Varicose veins BASICS DESCRIPTION: Elongated, dilated, tortuous super icial veins !

it" congenitall# a$sent valves, or valves t"at "ave $eco%e inco%petent& A ects legs !"ere reverse lo! occurs !"en dependent&

Staging
T"is classi ication is $ased on t"e clinical, etiological, anato%ic, pat"op"#siological 'CEAP( classi ication ro% t"e A%erican Venous )oru%, last revised *++,&-.*/ It is used to standardi0e recording o venous disease, as ollo!s:

Clinical o C+ 1 No visi$le or palpa$le signs o venous disease

o o o o o o o o

C. 1 Telangiectases or reticular veins C* 1 Varicose veins C2 1 Ede%a C,a 1 Pig%entation or ec0e%a C,$ 1 3ipoder%atosclerosis or atrop"ie $lanc"e C4 1 5ealed venous ulcer C6 1 Active venous ulcer S 7 S#%pto%atic, includes: ac"e, pain, tig"tness, s8in irritation, "eaviness, and %uscle cra%ps, and ot"er co%plaints attri$uta$le to venous d#s unction A 1 As#%pto%atic

Etiologic classi ication

o o o o

Ec 1 Congenital Ep 1 Pri%ar# Es 1 Secondar# 'post1t"ro%$otic( En 1 No venous cause identi ied

Anato%ic classi ication

o o o

As 1 Super icial veins Ap 1 Per orator veins Ad 1 Deep veins

An 1 No venous location identi ied

Pat"op"#siologic classi ication

o

Basic CEAP

Pr 1 Re lu9 Po 1 O$struction Pr,o 7 Re lu9 and o$struction Pn 1 No venous pat"op"#siolog# identi ia$le

Advanced CEAP: Sa%e as $asic CEAP, !it" addition t"at an# o .: na%ed venous seg%ents can $e used as locators or venous pat"olog#

Super icial veins: '.( telangiectasias or reticular veins, ;SV '*( a$ove 8nee or '2( $elo! 8nee, ',( s%all sap"enous vein, or '4( nonsap"enous veins Deep veins: '6( In erior vena cava, '<( co%%on iliac vein, ':( internal iliac vein, '=( e9ternal iliac vein, '.+( pelvic veins 1 gonadal, $road liga%ent veins, ot"er, '..( co%%on e%oral vein, '.*( deep e%oral vein, '.2( e%oral vein, '.,( popliteal vein, '.4( crural veins 'anterior ti$ial, posterior ti$ial, peroneal veins 'all paired((, or '.6( %uscular veins 1 gastrocne%ial, soleal veins, ot"er& Per orating veins: '.<( T"ig" or '.:( cal

Predo%inance actor ;enetics: )a%ilial, do%inant, 91lin8ed Incidence A$out *+> o adults Predo%inant age: ?iddle age Predo%inant se9: )e%ale @ ?ale '4:.(

SI;NS AND SA?PTO?S: BSo%eti%es as#%pto%atic B3eg %uscular cra%p BDilatation, tortuosit# o super icial veins c"ie l# in t"e lo!er e9tre%ities BEde%a o a ected li%$ B3eg ac"ing

B)atigue BS#%pto%s !orse during %enses BPain i varicose ulcer develops

Etiolog#: B)ault# valves in one or %ore per orator veins in t"e lo!er leg causing secondar# inco%petence at t"e sap"eno e%oral Cunction BDeep t"ro%$op"le$itis BIncreased venous pressure ro% an# cause BIn %an# individuals, no cause or precipitating actor ound

RISD )ACTORS: BPregnanc# BOccupations reEuiring prolonged standing, restrictive clot"ing 'e&g&, ver# tig"t girdles(

5o! to Diagnosis Inspection

Varicose veins& Reticular veins 'also called $lue veins, su$der%al varices, and venulectasias( 7 Visi$le, dilated $luis" su$der%al, nonpalpa$le veins .12 %%, as depicted in t"e i%age $elo!&

Reticular veins& Telangiectases 'also called spider veins, "#p"en !e$s, and t"read veins( 7 Dilated intrader%al venules greater t"an . %% in dia%eter, as depicted in t"e i%age $elo!&

Telangiectasias& Ec0e%a 7 Er#t"e%atous der%atitis, !"ic" %a# progress to $listering, !eeping, or scaling eruption o t"e s8in o t"e leg& Atrop"ie $lanc"e '!"ite atrop"#( 7 3ocali0ed, o ten circular !"itis" and atrop"ic s8in areas surrounded $# dilated capillaries and so%eti%es "#perpig%entation& 'Scars o "ealed ulceration are e9cluded ro% t"is de inition&( Corona p"le$ectatica 'also called %alleolar lare and an8le lare( 7 )an1s"aped pattern o nu%erous s%all intrader%al veins on t"e %edial or lateral aspects o t"e an8le and oot& Flcers o t"e %edial an8le 7 ?ost li8el# t"e result o underl#ing venous insu icienc#& 'S8in c"anges or ulcerations t"at are locali0ed onl# to t"e lateral aspect o t"e an8le are %ore li8el# to $e related to prior trau%a or to arterial insu icienc# t"an to pure venous

insu icienc#, as depicted in t"e i%ages $elo!& stasis ulcer&

3ipoder%atosclerosis&

Venous

Palpation

T"e entire sur ace o t"e s8in is palpated lig"tl# !it" t"e ingertips $ecause dilated veins %a# $e palpa$le even !"ere t"e# are not visi$le& Distal and pro9i%al arterial pulses are also palpated& An an8le1$rac"ial inde9 is use ul i arterial insu icienc# is suggested&

