Varicose veins are distended superficial veins measuring more than 3mm in diameter, usually affecting the legs.
Reticular veins are dilated blood vessels in the skin measuring less than 1-3mm in diameter.
Telangiectasia refers to dilated blood vessels in the skin measuring less than 1mm in diameter. They are also known as spider veins or thread veins.
Development
Veins contain valves that only allow blood to flow in one direction, towards the heart. In the legs, as the muscles contract, they squeeze blood upwards against gravity. The valves prevent gravity from pulling the blood back into the feet. When the valves become incompetent, the blood is drawn downwards by gravity and pools in the veins and feet.
The deep and superficial veins are connected by vessels called the perforating veins (or perforators), which allow blood to flow from the superficial veins to the deep veins. When the valves are incompetent in these perforators, blood flows from the deep veins back into the superficial veins and overloads them. This leads to dilatation and engorgement of the superficial veins, forming varicose veins.
Chronic Venous Insufficiency
When blood pools in the distal veins, the pressure causes the veins to leak small amounts of blood into the nearby tissues. The haemoglobin in this leaked blood breaks down to haemosiderin, which is deposited around the shins in the legs. This gives a brown discolouration to the lower legs.
Pooling of blood in the distal tissues results in inflammation. The skin becomes dry and inflamed, referred to as venous eczema.
The skin and soft tissues become fibrotic and tight, causing the lower legs to become narrow and hard, referred to as lipodermatosclerosis.
Risk Factors
- Increasing age
- Family history
- Female
- Pregnancy
- Obesity
- Prolonged standing (e.g., occupations involving standing for long periods)
- Deep vein thrombosis (causing damage to the valves)
Presentation
Varicose veins present with engorged and dilated superficial leg veins. They may be asymptomatic or have symptoms of:
- Heavy or dragging sensation in the legs
- Aching
- Itching
- Burning
- Oedema
- Muscle cramps
- Restless legs
Patients may also have signs and symptoms of chronic venous insufficiency (e.g., skin changes and ulcers).
Special Tests
Tap test – apply pressure to the saphenofemoral junction (SFJ) and tap the distal varicose vein, feeling for a thrill at the SFJ. A thrill suggests incompetent valves between the varicose vein and the SFJ.
Cough test – apply pressure to the SFJ and ask the patient to cough, feeling for thrills at the SFJ. A thrill suggests a dilated vein at the SFJ (called saphenous varix).
Trendelenburg’s test – with the patient lying down, lift the affected leg to drain the veins completely. Then apply a tourniquet to the thigh and stand the patient up. The tourniquet should prevent the varicose veins from reappearing if it is placed distally to the incompetent valve. If the varicose veins appear, the incompetent valve is below the level of the tourniquet. Repeat the test with the tourniquet at different levels to assess the location of the incompetent valves.
Perthes test – apply a tourniquet to the thigh and ask the patient to pump their calf muscles by performing heel raises whilst standing. If the superficial veins disappear, the deep veins are functioning. Increased dilation of the superficial veins indicates a problem in the deep veins, such as deep vein thrombosis.
Duplex ultrasound can be used to assess the extent of varicose veins. It is an ultrasound that shows the speed and volume of blood flow.
Management
Varicose veins in pregnancy often improve after delivery.
Simple treatment measures include:
- Weight loss if appropriate
- Staying physically active
- Keeping the leg elevated when possible to help drainage
- Compression stockings (exclude arterial disease first with an ankle-brachial pressure index)
Surgical options:
- Endothermal ablation – inserting a catheter into the vein to apply radiofrequency ablation
- Sclerotherapy – injecting the vein with an irritant foam that causes closure of the vein
- Stripping – the veins are ligated and pulled out of the leg
Complications
- Prolonged and heavy bleeding after trauma
- Superficial thrombophlebitis (thrombosis and inflammation in the superficial veins)
- Deep vein thrombosis
- All the issues of chronic venous insufficiency (e.g., skin changes and ulcers)
Last updated May 2021