Varicose Veins


Article Author:
Meghal Antani


Article Editor:
Jeffery Dattilo


Editors In Chief:
Susan Jeno
Renato Vilella
Sarah Fabiano


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Kyle Blair
Trevor Nezwek
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Abbey Smiley
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Daniyal Ameen
Altif Muneeb
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes
Komal Shaheen
Sandeep Sekhon


Updated:
6/3/2019 11:43:46 AM

Introduction

Venous reflux disease or venous reflux, which may also be referred to as chronic venous insufficiency, is a common condition. Venous reflux is usually the underlying cause of varicose veins, reticular veins, and telangiectasias (spider veins). In the lower extremities, venous reflux is categorized as superficial or deep. Superficial venous reflux involves the great and small saphenous veins and their tributaries, which are located between fascia and skin, and is treatable by a number of modalities including endovenous ablation, stripping, or avulsion. Deep venous reflux involves the femoral and other deep veins, which are located below fascia, and is not readily treated by endovascular methods. This article will focus on superficial venous reflux.[1][2][3]

Etiology

Venous reflux originates from the failure of the venous valves in the saphenous veins, which results in retrograde flow and stasis, or pooling, of venous blood in the branches of the saphenous veins. The normal ambulatory venous pressure in the extremity is regulated by the function of the valves.   If the valves no longer function this can translate into elevated ambulatory venous pressure and can produce symptoms.  The associated symptoms, including dilated visible veins at the skin surface (varicose veins, reticular veins, and telangiectasias), swelling, aching, heaviness, skin discoloration, and potential ulcer formation. A poor calf pump mechanism may worsen venous reflux.[4][5]

Risk Factors:

  • Family history 
  • Female sex
  • Increased age
  • Multiple pregnancies
  • Standing for long periods
  • Obesity
  • History of DVT

Ambulatory venous pressure with ambulation

  • Normal - 70% reduction 
  • Varicose veins - 30-40% reduction 

Epidemiology

Early stages of venous reflux may occur in as many as 25% of women and 15% of men.  Later stages of venous reflux, such as venous ulceration, may occur in 5% of the population (Rabe 2016).

Pathophysiology

There is a myriad of intrinsic and extrinsic faccotrs that contribute to the formation of varicose veins including, age gender, pregnancy, obesity, height, race, diet, occupation, hightory of DVT, and genetics.  The primary pathologies related to varicose veins are 1) elevated venous pressure in the extremities and 2) defective or destruction of the valves resulting in a reflux and thus elevated venous pressure in the extremity. 

History and Physical

The CEAP classification system of venous reflux is used to assess the clinical severity of symptoms:

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

Initial diagnosis is by clinical evaluation of swelling, discoloration, and skin ulcerations.

Evaluation

If venous reflux is suspected based on symptomatology and clinical evaluation the practitioner should obtain color duplex venous ultrasound exam.  This study is an objective assessment of the the anatomy of the veins as well as valvular function.   During the ultrasound, evaluation for deep vein thrombosis should also be performed to confirm that DVT/obstruction is not a contributing to the clinical scenario.[6][7]

Treatment / Management

Conservative Treatments

Some patients may obtain adequate symptom relief by using long-term graduated compression stockings, and through leg elevation and oral pain medications.  For compression rates the recommended graduation is 20-30 mmHg and in more severe cases can be elevated to 30-40 mmHg.  [8][9][10]

Surgical Treatment

Traditional surgical treatment consisted of ligation and stripping of the greater saphenous vein with avulsion of tributary veins.  

Endovascular Treatment

In the United States, surgical vein ligation and stripping has largely been replaced by catheter-based endovenous thermal ablation (EVTL). EVTL  is performed with either laser or radiofrequency as the source of the heat energy. The EVTL procedure is typically performed under ultrasound guidance and with a local anesthetic. If a patient is anxious, an oral anxiolytic may be of benefit.  Intravenous sedation is rarely required. During the EVTL procedure, a catheter is advanced (usually in an antegrade direction) into the incompetent saphenous vein, to within a few centimeters of the saphenofemoral (or saphenopopliteal junction). Tumescent anesthesia is administered to the entire length of the catheter. The catheter is connected to an external generator, and as the catheter is retracted out of the vein, the heat energy that is released by the catheter essentially cauterizes the saphenous vein in which the catheter is located. By doing so, the source of the reflux is eliminated. The venous blood return redirects via other "healthy" veins to the deep circulation.

