitting; bilateral vs unilateral
• Lipodermatosclerosis — firm, woody induration; "inverted champagne bottle" leg
• Saphenofemoral junction — feel for saphena varix in the groin

Special Tests

1. Cough Impulse Test (Morrissey's test)

• Patient stands; place fingers over the SFJ in the groin
• Ask patient to cough
• A thrill or impulse felt = SFJ incompetence (valve failure)

2. Trendelenburg Test (Brodie-Trendelenburg)

• Elevate leg to empty veins → apply tourniquet at upper thigh → stand patient up
• Veins fill slowly from below (>30 sec) → tourniquet controls filling = SFJ incompetence confirmed (releasing tourniquet causes rapid retrograde filling)
• Veins fill rapidly from below despite tourniquet = perforator incompetence below the tourniquet
• Can repeat at different levels to locate incompetent perforators

3. Perthes' Test (deep vein patency)

• Apply tourniquet mid-thigh with patient standing
• Ask patient to walk / exercise for a few minutes
• Veins disappear → deep veins patent (blood redirected to deep system)
• Veins remain or pain worsens → deep vein obstruction or incompetent perforators (do NOT strip — deep veins may be the only functional drainage)

4. Fegan's Test (perforator localisation)

• Elevate leg; mark dimples along the line of the GSV (sites of incompetent perforators — fascial gaps)
• These correspond to standard perforator locations: Dodd (mid-thigh), Boyd (below knee), Cockett I/II/III (medial calf/ankle)

5. Tap Test (Schwartz test)

• Tap the vein proximally and feel for an impulse distally (or vice versa)
• Positive impulse transmitted = continuous column of blood = valve incompetence

6. Auscultation

• Over varicosity — bruit suggests AVF

7. Examine Abdomen and Pelvis

• Palpate for masses, hepatomegaly, lymphadenopathy
• In women with unilateral varicosities: bimanual pelvic examination if indicated

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Investigations

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CEAP Classification (Clinical, Aetiological, Anatomical, Pathophysiological)

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Management

1. Conservative (All Patients)

• Weight reduction — reduces venous pressure
• Leg elevation — at rest and at night
• Avoid prolonged standing
• Exercise — regular walking activates the calf muscle pump
• Elastic compression stockings:
  • 20–30 mmHg for mild symptoms
  • 30–40 mmHg for moderate symptoms
  • 40–50 mmHg for severe CVI / ulcers
  • Knee-high to waist-high depending on extent of varicosities
  • Provides sufficient symptom relief in many patients

2. Interventional Indications

• Symptoms persist or worsen despite compression therapy
• Lipodermatosclerosis is present
• Active or recurrent venous ulceration
• Thrombophlebitis
• Bleeding from varicosity
• Patient preference (cosmesis)

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3. Sclerotherapy

• Foam sclerotherapy (sclerosant + air) is preferred for larger varicosities
• After injection: elastic bandage for 3–5 days, then compression stockings for ≥2 weeks

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4. Endovenous Thermal Ablation

• GSV punctured under ultrasound guidance (distal thigh / proximal calf) with 21-gauge needle
• Guidewire → sheath → laser fibre or RFA catheter advanced to near SFJ
• Tumescent anaesthesia injected around the GSV
• Vein treated as catheter is withdrawn
• Results: durable ablation, comparable recurrence rates to open surgery, faster recovery

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5. Non-Thermal, Non-Sclerosant Ablation

• Mechanochemical ablation (MOCA) — combines catheter-based mechanical endoluminal injury with sclerosant (e.g., ClariVein)
• Cyanoacrylate glue (VenaSeal) — proprietary adhesive obliterates the vein lumen; no tumescent anaesthesia required; promising early results

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6. Surgical Treatment

• Preferred for GSV >2 cm diameter
• Small incision in groin → ligate GSV flush with common femoral vein at SFJ + second incision just below knee
• GSV removed using blunt-tip catheter or invagination pin stripper
• Lower long-term recurrence than SFJ ligation alone

• For branch varicosities and larger residual varicosities after truncal ablation
• 2 mm stab incisions directly over varicosity → dissect and avulse the vein segment
• Bleeding controlled by elevation + compression + tumescent anaesthesia

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Important Caveat: Perthes' Test Negative (Deep Vein Obstruction)

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Complications of Untreated Varicose Veins

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• Schwartz's Principles of Surgery, 11th Ed, p. 1023–1024
• Pfenninger and Fowler's Procedures for Primary Care, 3rd Ed, p. 636–638
• Dermatology 2-Volume Set, 5th Ed, p. 3136