Varicose veins

Vascular

Clinicals - History

Fact Explanation
Introduction Varicose vein is the presence of dilated, tortuous superficial veins. The varicose veins are predominant and clinically significant in lower limb veins. It is a common disease and in most patients runs with out progressing to complications. The incidence rate varies in different regions of the world between 15-45% and commoner in adult female patients. The venous return of the leg occurs via superficial and deep veins of the leg, which are inter connected with perforators (Superficial to deep) mainly at three points; above ankle perforator, below knee perforator and above knee perforator. The pathophysiology of varicose veins is due to incompetent valves, saphenofemoral valve or incompetent perforators which allow the back flow of venous blood. In normal individuals the venous return is towards the heart, but in patients with varicose veins there is a back flow of venous column which develops a venous hypertension in the superficial veins. This venous hypertension causes the symptoms and complications of the disease. So the pooling of venous blood in the superficial venous system causes the tortuousity and related complications. The definite two territories can be identified in varicose veins as greater saphenous (from the medial malleolus, medial side of the thigh and up to the saphenofemoral junction closer to the inguinal region) and lesser saphenous (from the lateral malleolus, lateral and posterior aspect of the thigh up to the posterior aspect of popliteal fossa where the saphenopopliteal junction is) territories. Introduction
Varicose vein is the presence of dilated, tortuous superficial veins. The varicose veins are predominant and clinically significant in lower limb veins. It is a common disease and in most patients runs with out progressing to complications. The incidence rate varies in different regions of the world between 15-45% and commoner in adult female patients. The venous return of the leg occurs via superficial and deep veins of the leg, which are inter connected with perforators (Superficial to deep) mainly at three points; above ankle perforator, below knee perforator and above knee perforator. The pathophysiology of varicose veins is due to incompetent valves, saphenofemoral valve or incompetent perforators which allow the back flow of venous blood. In normal individuals the venous return is towards the heart, but in patients with varicose veins there is a back flow of venous column which develops a venous hypertension in the superficial veins. This venous hypertension causes the symptoms and complications of the disease. So the pooling of venous blood in the superficial venous system causes the tortuousity and related complications. The definite two territories can be identified in varicose veins as greater saphenous (from the medial malleolus, medial side of the thigh and up to the saphenofemoral junction closer to the inguinal region) and lesser saphenous (from the lateral malleolus, lateral and posterior aspect of the thigh up to the posterior aspect of popliteal fossa where the saphenopopliteal junction is) territories.
Age The disease in commoner in adult population and also the complications also can be seen among them with long standing varicose veins. Age
The disease in commoner in adult population and also the complications also can be seen among them with long standing varicose veins.
Gender Females are more prone to get varicose veins than males, could be mainly due to the pregnancy related insufficient venous flow due to the gravid uterus. Gender
Females are more prone to get varicose veins than males, could be mainly due to the pregnancy related insufficient venous flow due to the gravid uterus.
The occupation Occupations which needs prolong standing (eg;securities, soldiers) does not cause varicose veins, but they can detect the disease early and the symptoms would affect the occupation. Because on prolonged standing they may develop the pain and itching over the malleolar region. The occupation
Occupations which needs prolong standing (eg;securities, soldiers) does not cause varicose veins, but they can detect the disease early and the symptoms would affect the occupation. Because on prolonged standing they may develop the pain and itching over the malleolar region.
Dilated tortuous veins in the lower limb This the main presenting complain and the only symptom which is present in uncomplicated cases. Patient may complain than visible ugly worms like lumps in leg which are disappearing on lying down. In females and patients with cosmetic concerns this would be distressing and may present at early stage due to cosmetic reasons. The presentation could be unilateral or bilateral . Dilated tortuous veins in the lower limb
