Varicose veins are dilated

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1 Investigating and managing varicose veins in practice Varicose veins are common, and are usually caused by weak vein walls and valves. Most people with varicose veins will not have any complications at all, and may only present because of the appearance of the tortuous veins. Healthcare professionals should assess the degree of vascular incompetency and tailor treatment to the individual patient s needs. Varicose veins are common in both men and women, and are found in 20% of men and 30% of women. NASEER AHMAD Consultant Vascular Surgeon, Manchester Royal Infirmary, Manchester RAJAB KHAN Medical Student, University of Manchester, Manchester SANDHIR KANDOLA Specialist Registrar, Manchester Royal Infirmary, Manchester 24 Wound Essentials 2017, Vol 12 No 1 Varicose veins are dilated and tortuous veins; they can be considered the visible expression of venous insufficiency syndrome. The venous system in the lower limb is comprised of deep and superficial veins. The long saphenous vein and short saphenous vein drain into the deep venous system at the saphenofemoral junction (SFJ) and saphenopopliteal junction (SPJ) respectively. Multiple perforating veins allow further connections between the superficial and deep veins. When the gastrocnemius and soleus muscles in the calf contract, they increase the pressure in the deep venous system, allowing the blood to be moved. The consequent fall in pressure on relaxation allows passive flow of blood from the superficial venous system into the deep venous system. The veins contain bicuspid valves, which only allow flow of blood one way. Chronic venous insufficiency occurs when venous pressure increases, resulting in a decrease in venous return. This venous hypertension causes endothelial disruption, resulting in extravasated red blood cells, oedema and microlymphatic damage (Bergan et al, 2006; Sprague et al, 2009). The increase in venous pressure can be due to incompetence in the superficial or deep venous systems. Superficial venous incompetence is usually a primary problem. The valves in superficial veins that normally prevent reflux into the deep venous system are dysfunctional, resulting in increased superficial venous pressure. In particular, incompetence of the valves at the SFJ and SPJ is diagnostic of superficial venous incompetence. Deep venous incompetence is most often secondary to chronic obstruction of the deep venous system. It can be caused by previous deep venous thrombosis (DVT), or from scarring of the femoral vein from intravenous (IV) drug use, for example. Varicose veins are classed as primary or secondary. Primary venous disease is due to either innate morphological distortion of the vein walls or internal biochemical abnormalities. Indeed, prolonged standing is a major causative factor leading to intrinsic abnormalities and subsequent progressive dilation (Robertson et al, 2008).

2 Thrombophlebitis, DVT, arteriovenous fistula or generally increased pressure are all rare secondary causes of varicosities; of this small group DVTs are the most common. However, the pressure effects due to tumour growth or pregnancy cannot be overlooked. The pressure in deep veins is increased, which blocks the flow from the superficial veins and allows allowing progressive dilatation in the superficial veins. Varicose veins are common in both men and women, and are found in 20% of men and 30% of women aged years (Evans et al, 1999). Pregnancy can precipitate the development of varicose veins and may explain the increased prevalence in women. Other risk factors include (Beebe-Dimmer et al, 2005): 8 Increased age 8 Obesity 8 Positive family history 8 Coagulation disorders (Factor V Leiden) 8 Female 8 Lack of movement/prolonged standing. Presentation and assessment Varicose veins may be completely Style: Introduction asymptomatic. Patients most commonly notice the unsightly appearance of the veins themselves. Varicose veins are associated with aching, heaviness, swelling and throbbing of the affected limb, particularly after standing for long periods of time. People may also present with itching, swelling or dry skin around the varicosities. In patients with lower limb symptoms, it is difficult to establish how significant the contribution of varicose veins is (Bradbury et al, 1999). Some patients may present with a complication from their varicose veins (Table 