Approach to the patient with varicose veins

J.Rowen MD,CCFP(EM)

Varicose Veins

1)SCOPE OF THE PROBLEM2)ANATOMY3)PATHOPHYSIOLOGY4)CLINICAL5)TREATMENT OPTIONS– SCLEROTHERAPY– ENDOVASCULAR ABLATION(EVLT)– COMPRESSION– SURGERY

OBJECTIVES

Scope of the problem

• About 50 % by age 50 (women);men somewhat less 25 % by age 40

• Incidence increases with age for all types of v.v.(spider veins,truncal varicosities).

• Heredity impacts largely on the incidence;eg:if you are female and BOTH parents have v.v.,then the chance is 90%.

ANATOMY• Understand that there are 2 parallel systems:• -A)DEEP SYSTEM:responsible for >90% of

venous circulation.Surrounded by muscle pump.

• -B)SUPERFICIAL SYSTEM:Truncal veins are subfascial;the majority in loose subcutaneous tissue.

• -C)PERFORATING VEINS:connect surface to deep.

Pathophysiology

• No one specific ‘cause’.• Primary and secondary causes• Definite genetic component• Primary changes to the integrity of the vein

wall(poorly organized smooth muscle,reduced amounts of elastin,increased amounts of collagen)-all lead to lack of compliance and diminished coaptation of valves.

Pathophysiology

• All changes to the wall and valvular insufficiency lead to venous hypertension and resultant inflammation.

• Many other secondary causes:obstruction(dvt,abdominal,pelvic),mus-cle pump ineffeciency,environmental(hormones,clothing,trauma).

Spider veins

CLINICAL

.Asymptomatic VS Symptomatic

.Asymptomatic have esthetic concerns which may have an impact on their lives

Definite symptoms associated with V.V.

SYMPTOMS

• Discomfort described as heaviness, throbbing,and aching especially when standing

• Night cramps(restless legs)• Swelling-edema• Pruritus-rash• Even spider veins may be symptomatic.Relief

with compression.

Spectrum

• Surface varicosities:• -A)Telangiectasia:spider veins.Smallest veins 1

mm in caliber.May or may not be associated with deeper varicosities.

• -B)Reticular veins:usually 3 mm or less in caliber.Often found on lateral surface of legs.More common in women.

Spectrum

• Truncal varicosities:• -leads to dilated,tortuous and bulging veins• -A)GSV:medial aspect proximal to distal with

different patterns.May also be anterior or posterior if tributaries are involved

• -B)SSV:present in posterior calf• -C)Tributaries:more superficial because they

are not subfascial.Anterior/posterior.

Spectrum

• Other;• -Corona phlebectatica:flare of veins on

medial/lateral ankle.Often represents advanced disease.

• -Lipodermatosclerosis:Fibrosis of the skin and subcutaneous tissue.Advanced disease.

• -Venous ulcer:usually found medial ankle.Painful.Advanced CVD.