This the main presenting complain and the only symptom which is present in uncomplicated cases. Patient may complain than visible ugly worms like lumps in leg which are disappearing on lying down. In females and patients with cosmetic concerns this would be distressing and may present at early stage due to cosmetic reasons. The presentation could be unilateral or bilateral .
Pain over affected lower limb Patient will complain of pain over affected limb, especially following long standing. This occurs due to pooling of venous blood in limb for long time causing impairment of venous return leading to poor tissue perfusion. Typically the pain get relieved by elevating the limb or by walking. Pain over affected lower limb
Patient will complain of pain over affected limb, especially following long standing. This occurs due to pooling of venous blood in limb for long time causing impairment of venous return leading to poor tissue perfusion. Typically the pain get relieved by elevating the limb or by walking.
Swelling of the limb in standing for a long period Due to reduced venous return the intravasular pressure goes up and causes extravasation of fluids. Swelling of the limb in standing for a long period
Due to reduced venous return the intravasular pressure goes up and causes extravasation of fluids.
Itchiness of the affected limb The increased venous pressure causes extravasation of fluid and accumulation of inflammatory agents which leads venous eczema. Itchiness of the affected limb
The increased venous pressure causes extravasation of fluid and accumulation of inflammatory agents which leads venous eczema.
Bleeding from dilated veins Due to the pressure effect and excessive scratching resulting in damage to skin and underlying superficial dilated veins this bleeding can take place. The blood would spurt out from the veins and bleeding points can be identified separately as a more prominent bluish point.. Bleeding from dilated veins
Due to the pressure effect and excessive scratching resulting in damage to skin and underlying superficial dilated veins this bleeding can take place. The blood would spurt out from the veins and bleeding points can be identified separately as a more prominent bluish point..
Darkening of the skin in lower part mainly over the medial and lateral malleoli Due to the chronic venous pressure and extravasation of intravascular content the skin over the malleoli gets thickened and darkened. Hemosiderin causes staining over the affected skin. Darkening of the skin in lower part mainly over the medial and lateral malleoli
Due to the chronic venous pressure and extravasation of intravascular content the skin over the malleoli gets thickened and darkened. Hemosiderin causes staining over the affected skin.
Roughening of the skin Long standing venous hypertension would progress into lipodermatosclerosis causing skin changes.The mechanism of lipodermatosclerosis is multifactorial, involving leakage of proteins into the interstitium, tissue hypoxia, and leukocyte activation. Roughening of the skin
Long standing venous hypertension would progress into lipodermatosclerosis causing skin changes.The mechanism of lipodermatosclerosis is multifactorial, involving leakage of proteins into the interstitium, tissue hypoxia, and leukocyte activation.
Chronic non healing/ recurrent ulcers Venous ulcer is the most distressing complication of varicose veins which takes a long time to heal. This is multifactorial, poor venous return and resulting tissue congestion, poor capillary perfusion and deficient removal or organisms. These ulcers are typically occur over the malleoli (gaiter area of the leg). They are discrete or circumferential in shape with slopping and irregular edges. Chronic non healing/ recurrent ulcers
Venous ulcer is the most distressing complication of varicose veins which takes a long time to heal. This is multifactorial, poor venous return and resulting tissue congestion, poor capillary perfusion and deficient removal or organisms. These ulcers are typically occur over the malleoli (gaiter area of the leg). They are discrete or circumferential in shape with slopping and irregular edges.
History suggestive of Deep Venous Thrombosis The deep venous thrombosis can lead to insufficient flow through the perforators. But the varicose veins does not lead to deep venous thrombosis. So the history of prolong immobilization, painful leg swelling should be asked. History suggestive of Deep Venous Thrombosis