Equally as popular is thermal ablation of the saphous vein uring radiofrequency energy to ultimately ablate the saphanous vein conduit(RFA - Radiofrequency ablation). Approval for this technique was granted permission in 1999 by the FDA.   Many studies have been published comparing the two techniques but the general consensus states that both are equally successful but there tended to be fewer side effects with RFA. (**)need ref. 

Supplemental Procedures

In addition to treating the venous reflux within the saphenous veins, many patients will also have visible superficial veins including reticular veins (1 mm to 3 mm diameter) and telangiectasias (under 1  mm diameter). Collectively these may be referred to as "spider veins" in lay terminology.  In addition to being unsightly, may also be painful to local pressure. Liquid sclerotherapy involves the injection of a dilute medication (sclerosant) into the superficial telangiectasias and reticular veins. Phlebectomy involves the removal of larger superficial varicose veins through small 2 mm to 3 mm incisions.

Compression Therapy

Patients with milder symptoms of venous reflux disease may obtain adequate symptomatic relief with compression stockings.   Compression stockings should at the minimum reach the level of the upper calf.  Thigh high compression stockings are preferable if tolerated. After most treatments for venous reflux and its stigmata, compression stockings are recommended, although exact guidelines for duration and strength of compression are not available. A common compression strength after ablation is 20 mmHg to 30 mmHg. Recommended length of compression therapy may range from several days to 2 weeks, depending on the severity of symptoms and type of treatment (Nazarko 2017). Some patients with more severe lower extremity swelling may benefit from a longer period of compression therapy, with possible adjunctive home based pneumatic compression (Lurie 2017).

Post-Procedure Followup

After endovenous ablation treatment, most physicians recommend duplex ultrasound examination of the treated leg within the first week, focusing on the saphenofemoral (or saphenopopliteal) junction to evaluate for deep vein thrombosis, even though the likelihood of forming DVT after endovenous ablation is minimal, under 1% (Nazarko 2017).

Differential Diagnosis

  • Lymphedema
  • Deep vein thrombosis
  • Cellulitis
  • Stasis dermatitis

Complications

  • Venous ulcers
  • Pain
  • Poor cosmesis

Deterrence and Patient Education

  • Graduated compression hose
  • Healthy weight
  • Exercise

Pearls and Other Issues

Venous reflux disease is a common condition that results in a considerable lifestyle impact due to the symptoms of leg pain and swelling, and that has the potential to cause more significant morbidity by eventual venous ulcer formation. Treatment with endovenous ablation with a period of compression therapy is usually effective in reducing the associated symptoms.

Enhancing Healthcare Team Outcomes

Varicose veins are very common in society and often lead to poor cosmesis and fatigue. However, most patients seek medical assistance because of the poor cosmesis. Today, general and vascular surgeons perform several different types of procedures to treat varicose veins but recurrence is a problem. More important, varicose vein surgery is considered cosmetic and not covered by most health plans, so the patient is left to pay for the entire cost. Each year, consumers spend millions of dollars on care of varicose veins. In view of the fact that recurrences are common and that surgical procedures also have complications, prevention is key. Both the pharmacist and nurse are in a primary position to educate the patient on how to prevent varicose veins. By wearing compression stockings, maintaining a healthy weight, and exercise,  varicose veins can be prevented at low cost in most people. In addition, the patient should be educated that if the varicose vein is untreated, it can lead to a venous ulcer which is very difficult to cure and costs the healthcare system millions of dollars each year. Finally, when evaluating a patient with a varicose vein, suspicion for a DVT should be high and the patient should be referred for a duplex ultrasound. Before referring any patient for surgery, the nurse and pharmacist should advise the patient to change lifestyle, stop smoking, elevate the legs at bedtime and wear stockings- for those who comply there is no need for any type of surgery.[11][12][13] (Level V) 

Evidence-based Outcomes

Every type of surgical procedure has good to excellent outcomes for varicose veins, but each one is associated with recurrence. For those who develop a venous ulcer, the morbidity is very high as there is no cure. It is also important to note that patients with varicose veins are also at a high risk for deep vein thrombosis, which requires prolonged treatment with an anticoagulant which carries further morbidity from the side effects like bleeding. (Level V) Hence, a multidisciplinary approach to varicose veins is recommended to achieve good outcomes.  [9][3][14](Level V)


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Varicose Veins - Questions

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Which of the following is not true of varicose veins?