1). One of the most troublesome complications is the development of leg ulcers. Most people with varicose veins will not have any complications at all and it is important to reassure patients about this. The main reason for presentation is due to their unsightly appearance. Pain and heaviness in the legs are commonly reported, with 7% presenting because of complications and 16% due to concerns about future Table 1. Complications of varicose veins (Lamping et al, 2003; Racette and Sauvageau, 2005; Morton and Phillips, 2013). Style Quote Complication Mechanism of damage Management Superficial thrombophlebitis Corona phlebectatica STYLE: AUTHOR NAME Style: author details 26 Wound Essentials 2017, Vol 12 No 1 Inflammatory-thrombotic disorder of the superficial vessels. Predisposition due to intimal damage, turbulent blood flow or increased coagulability. Cutaneous manifestation of chronic venous insufficiency. Predominantly visible blood vessels at the ankle. Topical anti-inflammatory Duplex to rule out deep venous system involvement Oedema Swollen tissue. Exclude systemic causes Haemosiderin An iron-storage complex which when deposited can cause permanent discolouration. Can be exacerbated by haemolysis, excessive iron or decreased iron use. Venous eczema Dry, scaly and itchy rash. Investigate for generalised eczema Lipodermatosclerosis Atrophie blanche Haemorrhage Venous ulcer Connective tissue disease caused by inflammation of the fascia below the epidermis. Abnormality of skin scars. Can occur at the site of previous venous ulcers/surgical sites. The white scar tissue contains dilated capillaries. Very dilated and torturous veins can bleed with minimal trauma. Haemorrhage can be profuse. Shallow ulcer with sloughly edges found in the gaiter area this is the area around the medial malleolus. Elevate Apply pressure Offload Compressive bandaging

3 Table 2. Clinical Impact, Etiology, Anatomy and Pathology (CEAP) classification. Clinical classification Etiological classification Anatomical classification Pathophysiological classification C0 No visible or palpable signs of venous disease C1 Telangiectasia or reticular veins C2 Varicose veins C3 Oedema C4a Pigmentation or eczema C4b Lipodermatosclerosis or athrophie blanche C5 Healed venous ulcer C6 Active venous ulcer Ec Ep Es En As Congenital Primary Secondary No venous cause identified Superficial Ap Deep Ad Perforator veins An No venous location identified Pr Po Reflux Obstruction Pro Reflux and obstruction Pn No venous pathophysiology identifiable Investigation The degree of vascular incompetency can be assessed using a combination of history, examination and bedside tests, along with grading tools. Often patients will present with disease sequelae including: discomfort and leg heaviness, night cramps, oedema, restless legs and paraesthesia or complications (Table 1). Paradoxically, subjective symptoms can vary wildly between patients. However, as a general rule, the pain is severe in early disease, less severe in middle stage and much worse late stage (Piazza, 2014). The following details also need to be determined: 8 Previous venous problems including any during pregnancy 8 Risk factor assessment family history, job with prolonged standing, history of leg trauma 8 History of superficial vein thrombosis, deep vein thrombosis or thrombophlebitis 8 Any cardiovascular comorbidity. deterioration (O Leary et al, 1996; Campbell et al, 2006). Grading tools There are tools available which can be used to aid the assessment of venous disorders. The Clinical Impact, Etiology, Anatomy and Pathology (CEAP) classification can be used to stratify patients and allow treatment to be tailored to the patient s needs (Table 2) (Eklof et al, 2004). The CEAP classification can be used as a tool to support the clinician standardise treatment and be used as a reporting tool for prevalence and incidence of venous insufficiency. The Venous Clinical Severity Score uses a more patient-centred approach. This contains nine separate markers for venous disease that can be scored dependent on severity; from 0 to 3 (Table 3) (Vasquez et al, 2010). Venous leg ulcers Ulceration is the most troublesome complication of venous insufficiency, with venous ulcers being the most common type of leg ulcer. Venous ulcers take months or even years to heal and require intensive management with frequent dressings. Patients with venous or healed ulceration and superficial venous