The deep venous thrombosis can lead to insufficient flow through the perforators. But the varicose veins does not lead to deep venous thrombosis. So the history of prolong immobilization, painful leg swelling should be asked.
Previous history of pelvic trauma or trauma to lower limb Pelvic trauma/ previous leg trauma can cause impedance to the venous drainage and could lead to varicose veins. Previous history of pelvic trauma or trauma to lower limb
Pelvic trauma/ previous leg trauma can cause impedance to the venous drainage and could lead to varicose veins.
Alteration of bowel habits, constipation, anal lumps and per rectal bleeding, haematuria, bladder out flow symptoms. Bowel pathologies involving the rectum and and colon can increase the pelvic pressure and causes poor venous flow leading to varicose veins. Other than the bowel bladder and gynaecological pathologies also can cause the similar effect. In malignant pathologies the venous invasion of the tumour can cause venous obstruction leading to simple varicose veins. So the occurrence of simple varicose veins could be a manifestation of sinister bowel pathology. Alteration of bowel habits, constipation, anal lumps and per rectal bleeding, haematuria, bladder out flow symptoms.
Bowel pathologies involving the rectum and and colon can increase the pelvic pressure and causes poor venous flow leading to varicose veins. Other than the bowel bladder and gynaecological pathologies also can cause the similar effect. In malignant pathologies the venous invasion of the tumour can cause venous obstruction leading to simple varicose veins. So the occurrence of simple varicose veins could be a manifestation of sinister bowel pathology.
In females gynaecological history such as per vaginal bleeding, pelvic pain, post coital bleeding, pelvic discharge As above gynaecological pathologies such as cervical carcinoma, endometrial carcinoma could lead to varicose veins due to increased pressure or vascular invasion. In females gynaecological history such as per vaginal bleeding, pelvic pain, post coital bleeding, pelvic discharge
As above gynaecological pathologies such as cervical carcinoma, endometrial carcinoma could lead to varicose veins due to increased pressure or vascular invasion.
cosmetic concerns Some patients even though the varicose veins are asymptomatic due to the cosmetic reasons they need interventions. cosmetic concerns
Some patients even though the varicose veins are asymptomatic due to the cosmetic reasons they need interventions.
Effect on daily living Some times the symptoms of varicose veins like pain ant itching on standing could lead negative effect on day to day activities. Effect on daily living
Some times the symptoms of varicose veins like pain ant itching on standing could lead negative effect on day to day activities.
method of contraception As exogenous hormones (eg; estrogen and progesterone in oral contraceptive pills) can make all symptoms worse, it is important to identify the female patient's method of contraception. This mainly due to the relaxation of smooth muscles of the veins . method of contraception
As exogenous hormones (eg; estrogen and progesterone in oral contraceptive pills) can make all symptoms worse, it is important to identify the female patient's method of contraception. This mainly due to the relaxation of smooth muscles of the veins .
History of previous treatments, if the patient is a diagnosed patient Detailed history about past history of varicose veins is very important as it can recur. Duration, previous treatments given are important. History of previous treatments, if the patient is a diagnosed patient
Detailed history about past history of varicose veins is very important as it can recur. Duration, previous treatments given are important.
Family history In some the varicose veins run in families. Family history
In some the varicose veins run in families.
Obstetric history In pregnancy varicose veins in lower limbs is a common complain. This is due to the hormonal changes (progesterone causes vascular smooth muscle relaxation) and increased intra-abdominal pressure by gravid uterus causing reduction of pelvic venous return.
Due to the same reasons Vulval varices (dilatation of vulval veins and venous pooling) also commonly arise during pregnancy causing pelvic discomfort and vulval itchiness.
Obstetric history
In pregnancy varicose veins in lower limbs is a common complain. This is due to the hormonal changes (progesterone causes vascular smooth muscle relaxation) and increased intra-abdominal pressure by gravid uterus causing reduction of pelvic venous return.
Due to the same reasons Vulval varices (dilatation of vulval veins and venous pooling) also commonly arise during pregnancy causing pelvic discomfort and vulval itchiness.

