Varicose veins

Most patients with varicose veins do not have any symptoms, but if present they include discomfort/pain
(especially on standing and in heat), itching ankles, swelling, ulceration, thrombophlebitis (pain, swelling
and redness over the varicose veins).

If you find a patient with varicose veins whilst doing a peripheral vascular system exam:

1. Inspect - distribution of VVs; is it long or short saphenous? Look with the patient standing and laying.

2. Feel the legs for any differences in temperature.

3. Feel the veins for localised tenderness, thickening and induration (thrombophlebitis), ulcers, oedema
around the ankles.

4. Elevate the limb to 15o and note the rate of emptying of the veins.

5. Perform the Trendelenberg test. Encourage the varicose veins to empty by stroking them in the
direction of flow and raise the leg to remove blood further. Use fingers or a tourniquet to occlude the
saphenofemoral junction. Ask the patient to stand. Remove the pressure – if the veins fill, there is
incompetence (if the incompetency is low down the leg, the veins may still fill even if you are still
occluding the saphenofemoral junction). The principle of the test is that varicose veins occur due to
retrograde flow of blood through incompetent valves from deep to superficial veins. If you stop the
backflow, the VVs remain collapsed, but fill when you release the pressure because backflow can occur
again.

6. Perform a tourniquet test. This is for when you think the incompetency is low down the leg (eg. veins
still fill even when pressure applied to saphenofemoral junction in Trendelenberg test). The veins are
emptied of blood and the tourniquet applied below the level of a suspected perforator. If there is
incompetence the veins will remain collapsed and will fill in a retrograde manner when the tourniquet is
released.

Questions around the topic

What other investigations might you want to do in a patient with varicose veins?
Duplex ultrasound
Colour Doppler can identify retrograde flow of blood at incompetent valves and perforators.

What is a varicose vein?

Varicose veins occur due to retrograde flow of blood through incompetent valves from deep to superficial
veins.

What is the basic anatomy of the long and short saphenous veins?
Long saphenous vein passes anterior to medial malleolus up the medial aspect of the calf to behind the
knee, then up the middle aspect of the thigh to join the common femoral vein in the groin at the
saphenofemoral junction. (ie. up medial aspect of leg)
Short saphenous vein passes behind lateral malleolus and up posterior aspect of calf. Commonly joins
popliteal vein at the saphenopopliteal junction – 2cm above posterior knee crease. (ie. up back of calf)

How can lower limb venous disease present?

4 types of venous leg disease:
DVT
Varicose veins
Superficial thrombophlebitis
Chronic venous insufficiency and ulceration

The four cardinal symptoms they present with are: Pain, Swelling, Discolouration, Ulceration