T"e antero%edial sur ace o t"e lo!er li%$ is t"e territor# o t"e greater sap"enous vein ';SV(& T"e arc" o t"e vein %a# $e palpated in so%e patients !it" "ealt"# veins, $ut t"is seg%ent o t"e vein is particularl# !ell appreciated in patients !it" truncal re lu9 at t"e sap"eno e%oral Cunction 'S)G(& It is $est palpated * inger$readt"s $elo! t"e inguinal liga%ent and Cust %edial to t"e e%oral arter#& I re lu9 is present, a orced coug"ing %aneuver %a# produce a palpa$le t"rill or sudden e9pansion at t"is level& T"e posterior sur ace o t"e cal is t"e territor# o t"e s"ort sap"enous vein& T"is %a# $e palpa$le in t"e popliteal ossa in so%e slender patients& Nor%al super icial veins a$ove t"e oot are usuall# not palpa$le even a ter prolonged standing& Palpation o an area o leg pain or tenderness %a# reveal a ir%, t"ic8ened, t"ro%$osed vein& T"ese palpa$le t"ro%$osed vessels are super icial veins, $ut an associated DVT %a# e9ist in as %an# as ,+> o patients !it" super icial p"le$itis& Varices o recent onset are easil# distinguis"ed ro% c"ronic varices $# palpation& Ne!l# dilated vessels sit on t"e sur ace o t"e %uscle or $oneH c"ronic varices erode into underl#ing %uscle or $one, creating deep I$ogg#I or Ispong#I poc8ets in t"e cal %uscle and deep palpa$le $on# notc"es, especiall# over t"e anterior ti$ia& Palpation o ten reveals ascial de ects in t"e cal along t"e course o an a$nor%al vein at sites !"ere super icial tri$utaries e%erge t"roug" openings in t"e super icial ascia& Inco%petent per orating veins %a# connect t"e super icial and deep venous s#ste%s t"roug" t"ese ascial de ects, $ut t"e inding is neit"er sensitive nor speci ic or per orator inco%petence&

Percussion

T"is tec"niEue is use ul in deter%ining !"et"er * venous seg%ents are directl# interconnected& Jit" t"e patient in a standing position, a vein seg%ent is percussed at one position !"ile an e9a%ining "and eels or a Ipulse !aveI at anot"er position& Percussion can $e used to trace out t"e course o veins alread# detected $# palpation, to discover varicose veins t"at could not $e palpated, and to assess t"e relations"ips $et!een t"e various varicose vein net!or8s& Valsalva or coug" !it" t"e e9a%iners "and over t"e %edial aspect o t"e 8nee can o ten elicit a palpa$le pulse !ave !it" lorid sap"eno e%oral Cunction inco%petence&

KNotes:A nor%al ;SV is t#picall# 21, %% in dia%eter in t"e %id t"ig"&

DI))ERENTIA3 DIA;NOSIS: BNerve root co%pression BArt"ritis BPerip"eral neuritis BTelangiectasia 1 s%aller, visi$le $lood vessels t"at are per%anentl# dilated BDeep vein t"ro%$osis

PAT5O3O;ICA3 )INDIN;S: BElongation and tortuosit# o veins B?edial i$rosis o veins BDisappearance or atrop"# o valves

SPECIA3 TESTS: Trendelen$urgLs test 'a test o t"e valves o t"e leg veinsH t"e leg is raised a$ove t"e level o t"e "eart until t"e

veins are e%pt# and is t"en rapidl# lo!eredH in varicosit# and inco%petence o t"e valves t"e veins !ill at once $eco%e distended, $ut place%ent o a touriEuet around t"e leg !ill prevent distention o veins $elo! t"e inco%petent per orators or valves $elo! t"e tourniEuet(
Pert"eLs test 'a test or patenc# o deep e%oral veinH !it" t"e patient standing, a tourniEuet is applied

a$ove t"e 8neeH a ter !al8ing, i deep circulation is co%petent, t"e super icial varicosities re%ain unc"anged and legs $eco%e pain ul&(
DIA;NOSTIC PROCEDFRES: BClinical inspection BDuple9 scanning, venous Doppler stud#, p"otoplet"#s%ograp"#, lig"t re lection r"eograp"#, air plet"#s%ograp"#, and ot"er vascular testing s"ould $e reserved or t"ose patients !"o "ave venous s#%pto%s andMor large '@, %% in dia%eter( vessels or large nu%$ers o spider telangiectasia indicating venous "#pertension