Clinicals - Examination

Fact Explanation
General condition of the patient like in pain/ discomfort, weight, height The obese patients are more prone to get varicose veins than lean ones. At general glance we can see whether patient is in discomfort while sitting with itching of the limbs like that. General condition of the patient like in pain/ discomfort, weight, height
The obese patients are more prone to get varicose veins than lean ones. At general glance we can see whether patient is in discomfort while sitting with itching of the limbs like that.
Inspection of the lower limb 1. Nature of the varicose veins 2. saphina varix 3. Ankle swelling 4. Darkening of the overlying skin 5. Superficial thrombophlebitis 6. Eczema 7. Bleeding points 8. Ulceration 9. Any evidence of associated deep vein thrombosis 1. Nature of the varicose veins
Tortuous dilated palpable superficial veins can be identified. They are compressible and can empty by compression. Left leg is more likely to affect than right. Veins are more prominent on standing. Affected territory must be checked. When greater saphenous is affected veins can be seen over thighs while lesser saphenous is affected, veins will be visible over popliteal fossa to below. usually greater saphenous vein is more affected than lesser. Previous surgical scars must be checked as it can be a recurrence.

2. saphina varix
This is a large dilated vein which can be seen in the antero lateral aspect of the thigh. There will be a vibratory sensation over( following turbulent flow) this and cough impulse will be present.

3. Ankle swelling
Due to reduced venous return the intravasular pressure goes up and causes extravasation of fluids.

4. Darkening of the overlying skin
There would be a skin thickening over the medial and lateral malleolar regions which is named as greator area. This is mainly multi-factorial and due to the fluid and plasma proteins extravasation (fibrin) which leads to sub cutaneous inflammation which is named as lipodermatosclerosis. Due to the subcutaneous inflammation and fibrous tissue formation the swelling would be less pitting. The overlying skin would be darkened due to the deposition of hemosiderin and other pigments.

5. Superficial thrombophlebitis
The veins would be inflamed with redness and tenderness over that.

6. Eczema
The so called venous eczema would be due to the long standing back pressure. Scratch marks will also be obvious in symptomatic patients.

7. Bleeding points
As another complications some dilated veins would rupture and start to bleed and there will be spurting of blood. This is mainly due to the venous pressure as well as due the weakened skin due to frequent scratching .

8. Ulceration
Venous ulcer is the most distressing complication of varicose veins which takes a long time to heal. Long standing venous hypertension would progress into lipodermatosclerosis and then in to venous ulcer. These wounds are typically over the malleoli (gaiter area of the leg). They are discrete or circumferential in shape with slopping and irregular edges.

9. Any evidence of associated deep vein thrombosis
Generalized assymetrical painful limb swelling without features of cellulitis would suggest deep vein thrombosis.
Inspection of the lower limb 1. Nature of the varicose veins 2. saphina varix 3. Ankle swelling 4. Darkening of the overlying skin 5. Superficial thrombophlebitis 6. Eczema 7. Bleeding points 8. Ulceration 9. Any evidence of associated deep vein thrombosis
1. Nature of the varicose veins
Tortuous dilated palpable superficial veins can be identified. They are compressible and can empty by compression. Left leg is more likely to affect than right. Veins are more prominent on standing. Affected territory must be checked. When greater saphenous is affected veins can be seen over thighs while lesser saphenous is affected, veins will be visible over popliteal fossa to below. usually greater saphenous vein is more affected than lesser. Previous surgical scars must be checked as it can be a recurrence.

2. saphina varix
This is a large dilated vein which can be seen in the antero lateral aspect of the thigh. There will be a vibratory sensation over( following turbulent flow) this and cough impulse will be present.

3. Ankle swelling
Due to reduced venous return the intravasular pressure goes up and causes extravasation of fluids.

4. Darkening of the overlying skin
There would be a skin thickening over the medial and lateral malleolar regions which is named as greator area. This is mainly multi-factorial and due to the fluid and plasma proteins extravasation (fibrin) which leads to sub cutaneous inflammation which is named as lipodermatosclerosis. Due to the subcutaneous inflammation and fibrous tissue formation the swelling would be less pitting. The overlying skin would be darkened due to the deposition of hemosiderin and other pigments.

5. Superficial thrombophlebitis
The veins would be inflamed with redness and tenderness over that.

6. Eczema
The so called venous eczema would be due to the long standing back pressure. Scratch marks will also be obvious in symptomatic patients.

7. Bleeding points
As another complications some dilated veins would rupture and start to bleed and there will be spurting of blood. This is mainly due to the venous pressure as well as due the weakened skin due to frequent scratching .

8. Ulceration
Venous ulcer is the most distressing complication of varicose veins which takes a long time to heal. Long standing venous hypertension would progress into lipodermatosclerosis and then in to venous ulcer. These wounds are typically over the malleoli (gaiter area of the leg). They are discrete or circumferential in shape with slopping and irregular edges.

9. Any evidence of associated deep vein thrombosis
Generalized assymetrical painful limb swelling without features of cellulitis would suggest deep vein thrombosis.
Palpation of the lower limb 1. Compressibility 2. Tap test 3. Tourniquet test 4. Peripheral pulse and evidence of peripheral vascular disease The varicose veins disappear on lying down position and on standing position the get compressed and get refilled with the release of pressure. That is called compressibility.