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Which of the following is a not surgical treatment for varicose veins?



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A 37-year-old woman is one day postpartum. She is noted to have multiple lower extremity varicosities. Which of the following would be most appropriate?



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What is the name given to torturous enlarged veins?



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What is the most important underlying risk factor for the development of venous reflux disease?



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Which of the following may be used to treat varicose veins? Select all that apply.



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A nurse is caring for a patient with varicose veins, and the patient asks about how she can prevent them from getting worse. What should be included in patient education regarding varicose veins? Select all that apply.



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A 66-year old female presents to the office complaining of pain in her lower left extremity with a burning and itching sensation. Upon physical examination, there is edema and enlarged veins just below the surface of the skin. What is the most significant risk factor associated with this diagnosis?



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Varicose Veins - References

References

Yang GK,Parapini M,Gagnon J,Chen JC, Comparison of cyanoacrylate embolization and radiofrequency ablation for the treatment of varicose veins. Phlebology. 2018 Aug 16     [PubMed]
Epstein D,Onida S,Bootun R,Ortega-Ortega M,Davies AH, Cost-Effectiveness of Current and Emerging Treatments of Varicose Veins. Value in health : the journal of the International Society for Pharmacoeconomics and Outcomes Research. 2018 Aug     [PubMed]
Oliveira RÁ,Mazzucca ACP,Pachito DV,Riera R,Baptista-Silva JCDC, Evidence for varicose vein treatment: an overview of systematic reviews. Sao Paulo medical journal = Revista paulista de medicina. 2018 Jul 16     [PubMed]
de Mik SM,Stubenrouch FE,Legemate DA,Balm R,Ubbink DT, Treatment of varicose veins, international consensus on which major complications to discuss with the patient: A Delphi study. Phlebology. 2018 Jan 1     [PubMed]
DePopas E,Brown M, Varicose Veins and Lower Extremity Venous Insufficiency. Seminars in interventional radiology. 2018 Mar     [PubMed]
Tolu I,Durmaz MS, Frequency and Significance of Perforating Venous Insufficiency in Patients with Chronic Venous Insufficiency of Lower Extremity. The Eurasian journal of medicine. 2018 Jun     [PubMed]
Nybo J,Nybo M,Hvas AM, [Diagnostic work-up and treatment of superficial vein thrombosis]. Ugeskrift for laeger. 2018 Aug 13     [PubMed]
Davies HOB,Popplewell M,Bate G,Ryan RP,Marshall TP,Bradbury AW, Analysis of Effect of National Institute for Health and Care Excellence Clinical Guideline CG168 on Management of Varicose Veins in Primary Care Using the Health Improvement Network Database. European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery. 2018 Aug 24     [PubMed]
Wallace T,El-Sheikha J,Nandhra S,Leung C,Mohamed A,Harwood A,Smith G,Carradice D,Chetter I, Long-term outcomes of endovenous laser ablation and conventional surgery for great saphenous varicose veins. The British journal of surgery. 2018 Aug 22     [PubMed]
Kemp N, A synopsis of current international guidelines and new modalities for the treatment of varicose veins. Australian family physician. 2017     [PubMed]
Caputo WJ,Kaplan MD,Kamieniecki RE,Hawkins M,Monterosa P,Eagen K,Ike T,Iannitelli A, Venous Intervention Improves Patient Outcomes. Surgical technology international. 2017 Jul 25     [PubMed]
Marola S,Ferrarese A,Solej M,Enrico S,Nano M,Martino V, Management of venous ulcers: State of the art. International journal of surgery (London, England). 2016 Sep     [PubMed]
Alavi A,Sibbald RG,Phillips TJ,Miller OF,Margolis DJ,Marston W,Woo K,Romanelli M,Kirsner RS, What's new: Management of venous leg ulcers: Approach to venous leg ulcers. Journal of the American Academy of Dermatology. 2016 Apr     [PubMed]
Al Shakarchi J,Wall M,Newman J,Pathak R,Rehman A,Garnham A,Hobbs S, The role of compression after endovenous ablation of varicose veins. Journal of vascular surgery. Venous and lymphatic disorders. 2018 Jul     [PubMed]

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