incompetence will usually meet the criteria for surgical treatment of varicose veins. Once healed, varicose vein surgery is effective in reducing the incidence of recurrent venous ulceration. In the presence of active ulceration, surgery does not increase the rate of ulcer healing (Gohel et al, 2007; Kheirelseid et al, 2016). Therefore, any venous ulcer must be healed at the time of treatment, to minimise the risk of infective complications. Duplex ultrasound is the investigation of choice and is used to assess for reversed flow and valve closure time. It is the gold standard as it is non-invasive, cost effective and able to be performed anywhere. Reflux is defined as valve closure >0.5 seconds in the superficial veins and >1.0 seconds in the deep system. The patient should be standing up, with the leg being investigated externally rotated. Colour-flow imaging (triplex ultrasonography) is very sensitive and can be used to visualise small valve leaks and incompetency in small perforator veins. Other imaging modalities are rarely indicated, although MRI is useful for pelvic veins. Those with deep vein obstruction or requiring open surgery can be offered contrast venography, where contrast dye is injected, allowing complete visualisation. Wound Essentials 2017, Vol 12 No 1 27

4 Treatment For patients with asymptomatic varicose veins, reassurance that they do not cause harm and that surgical intervention is not necessarily indicated is important. Patients with both asymptomatic symptomatic varicose veins may employ some simple measures to alleviate their condition: 8 Elevate legs when sitting or lying down to minimise oedema 8 Moisturise the skin to prevent eczema 8 Avoid trauma to prevent episodes of bleeding 8 Maintain a healthy weight 8 Take light to moderate physical activity 8 Stop smoking. This is of particular importance in those with an ulcer, because smoking impairs wound healing 8 Wear compression hosiery. Compression hosiery applies graduated pressure along the limb. The highest pressure (25mmHg) is around the talocrural region (ankle) with the pressure decreasing proximally (Mauck et al, 2014). Compression hosiery has been shown to alleviate the symptoms of varicose veins (Chant et al, 1985; Lurie and Kistner, 2011). However, compression hosiery will not eliminate the varicosities themselves. To be effective, compression hosiery must be class 1 or 2, and below knee length, unless swelling and varicosities are significant in the thigh. Prior to commencing any compression therapy, carry out a full patient assessment and a Doppler to exclude arterial disease. The patient s anklebrachial pressure index (ABPI) must be measured and be above 0.8 prior to stockings being issued. If the ABPI is reduced, refer to a vascular specialist. Compression hosiery must always be fitted to the patient. Compression stockings are only recommended as treatment for varicose veins if the patient is not suitable for any kind of surgical intervention (National Institute for Health and Care Excellence [NICE], 2013). Table 3. The Venous Clinical Severity Score. Attribute Absent = 0 Mild = 1 Moderate = 2 Severe = 3 Pain None Occasional, not restricting activity or requiring pain medication Daily moderate activity limitation; occasional pain medication Varicose veins None Few scattered Multiple; great saphenous veins, confined to calf and thigh Venous oedema None Evening ankle swelling only Skin pigmentation None Diffuse, but limited in area and old (brown) Inflammation None Mild cellulitis, limited to marginal area around ulcer Afternoon swelling, above ankle Diffuse over most of gaiter distribution (lower third) or recent pigmentation (purple) Moderate cellulitis, involves most of (lower third) Induration None Focal, circummalleolar Medial or lateral, less than lower third of leg Number of active ulcers >2 Active ulcer duration None <3 months Between 3 months and 1 year Active ulcer diameter (cm) None <2 2 6 >6 Compression therapy Not used/patient not compliant Intermittent stocking use Elastic stocking use on most days Daily, severe limiting activities or requiring regular use of pain medications Extensive; thigh and calf or great and small saphenous distribution Morning swelling above ankle and requiring activity change, elevation Wider distribution (above lower third) plus recent pigmentation Severe cellulitis (lower third and above) or significant Entire lower third of leg or more >1 year Full compliance, stockings and elevation 28 Wound Essentials 2017, Vol 12 No 1

5 Surgical intervention Current NICE guidance advises that all patients with symptomatic varicose veins should be referred to a specialist vascular service (NICE, 2013). At present, local clinical commissioning groups ration surgical intervention for varicose veins, and the referral criteria are determined locally. The eligibility for surgical treatment is determined by the Venous Scoring System, the CEAP classification or another validated scoring system. In general, patients with active or healed venous ulceration will usually meet the criteria for treatment. Surgical intervention for varicose veins is directed at those patients with superficial venous incompetence. Deep venous incompetence is not routinely treated with surgery and the mainstay of treatment is compression therapy. The aim of surgery is to ablate or remove the incompetent superficial vein, forcing the varicose veins to drain into the deep venous system by other means. Over the past 10 years, endovenous treatment has become the mainstay of superficial venous surgical intervention, replacing open surgery as the firstline treatment modality and endorsed by NICE. Endovenous ablation Endovenous ablation is usually performed as day case surgery under local anaesthesia. It involves introducing a catheter into the incompetent vein (usually the long saphenous or short saphenous vein) and using radiofrequency, laser or mechanochemical means to cause ablation of the vein. The procedure takes approximately 45 minutes and the patient is able to mobilise immediately. The leg may be bandaged afterwards and a compression stocking may be recommended up to one week postprocedure. The patient can mobilise immediately and can be discharged 1 2 hours later. Endovenous ablation is safe and effective in the long term, with low recanalization and recurrence rates (Nesbitt et al, 2014). It carries a small risk of bruising or haematoma, bleeding, scarring or hyperpigmentation, phlebitis, residual varicosities and long term recurrence. Foam sclerotherapy Foam sclerotherapy involves the direct injection of a chemical into the vein resulting in its ablation, and is an effective treatment for varicose veins (Jia et al, 2007). As the chemical is an irritant to the vein, the risk of phlebitis is higher with this technique. No anaesthesia is usually required and the procedure can be performed in the outpatient clinic, sometimes with the use of ultrasound guidance. Repeat treatments may be necessary as only small areas of varicose veins can be treated at a time. Foam sclerotherapy is nevertheless the recommended treatment for recurrences of varicose veins (van den Bos, 2009). Open surgery Endovenous techniques require that the incompetent vein be of a suitably wide calibre and not too tortuous to allow passage of the catheter. Should the incompetent vein be unsuitable for endovenous treatment open surgery can be performed. This involves disconnecting the incompetent vein (in Table 4. When to refer to secondary care. Emergency referral (within 24 hours) Urgent referral (within 1 week) the groin for long saphenous surgery, in the popliteal fossa for short saphenous surgery) and removing it. At the same time, the individual varicose veins are also usually picked out. Although still usually a day case procedure, this operation requires general or regional anaesthesia and has a longer recovery time than endovenous treatments (Brar et al, 2010). An open operation will leave a scar in the groin or behind the knee and carries additional risks of poor wound healing, nerve damage, seroma formation and any risks from the anaesthetic. NICE (2013) recommends the following interventional treatment for people with confirmed varicose veins and truncal reflux: 8 Offer endothermal ablation and endovenous laser treatment of the long saphenous vein. 8 If endothermal ablation is unsuitable, offer ultrasound-guided foam sclerotherapy. 8 If ultrasound-guided foam sclerotherapy is unsuitable, offer surgery. 8 If incompetent varicose tributaries are to be treated, consider treating them at the same time. Referral to secondary care needs to be prompt to prevent limb deterioration and to enable limb salvage (Table 4). 8Active bleeding from varicose veins which has eroded the skin 8 History of active bleeding 8 High risk of future bleeding 8 Individuals with worsening or painful leg ulcers despite treatment optimisation Routine referral 8 Symptom causing varicose veins 8 Skin pigmentation or eczema as a result of chronic venous insufficiency 8 Hard and painful veins 8 Healed venous leg ulcer 8 Pregnant women Wound Essentials 2017, Vol 12 No 1 29

6 Recent discussions about treating varicose veins have largely centred around the controversy of treating a condition that has a low clinical priority. According to NICE, treatment should be offered, however, many commissioning groups will only allow treatment when varicose veins have caused complications such as skin changes or ulceration. Therefore, there are wide regional variations in the management of varicose veins in the UK (NICE, 2013). This topic is beyond the remit of this article, however, its importance cannot be emphasised enough. Conclusion Varicose veins are a common problem. Healthcare professionals must be able to ensure optimal treatment and management in order to avoid the longterm sequelae of varicose veins. Current treatments include conservative, radiological and surgical methods. The level of intervention needed is dependent on the clinical need (utilising scoring systems) and, of course, resource availability. We References Beebe-Dimmer J, Pfeifer J, Engle J, Schottenfeld D (2005) The epidemiology of chronic venous insufficiency and varicose veins. Ann Epidemiol 15(3): Bergan J, Schmid-Schönbein G, Smith P, et al (2006) Chronic venous disease. N Engl J Med 355(5): Bradbury A, Evans C, Allan P, et al (1999) What are the symptoms of varicose veins? BMJ 318: Brar R, Nordon IM, Hinchliffe RJ et al (2010) Surgical management of varicose veins. Vascular 18(4): Campbell WB, Decaluwe H, Macintyre JB et al (2006) Most patients with varicose veins have fears or concerns about the future, in addition to their presenting symptoms. Eur J Vasc Endovasc Surg 31(3): Chant AD, Magnussen P, Kershaw C (1985) Support hose and varicose veins. BMJ (Clin Res Ed) 290: 204 Eklof B, Rutherford RB, Bergan JJ et al (2004) Revision of the CEAP classification for chronic venous disorders: consensus statement. J Vasc Sur 40(6): Evans CJ, Fowkes FG, Ruckley CV, Lee AJ (1999) Prevalence of varicose veins and chronic venous insufficiency in men and women in the general population. J Epidemiol Community Health 53(3): Gohel MS, Barwell JR, Taylor M, et al (2007) Long term results of compression therapy alone versus compression plus surgery in chronic venous ulceration (ESCHAR). BMJ 335(7610): 83 Jia X, Mowatt G, Burr JM, et al (2007) Systematic review of foam sclerotherapy for varicose veins. Br J Surg 94(8): Kheirelseid EA, Bashar K, Aherne T, et al (2016) Evidence for varicose vein surgery in venous leg ulceration. Surgeon 14(4): Lamping DL, Schroter S, Kurz X, et al (2003) Evaluation of outcomes in chronic venous disorders of the leg. J Vasc Surg 37(2): Lurie F, Kistner RL (2011) Trends in patient reported outcomes of conservative and surgical treatment of primary chronic venous disease contradict current practices. Ann Surg 254(2): Mauck KF, Asi N, Undavalli C, et al (2014) Systematic review and metaanalysis of surgical interventions versus conservative therapy for venous ulcers. J Vasc Surg 60(2 Suppl): 60S 70 Morton L, Phillips T (2013) Venous eczema and lipodermatosclerosis. Semin Cutan Med Surg 32(3): NICE (2013) Varicose veins: diagnosis and management. Available at: (accessed ) Nesbitt C, Bedenis R, Bhattacharya V, Stansby G (2014) Endovenous ablation (radiofrequency and laser) and foam sclerotherapy versus open surgery for great saphenous vein varices. Cochrane Database Syst Rev CD O Leary DP, Chester JF, Jones SM (1996) Management of varicose veins according to reason for presentation. Ann R Coll Surg Engl 78(3 Pt 1): Piazza G (2014) Varicose veins. Circulation 130(7): Racette S, Sauvageau A (2005) Unusual sudden death. Am J Forensic Med Pathol 26(3): Robertson L, Evans C, Fowkes F (2008) Epidemiology of chronic venous disease. Phlebology 23(3): Sprague A, Khalil R (2009) Inflammatory cytokines in vascular dysfunction and vascular disease. Biochem Pharmacol 78(6): van den Bos R, Arends L, Kockaert M, et al (2009) Endovenous therapies of lower extremity varicosities. J Vasc Surg 49(1): Vasquez M, Rabe E, McLafferty R et al (2010) Revision of the venous clinical severity score: venous outcomes consensus statement: special communication of the American Venous Forum Ad Hoc Outcomes Working Group. J Vasc Surg 52(5): Wound Essentials 2017, Vol 12 No 1