2. Tap test
Tapping over the one upper end of the dilated veins will transmit the impulse to the down end of the vein following valve incompetence.

3. Tourniquet test
This will be useful in identifying the incompetent territory.
Trendelenburg's test- this test will assess the valvular compitence.
Perthes' manoeuvre- this is useful in assessing deep venous patency.

4. Peripheral pulse and evidence of peripheral vascular disease
Peripheral pulse and evidence of peripheral vascular disease (cold periphery, absent pulse, pale skin and ulcers with necrotic surrounding) is very important in deciding the method of treatment. Pressure graded stockings will aggregate the symptoms in the absence of pulse/ presence of peripheral vascular disease, so need to be avoid.
Palpation of the lower limb 1. Compressibility 2. Tap test 3. Tourniquet test 4. Peripheral pulse and evidence of peripheral vascular disease
The varicose veins disappear on lying down position and on standing position the get compressed and get refilled with the release of pressure. That is called compressibility.

2. Tap test
Tapping over the one upper end of the dilated veins will transmit the impulse to the down end of the vein following valve incompetence.

3. Tourniquet test
This will be useful in identifying the incompetent territory.
Trendelenburg's test- this test will assess the valvular compitence.
Perthes' manoeuvre- this is useful in assessing deep venous patency.

4. Peripheral pulse and evidence of peripheral vascular disease
Peripheral pulse and evidence of peripheral vascular disease (cold periphery, absent pulse, pale skin and ulcers with necrotic surrounding) is very important in deciding the method of treatment. Pressure graded stockings will aggregate the symptoms in the absence of pulse/ presence of peripheral vascular disease, so need to be avoid.
Abdominal examination For presence of previous surgical scars suggestive of pelvic surgeries.
Any abdominal and pelvic masses causing venous obstruction.
Abdominal examination
For presence of previous surgical scars suggestive of pelvic surgeries.
Any abdominal and pelvic masses causing venous obstruction.
Digital examination of the rectum and vagina This just to exclude clinically detectable colonic and gynaecological malignancies. Digital examination of the rectum and vagina
This just to exclude clinically detectable colonic and gynaecological malignancies.

Investigations - Diagnosis

Fact Explanation
Hand-held Doppler This is a simple non invasive test use to assess the presence of varicose veins. It will assess the venous dilatation and the direction of the blood flow alone the superficial veins. also useful in measurement of ankle-brachial pressure index (ABPI). Hand-held Doppler
This is a simple non invasive test use to assess the presence of varicose veins. It will assess the venous dilatation and the direction of the blood flow alone the superficial veins. also useful in measurement of ankle-brachial pressure index (ABPI).
Duplex ultrasound imaging This is a combined investigation of both doppler studies and ultrasound scanning. it assess the anatomy of the veins and the extend of varicose veins. This also useful in excluding the associated deep vein thrombosis. Duplex ultrasound imaging
This is a combined investigation of both doppler studies and ultrasound scanning. it assess the anatomy of the veins and the extend of varicose veins. This also useful in excluding the associated deep vein thrombosis.
Colour-flow imaging In here the results of doppler studies are seen through the colour images. It is more sensitive and can be used to detect valve incompetence in small veins. Colour-flow imaging
In here the results of doppler studies are seen through the colour images. It is more sensitive and can be used to detect valve incompetence in small veins.
Magnetic resonance venography This is useful in finding out the other causes which can leads to similer symptoms by anatomical obstruction. Magnetic resonance venography
This is useful in finding out the other causes which can leads to similer symptoms by anatomical obstruction.
Plethysmography Plethysmography measures the volume changes of the venous system of the leg. This is useful in measuring maximum venous outflow, muscle pump ejection fraction and Venous refilling time. These indicators give an idea about the severity of disease and possible complications. Plethysmography
Plethysmography measures the volume changes of the venous system of the leg. This is useful in measuring maximum venous outflow, muscle pump ejection fraction and Venous refilling time. These indicators give an idea about the severity of disease and possible complications.
Ultrasound scan of the abdomen and pelvis This is important in assessing the presence of any intra abdominal/ pelvic masses which leads to development of varicose veins following venous out flow obstruction. Ultrasound scan of the abdomen and pelvis
This is important in assessing the presence of any intra abdominal/ pelvic masses which leads to development of varicose veins following venous out flow obstruction.