?anage%ent APPROPRIATE 5EA3T5 CARE: ;ENERA3 ?EASFRES: BConservative %et"ods B)reEuent rest periods !it" legs elevated B3ig"t!eig"t, elastic co%pression "osier#& Best put on $e ore getting out o $ed& BAvoid girdles and ot"er restrictive clot"ing BI stasis ulcers present, use !ar%, !et dressings BSpider veins 'idiopat"ic telangiectases( B)ine intracutaneous angiectasis B?a# $e e9tensiveMunsig"tl# BEli%inate !it" intracapillar# inCections o .> solution o sodiu% tetradec#l sul ate 'or "#pertonic saline *2&,>( using a ine1$ore needle BSu$seEuent treat%ents %a# $e reEuired until opti%al results attained SFR;ICA3 ?EASFRES: BSurgical and ot"er %et"ods BI t"ere is pain, recurrent p"le$itis, s8in c"anges, or or cos%etic i%prove%ent or severe cases B3igation and stripping o t"e sap"enous vein BInCection o sclerosing solution BSta$ evulsion p"le$ecto%# 1 ne!er procedure !it" s"orter recover# ti%e B)or e9tensive i$rosis 1 e9cision o t"e entire area, ollo!ed $# s8in gra t %a# $e necessar#

Indications
Surgical re%oval or o$literation o varicose veins is o ten or cos%etic reasons alone& Noncos%etic indications include s#%pto%atic varicosities 'eg, pain, atiga$ilit#, "eaviness, recurrent super icial t"ro%$op"le$itis, $leeding(, or or t"e treat%ent o venous "#pertension a ter s8in or su$cutaneous tissue c"anges, suc" as lipoder%atosclerosis, atrop"ie $lanc"e, ulceration, or "#perpig%entation, "ave developed&-:/ Conservative treat%ent !it" stoc8ings and e9ternal co%pression is an accepta$le alternative to surger#, $ut !orsening cutaneous indings or s#%pto%s despite t"ese %easure usuall# !arrant intervention& Nonet"eless, a patientLs desire or surgical %anage%ent over conservative treat%ent or or cos%etic purposes alone are $ot" reasona$le relative indications or surger#&

Contraindications
Patients !it" venous out lo! o$struction s"ould not "ave t"eir varicosities a$lated $ecause t"e# are i%portant $#pass pat"!a#s t"at allo! $lood to lo! around t"e o$struction& T"ose patients !"o cannot re%ain active enoug" to reduce t"e ris8 o postoperative deep vein t"ro%$osis 'DVT( s"ould not undergo surger#&
Surger# during pregnanc# is contraindicated $ecause %an# varicose veins o pregnanc# spontaneousl# regress a ter deliver# ACTIVITA:

BAvoid long periods o standing BAppropriate e9ercise routine as part o conservative treat%ent BJal8ing regi%en a ter sclerot"erap# is i%portant to "elp pro%ote "ealing BAppl# elastic stoc8ings $e ore lo!ering legs ro% t"e $ed BNever sit !it" legs "anging do!n Endovascular techniques

Endovenous 'EV( laser Radio reEuenc# 'R)( a$lation

Minimally invasive techniques

Cutaneous electrodesiccation Sclerot"erap#

DIET: BNo special diet BJeig"t loss diet reco%%ended, i o$esit# a pro$le%

EDFCATION: BIn or% patients t"at t"e surger# or sclerot"erap# %a# not prevent develop%ent o varicosities and t"at t"e procedure %a# need to $e repeated in later #ears

?EDICA?ENTOSA DRF;'S( O) C5OICE: InCection sclerot"erap# !it" co%pression to totall# o$literate t"e vein $# i$rosis& Sclerosant is sodiu% tetradec#l sul ate .12> solution& Bandages re%ain 2 !ee8s or longer&

Precautions: No oral contraceptives or at least 6 !ee8s prior to sclerot"erap# $ecause o t"eir t"ro%$ogenic e ect

A3TERNATIVE DRF;S:

Anti$iotics or in ected varicose ulcers

)O33OJ FP ?ONITORIN;: Fntil surger# or conservative t"erap# $rings %a9i%al $ene it

CO?P3ICATIONS: BPetec"ial "e%orr"ages BC"ronic ede%a BSuperi%posed in ection BVaricose ulcers BPig%entation BEc0e%a BRecurrence a ter surgical treat%ent BScarring or nerve da%age ro% stripping tec"niEue

PRO;NOSIS: BFsual course 1 c"ronic avora$le !it" appropriate treat%ent

RE)ERENCES

BBer8o! R, et al, eds: ?erc8 ?anual& .6t" Ed& Ra"!a#, NG, ?erc8 S"arp N Do"%e, .==* B;uidelines o care or sclerot"erap# treat%ent o varicose and telangiectatic leg veins& A%erican Acade%# o Der%atolog#& G A% Acad Der%atol .==6 ?arH2,'2(:4*21: