Recent Published Articles

Varicose veins - ABC of Arterial and Venous Disease

British Medical Journal May 20, 2000 by Nick J M London, Roddy Nash

Varicose veins are tortuous, twisted, or lengthened veins. Unless the enlargement is severe, size alone does not indicate abnormality because size can vary depending on ambient temperature and, in women, hormonal factors. In addition, normal superficial veins in a thin person may appear large, whereas varicose veins in an obese person may be hidden. Varicose veins can be classified as trunk, reticular, or telangiectasia. Telangiectasia are also referred to as spider veins, star bursts, thread veins, or matted veins. Most varicose veins are primary; only the minority are secondary to conditions such as deep vein thrombosis and occlusion, pelvic tumours, or arteriovenous fistulae.

Incidence and prevalence

A study of people aged 35 to 70 years in London in 1992 concluded that the prevalence of varicose veins in men and women was 17% and 31% respectively. Although varicose veins have traditionally been considered commoner in women, a recent study from Edinburgh of people aged 18 to 64 years found that the prevalence of trunk varices was 40% in men and 32% in women. Over 80% of the total population had reticular varicosities or telangiectasia. There are few studies on the incidence of varicose veins; however, the Framingham study found that the two year incidence of varicose veins was 39.4/1000 for men and 51.9/1000 for women.

Pathophysiology and risk factors

The theory that varicose veins result from failure of valves in the superficial veins leading to venous reflux and vein dilatation has been superseded by the hypothesis that valve incompetence follows rather than precedes a change in the vein wall. Thus, the vein wall is inherently weak in varicose veins, which leads to dilatation and separation of valve cusps so that they become incompetent. This theory is strongly supported by the observation that the dilatation of varicose veins is initially distal to the valve; if the primary abnormality was descending valve incompetence, the initial dilatation should be proximal to the valve.

Risk factors for varicose veins include increasing age and parity and occupations that require a lot of standing. There is no evidence that social class, smoking, or genetic makeup influence the prevalence of varicose veins. Obesity is associated with the development of varicose veins in women but not in men.

Symptoms

The Edinburgh vein study recently compared the prevalence of symptoms in men and women with and without varicose veins. In men, the only symptom that was significantly associated with trunk varices was itching, whereas in women, heaviness or tension, aching, and itching were significantly associated with trunk varices. No association was found between reticular varices and lower limb symptoms in either men or women.

Complications of varicose veins

Some complications of varicose veins, such as haemorrhage and thrombophlebitis, result from the varicose veins themselves, whereas others, such as oedema, skin pigmentation, varicose eczema, atrophie blanche, lipodermatosclerosis, and venous ulceration result from venous hypertension. The size of varicose veins does not seem related to the degree of venous hypertension. Indeed, 40% of limbs with ulceration due to superficial venous incompetence do not have visible varicose veins. Venous ulceration is discussed in a subsequent article.

Recurrent varicose veins

In the United Kingdom, about 20% of varicose vein surgery is for recurrence, and the estimated annual cost of such surgery is 11 m [pounds sterling]. Recurrent varicose veins can result from inadequate or defective primary surgery or the development of new sites of reflux. Improved patient assessment and more rigorous primary surgery should reduce the socioeconomic impact of recurrent varicose veins.

Clinical management

History

It is important to determine precisely why the patient has sought treatment. One third of patients presenting with varicose veins have symptoms unrelated to their varicose veins or are worried about deterioration or complications. Such patients simply need reassurance. It is important to determine whether the patient has had deep vein thrombosis or thrombophlebitis and any family history of deep vein thrombosis. History of these conditions increases the risk of deep vein thrombosis after varicose vein surgery and may lead to a decision not to operate. Patients with a history of deep vein thrombosis or thrombophlebitis who have surgery should receive perioperative subcutaneous heparin prophylaxis. It is important to note whether women are taking the contraceptive pill or hormone replacement therapy. Any history of skin changes is also important because affected patients are at high risk of developing ulceration.

Examination and investigation

Examination of the patient should include an abdominal examination to exclude some of the secondary causes of varicose veins. With the patient standing, note the distribution of the varicose veins, in particular whether they are long or short saphenous, or both. Secondary skin changes should be noted. Most vascular surgeons would then investigate the patient in the clinic using handheld Doppler or colour duplex scanning. Although ideally all patients presenting with varicose veins would have colour duplex scanning, the NHS does not have the resources to allow this. Patients with recurrent varicose veins should be scanned to determine the precise site of recurrence. Patients with varicose veins in limbs with a history of deep vein thrombosis or thrombophlebitis should be scanned to make sure that the superficial veins are not acting as collaterals in the presence of deep vein obstruction. Scanning is also essential for patients with venohypertensive skin changes. If the deep veins are competent in the presence of refluxing superficial veins, superficial venous surgery is potentially curative.

Treatment

As discussed, about a third of patients presenting with varicose veins will require only reassurance or explanation that their symptoms are not related to their varicose veins. Patients whose main symptoms are aching or oedema may benefit from compression hosiery. Indeed, if it is uncertain whether the patient's symptoms are caused by varicose veins, a trial of compression hosiery may help; a response to compression indicates that surgery may be beneficial.

The treatment options for trunk varices are injection sclerotherapy or surgery. The use of injection sclerotherapy for trunk varices has fallen in recent years, partly because of concerns about complications such as skin staining and ulceration and also because up to 65% of patients treated by sclerotherapy develop recurrent varicose veins within five years. Currently, sclerotherapy is most commonly used to treat residual varicosities after surgery. Surgery is generally directed at the underlying abnormality, in the form of saphenofemoral or saphenopopliteal disconnection, and in the case of long saphenous varices, stripping of the long saphenous vein with multiple avulsions.

Many patients can be treated as day cases, most can return to driving after one week, and the time off work varies between one and three weeks depending on the patient's occupation. The risk of serious complication (deep venous thrombosis, pulmonary embolism, or arterial or nerve injury) is less than 1%, but roughly 17% of patients will suffer minor complications, most commonly temporary saphenous or sural nerve neuralgia. All patients should be warned of this possibility. After surgery, 20-30% of patients develop recurrent varicose veins within 10 years.

Reticular varices are not connected to major trunk varices and are treated by sclerotherapy or avulsion through small stab incisions. Patients who present with capillary telangiectasia should have colour duplex scanning because roughly 25% will have clinically unapparent long or short saphenous incompetence. The telangiectasia are treated by microinjections, laser, or high intensity light. The last two methods are being increasingly used.

Management of complications

Thrombophlebitis

There is no indication for antibiotics in patients with thrombophlebitis. Patients should be referred to a vascular specialist and surgery considered because thrombophlebitis tends to recur if the underlying venous abnormality is not corrected. Colour duplex studies have shown that up to a quarter of patients with superficial thrombophlebitis have underlying deep venous thrombosis, and it has therefore been suggested that all patients with thombophlebitis should have duplex scanning to exclude deep vein thrombosis. However, a more realistic suggestion is that patients with phlebitis extending up the long saphenous vein towards the saphenofemoral junction should have urgent duplex scanning. If the thrombus extends into the femoral vein, urgent saphenofemoral ligation should be considered.

Bleeding varicose veins

Bleeding varicose veins can be stemmed by raising the foot above the level of the heart and applying compression. The patients should then be seen by a vascular surgeon with a view to correcting the underlying abnormality. If the deep veins are incompetent, the patient should wear compression hosiery.

Varicose eczema, lipodermatosclerosis, and venous ulceration

Patients with varicose eczema or lipodermatosclerosis require colour duplex scanning to define the underlying venous abnormality. Generally, if the only abnormality is superficial venous incompetence this should be surgically corrected. If, however, the deep veins are incompetent, then superficial surgery will not help and the patient should be treated with a topical steroid and wear compression hosiery.

Areas of controversy

Whose varicose veins should be treated?

In the absence of clear national guidelines the decision about who should receive varicose vein surgery under the NHS is being made at a local level. In general terms patients with only cosmetic problems are not treated whereas patients with skin changes (eczema, lipodermatosclerosis, and ulceration) are treated. The most controversial group is patients with symptomatic trunk varices and no skin changes. Unfortunately, there is no way of predicting which limbs with varicose veins will subsequently develop venous ulceration, and it is clearly not sensible to operate on the 30% of the population with varicose veins in order to prevent 1% developing an ulcer.

Varicose veins, deep vein thrombosis, contraceptive pill, and hormone replacement therapy

Although varicose veins increase the risk of deep vein thrombosis after major abdominal or orthopaedic surgery, there is no evidence that primary varicose veins are a risk factor for spontaneous deep vein thrombosis. Similarly, there is no evidence that women with varicose veins who take the contraceptive pill or hormone replacement therapy are at increased risk of deep vein thrombosis compared with women without varicose veins. Evidence exists, however, that women with varicose veins who take the pill are more likely to develop thrombophlebitis; a history of thrombophlebitis is therefore a contraindication to the pill and a reason for stopping the pill in current takers. Although not evidence based, the same considerations should probably apply to hormone replacement therapy.

Varicose vein surgery, contraceptive pill, and hormone replacement therapy

Although there is no evidence that varicose vein surgery is high risk for deep vein thrombosis, women taking the combined contraceptive pill or hormone replacement therapy are at increased risk of deep vein thrombosis after varicose vein surgery. Women taking the combined contraceptive pill should either stop the pill four weeks before surgery and restart two weeks later or receive subcutaneous heparin prophylaxis. If the pill is stopped advice must be given about alternative contraception. Women taking hormone replacement therapy should continue taking it and receive heparin thromboprophylaxis.

Symptoms associated with varicose veins
* Heaviness
* Tension
* Aching
* Itching

Complications of varicose veins
* Haemorrhage
* Thrombophlebitis
* Oedema
* Skin pigmentation
* Atrophie blanche
* Varicose eczema
* Lipodermatosclerosis
* Venous ulceration

Indications for colour duplex scanning of varicose veins
* Recurrent varicose veins
* History of superficial thrombophlebitis
* History of deep venous thrombosis
* Varicose eczema
* Haemosiderin staining
* Lipodermatosclerosis
* Venous ulceration

Management of thrombophlebitis
* Crepe bandaging to compress vein and minimise propogation of thrombus
* Analgesia (preferably non-steroidal anti-inflammatory drug)
* Low dose aspirin

Further reading
* Franks PJ, Wright DD, Moffatt CJ, Stirling J, Fletcher AE, Bulpitt CJ, et al. Prevalence of venous disease: a community study in West London. Eur J Surg 1992:158:143-7.
* Brand FN, Dannenberg AL, Abbott RD, Kannell WB. The epidemiology of varicose veins: the Framingham study. Am J Prev Med 1988;4:96-101.
* Bradbury A, Evans C, Allan P, Lee A, Ruckley CV, Fowkes FGR. What are the symptoms of varicose veins? Edinburgh vein study cross sectional population survey. BMJ 1999;318:353-6.
* Campbell B. Thrombosis, phlebitis, and varicose vein surgery. BMJ 1996;312:198-9.
* Royal College of General Practitioners' oral contraception study: oral contraceptives, venous thrombosis, and varicose veins. J R Coll Gen Pract 1978;28:393-9.
* Drugs in the peri-operative period: 3--Hormonal contraceptives and hormone replacement therapy. Drug Ther Bull 1999;37:78-80.
* Tibbs DJ. Varicose veins and related disorders. Oxford: Butterworth-Heinemann, 1992.
* Tibbs DJ, Sabiston DC, Davies MG, Mortimer PS, Scurr JH. Varicose veins, venous disorders, and lymphatic problems in the lower limbs. Oxford: Oxford University Press, 1997.
* Ruckley CV, Fowkes FGR, Bradbury AW. Venous disease. London: Springer-Verlag, 1998.
* Browse NI, Burnand KG, Irvine AT, Wilson NM. Diseases of the veins. London: Arnold, 1999.

Roddy Nash is consultant surgeon at Derbyshire Royal Infirmary, Derby. The ABC of arterial and venous disease is edited by Richard Donnelly, professor of vascular medicine, University of Nottingham and Southern Derbyshire Acute Hospitals NHS Trust (richard.donnelly@nottingham.ac.uk) and Nick J M London, professor of surgery, University of Leicester, Leicester (sms16@leicester.ac.uk). It will be published as a book later this year.

BMJ 2000;320:1391-4

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