Investigations - Management

Fact Explanation
Duplex ultrasound imaging This will be useful in assessing the patients condition during follow up. Duplex ultrasound imaging
This will be useful in assessing the patients condition during follow up.
renal function tests like urine for protein urea, serum creatinine and blood urea As patient can develop ankle oedema renal failure need to be excluded. renal function tests like urine for protein urea, serum creatinine and blood urea
As patient can develop ankle oedema renal failure need to be excluded.
Echocardiogram As patient can develop ankle oedema heart failure also need to be excluded. Echocardiogram
As patient can develop ankle oedema heart failure also need to be excluded.
Liver function tests like AST,ALT, Serum protein Similerly renal disease also need to be excluded. Liver function tests like AST,ALT, Serum protein
Similerly renal disease also need to be excluded.
Swab from ulcer for culture and ABST As venous ulcers are chronic and at risk of getting infected, this will be useful. Swab from ulcer for culture and ABST
As venous ulcers are chronic and at risk of getting infected, this will be useful.
Full blood count, ESR, CRP These basic blood tests will assess the patients haemoglobin level and any evidence of ongoing inflammatory condition. Full blood count, ESR, CRP
These basic blood tests will assess the patients haemoglobin level and any evidence of ongoing inflammatory condition.
Hand-held Doppler This will useful in assessing the ankle-brachial pressure index (ABPI) which gives an idea about the arterial blood supply to the limb. Hand-held Doppler
This will useful in assessing the ankle-brachial pressure index (ABPI) which gives an idea about the arterial blood supply to the limb.
Duplex ultrasound imaging This also useful in assessing the disease condition. Duplex ultrasound imaging
This also useful in assessing the disease condition.
FBC, ESR, CRP These blood test will assess the patients basic conditions of haemoglobin levels( to detect any associated anaemic condition), ongoing inflammatory conditions (presence of infections) and platelet levels (to assess the bleeding tendency before invasive procedures). FBC, ESR, CRP
These blood test will assess the patients basic conditions of haemoglobin levels( to detect any associated anaemic condition), ongoing inflammatory conditions (presence of infections) and platelet levels (to assess the bleeding tendency before invasive procedures).
Chest x ray This will helpful in preoperative assessment of the Patient's fitness before giving general anaesthesis. Chest x ray
This will helpful in preoperative assessment of the Patient's fitness before giving general anaesthesis.
ECG and if needed echo cardiogram These test also important in pre operative fitness assessment. ECG and if needed echo cardiogram
These test also important in pre operative fitness assessment.
Clotting profile (PT/INR, APTT) Prior to surgery or other invasive procedures these test should be done to assess patients clotting status. Clotting profile (PT/INR, APTT)
Prior to surgery or other invasive procedures these test should be done to assess patients clotting status.
Hand-held Doppler This is useful as a screening test for identifying varicose veins and pheripheral vasculr disease using ankle-brachial pressure index (ABPI). Hand-held Doppler
This is useful as a screening test for identifying varicose veins and pheripheral vasculr disease using ankle-brachial pressure index (ABPI).
Clinical, etiological, anatomic, pathophysiological (CEAP) classification from the American Venous Forum( 2004) Clinical classification

C0: no visible or palpable signs of venous disease
C1: telangiectasies or reticular veins
C2: varicose veins
C3: edema
C4a: pigmentation or eczema
C4b: lipodermatosclerosis or atrophie blanche
C5: healed venous ulcer
C6: active venous ulcer

S: symptomatic, including ache, pain, tightness, skin irritation, heaviness, and muscle cramps, and other complaints attributable to venous dysfunction

A: asymptomatic

Etiologic classification

Ec: congenital
Ep: primary
Es: secondary (postthrombotic)
En: no venous cause identified

Anatomic classification

As: superficial veins
Ap: perforator veins
Ad: deep veins
An: no venous location identified

Pathophysiologic classification

Pr: reflux
Po: obstruction
Pr,o: reflux and obstruction
Pn: no venous pathophysiology identifiable
Clinical, etiological, anatomic, pathophysiological (CEAP) classification from the American Venous Forum( 2004)
Clinical classification

C0: no visible or palpable signs of venous disease
C1: telangiectasies or reticular veins
C2: varicose veins
C3: edema
C4a: pigmentation or eczema
C4b: lipodermatosclerosis or atrophie blanche
C5: healed venous ulcer
C6: active venous ulcer

S: symptomatic, including ache, pain, tightness, skin irritation, heaviness, and muscle cramps, and other complaints attributable to venous dysfunction

A: asymptomatic

Etiologic classification

Ec: congenital
Ep: primary
Es: secondary (postthrombotic)
En: no venous cause identified

Anatomic classification

As: superficial veins
Ap: perforator veins
Ad: deep veins
An: no venous location identified

Pathophysiologic classification

Pr: reflux
Po: obstruction
Pr,o: reflux and obstruction
Pn: no venous pathophysiology identifiable

Management - Supportive

Fact Explanation
Health education Patient should be educated about the condition, symptoms, complications, treatment options and prognosis. Health education
Patient should be educated about the condition, symptoms, complications, treatment options and prognosis.
reassurance If the patient is asymptomatic and not concerning it as a cosmetic problem reassurance can be done by modifying causative factors. reassurance
If the patient is asymptomatic and not concerning it as a cosmetic problem reassurance can be done by modifying causative factors.
lifestyle modifications maintain body weight by diet control, taking balanced diet and by regular physical exercise (avoid sedentary lifestyles). Reduction in obesity will be useful in primary, secondary and tertiary prevention. Reduced time of long standing will help in improving the symptoms. Maintaining good bowel habits, taking more fruits and fiber containing diet will help in improving the constipation. Stop smoking also important in prevention. lifestyle modifications
maintain body weight by diet control, taking balanced diet and by regular physical exercise (avoid sedentary lifestyles). Reduction in obesity will be useful in primary, secondary and tertiary prevention. Reduced time of long standing will help in improving the symptoms. Maintaining good bowel habits, taking more fruits and fiber containing diet will help in improving the constipation. Stop smoking also important in prevention.
Compression stockings Presence of peripheral vascular disease should be excluded before deciding this treatment option as it can aggravate the ischemia. this will nor improve the condition but will minimize the progression. various types of stockings are available and type will decide individually according to the patients current condition. According to the available evidence this has been shown to reduce the occurrence of venous ulcers. Compression stockings
Presence of peripheral vascular disease should be excluded before deciding this treatment option as it can aggravate the ischemia. this will nor improve the condition but will minimize the progression. various types of stockings are available and type will decide individually according to the patients current condition. According to the available evidence this has been shown to reduce the occurrence of venous ulcers.
post operative care and look for post operative complications Especially following the surgerry, patient is at risk of developing DVT and pulmonary embolus. So prophylactic phophilactic measures are important.
eg; well hydration, adequate mobilization of the patient, limb physiotherapy, thrombo embolic detergenic stocking and low molecular weight heparin in high risk patients.
As patient can develop pulmonary embolism need close monitoring for any recent symptoms of acute breathlessness, pleuritic type chest pain, haemoptysis, dizziness and syncopy.
There will be numbness over the limb in areas supplying sensation by sural nerve/ saphenous nerve. This can be due to the damage during the surgery.
Haematomas and bruising can occur over the surgical sites. as they are superficial will resolve spontaneously. if the haematoma is very large evacuation will be needed.
Other than these specific complications common post operative complications can occur like wound site infections, chest infections. So strict aseptic precautions will be needed in handling the patient and post operative prophylactic antibiotics will be helpful.
post operative care and look for post operative complications
Especially following the surgerry, patient is at risk of developing DVT and pulmonary embolus. So prophylactic phophilactic measures are important.
eg; well hydration, adequate mobilization of the patient, limb physiotherapy, thrombo embolic detergenic stocking and low molecular weight heparin in high risk patients.
As patient can develop pulmonary embolism need close monitoring for any recent symptoms of acute breathlessness, pleuritic type chest pain, haemoptysis, dizziness and syncopy.
There will be numbness over the limb in areas supplying sensation by sural nerve/ saphenous nerve. This can be due to the damage during the surgery.
Haematomas and bruising can occur over the surgical sites. as they are superficial will resolve spontaneously. if the haematoma is very large evacuation will be needed.
Other than these specific complications common post operative complications can occur like wound site infections, chest infections. So strict aseptic precautions will be needed in handling the patient and post operative prophylactic antibiotics will be helpful.

Management - Specific

Fact Explanation
Sclerotherapy (Injection sclerotherapy, Ultrasound guided form sclerotherapy) Sclerotherapy destroy the endothelium causing inducing clot formation finally leading to block and destroy the veins. Sclerosants are used like Sodium tetradecyl sulfate and polidocanol . This is useful in treating small veins. Sclerotherapy (Injection sclerotherapy, Ultrasound guided form sclerotherapy)
Sclerotherapy destroy the endothelium causing inducing clot formation finally leading to block and destroy the veins. Sclerosants are used like Sodium tetradecyl sulfate and polidocanol . This is useful in treating small veins.
endovascular ablation (Endovenous laser ablation and Radiofrequency ablation) In Endovenous laser ablation thrombosis and permanent endothelial damage is induced using heat.
In radio-frequency ablation, saphenous vein is blocked using radiofrequency thermal energy. Vein diameter should be more than 4.5mm for endovascular ablation. These are done with an endovenous catheter under the guidance of ultrasound scan.
endovascular ablation (Endovenous laser ablation and Radiofrequency ablation)
In Endovenous laser ablation thrombosis and permanent endothelial damage is induced using heat.
In radio-frequency ablation, saphenous vein is blocked using radiofrequency thermal energy. Vein diameter should be more than 4.5mm for endovascular ablation. These are done with an endovenous catheter under the guidance of ultrasound scan.
Ambulatory phlebectomy Remove all affected veins except proximal part of the long saphenous vein. This is being done with local anesthesia as an outpatient procedure. Ambulatory phlebectomy
Remove all affected veins except proximal part of the long saphenous vein. This is being done with local anesthesia as an outpatient procedure.
Transilluminated powered phlebectomy The surgical procedure is similer to ambulatory phlebectomy but it is done using a small surgical device. This needs general anesthesia. Transilluminated powered phlebectomy
The surgical procedure is similer to ambulatory phlebectomy but it is done using a small surgical device. This needs general anesthesia.
Saphenofemoral junction ligation and greater saphenous stripping or Saphenopopliteal junction ligation and lesser saphenous stripping The type of ligation and stripping is depend on the affected territory of the superficial veins. This is the final option of treatment following failing of other consecutive treatment options.
In greater Saphenofemoral junction ligation and greater saphenous stripping, First put small cut over groin and identify the femoral vein and Saphenofemoral junction. Then stripping is being done using various devices (eg: Mayo stripper, babcock device, keller device).
In saphenopopliteal junction ligation and lesser saphenous stripping, saphenopopliteal junction identified using an ultrasound scan and ligation done. then similerly stripping is done. This is associated with the risk of damaging to the vessels and nerves in the popliteal fossa.
Saphenofemoral junction ligation and greater saphenous stripping or Saphenopopliteal junction ligation and lesser saphenous stripping
The type of ligation and stripping is depend on the affected territory of the superficial veins. This is the final option of treatment following failing of other consecutive treatment options.
In greater Saphenofemoral junction ligation and greater saphenous stripping, First put small cut over groin and identify the femoral vein and Saphenofemoral junction. Then stripping is being done using various devices (eg: Mayo stripper, babcock device, keller device).
In saphenopopliteal junction ligation and lesser saphenous stripping, saphenopopliteal junction identified using an ultrasound scan and ligation done. then similerly stripping is done. This is associated with the risk of damaging to the vessels and nerves in the popliteal fossa.
Subfascial endoscopic perforator vein surgery This is a minimally invasive surgical procedure use in varicose veins to prevent complications. Subfascial endoscopic perforator vein surgery
This is a minimally invasive surgical procedure use in varicose veins to prevent complications.

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