Vascular examination: varicose veins
BMJ 2004; 329 doi: https://doi.org/10.1136/sbmj.0412448 (Published 01 December 2004) Cite this as: BMJ 2004;329:0412448
Varicose veins are dilated, tortuous, and prominent veins of the superficial venous system seen in the distribution of the long and short saphenous veins. Varicose veins are common: estimates imply that 25% of women and 15% of men will get them.1 The most common cause is incompetent valves in the veins and increasing age, pregnancy, obesity, and family history all increase the risk.
Anatomy
The venous drainage of the legs consists of a superficial and a deep system of veins. The superficial venous system drains the skin and subcutaneous tissue; its vessels form the long and short saphenous veins (figure). The long saphenous vein travels from the foot, in front of the inner ankle (medial malleolus), along the inner (medial) part of the leg, and joins the femoral vein at the saphenofemoral junction. The short saphenous vein travels from the foot, behind the outer ankle (lateral malleolus), along the midline of the calf, ending when it joins the popliteal vein at the saphenopopliteal junction.
The deep venous system lies deep within the muscles of the legs and consists of both veins and sinusoids (small blood vessels--like large capillaries). Both the sinusoids of the deep system and the superficial veins drain into the deep veins through perforating veins, which traverse the deep fascia and prevent backflow of blood from the deep to the superficial system. These veins have valves, and contraction of the muscles surrounding the deep venous system pushes blood towards the heart, whilst the valves prevent backflow.
Drainage of the venous system of the legs therefore requires three components: competent valves, patent venous outflow tracts, and an efficient muscle pump.
Taking a history
You should take a full history from any person presenting with varicose veins, bearing in mind that pelvic masses, trauma, and previous deep venous thrombosis are recognised causes. You should ask about if they have aching leg pain; if their legs fatigue easily or feel heavy; and if there is any swelling. All of these symptoms become worse as the day progresses especially with long periods of standing. In severe cases, people may describe acute, bursting pain on walking that is relieved by rest and leg elevation. This is called venous claudication. People with severe venous hypertension may complain of skin changes including venous eczema and ulceration, classically in the gaiter region of the lower leg. You should also ask about any previous treatments. For some people, cosmetic issues may be the most important, but you should remember that some people with symptoms might have few visible varicose veins.
Examination
Inspection
You should start the examination by inspecting the patient standing--if he or she is able to stand--with both legs appropriately exposed to the groin. If varicose veins seem present then gently press on the affected areas, release, and watch the varicosities refill. By doing this, you are simply confirming that the areas are vascular. Consider whether the affected areas are warmer than the surrounding skin by using the back of your hand. Next try to see if the varicosities follow the long or short saphenous vein distribution. Varicosities in the short saphenous vein are seen only below the knee and are usually at the back and to the outer edge of the leg (posterolateral). Long saphenous varicosities may be found along the length of the leg, usually on the medial aspect. Some people have a large accessory vein on the back (posterior) part of the thigh, which may become varicose. This is the accessory vein of Giacomini.
On inspection, look for:
Venous stars (venulectasias). These are bluish vessels that may distend above the skin surface and are usually 1-2 mm in diameter
Superficial thrombophlebitis, which shows as a red, painful lump
The brown pigmentation of haemosiderin deposition characteristic of increased venous pressure
Venous eczema
Ulceration and scarring from previous ulceration, especially in the gaiter area
Lipodermatosclerosis; this is caused by chronic venous hypertension when fibrin deposition results in progressive sclerosis of the skin and subcutaneous fat
Scars from previous vein surgery (look for harvesting of vein grafts for coronary artery bypass grafting).
Locating the saphenofemoral junction
Once you have finished the inspection, ask the patient to lie down and identify the saphenofemoral junction. One good way to do this is by locating the femoral artery--which lies between the anterior superior iliac spine and the pubic tubercle--by feeling for the pulse. The vein is medial to the artery and the saphenofemoral junction about two fingers' breadths below the inguinal ligament.
Next ask the patient to stand if he or she can. You then should place one hand on the varicosities and tap on the saphenofemoral junction. If the saphenofemoral junction is incompetent you may feel a fluid thrill. You can confirm the incompetence with a handheld Doppler ultrasonograph if you put it at the saphenofemoral junction and press on the varicosities. You should be able to hear blood flowing up the vein to the junction and with an incompetent valve at the saphenofemoral junction, you can hear the blood flowing back again.
Trendelenberg test
Again ask the patient to lie down, raise his or her leg, and empty the engorged varicosities. To do this, press on the saphenofemoral junction to occlude it. Then ask the patient to stand up and see if the varicosities refill immediately. If by putting pressure at the saphenofemoral junction the varicose veins are controlled saphenofemoral incompetence is present. If the veins simply refill then there is a leaky perforating vein further down. This is known as the Trendelenberg test.
Tourniquet test
If there is a leaky perforating vein--or as an alternative to the Trendelenberg test--you can do the tourniquet test. For this you ask the patient to lie down and lift the affected leg. By doing this, the veins will empty and you should put on the tourniquet, in turn, to the thigh, the lower thigh, and then below the knee. If the tightened tourniquet controls the varicose veins then the defect is above the tourniquet, if the veins refill then the defect is below. Reflux from venous valvular incompetence accounts for most chronic venous disease.
Once you have diagnosed varicose veins, you should consider the cause (aetiology). You should also do a full abdominal and scrotal examination to rule out intra-abdominal or pelvic pathology and do an arterial examination.
Investigations
You may need to do further investigations to clarify the area of valvular incompetence. This is best done by using Duplex ultrasonography.2 With the patient standing, cuffs are placed on the thigh, calf, and foot. The cuffs are inflated and then rapidly deflated to create retrograde venous blood flow in segments of valvular incompetence. It is possible to map valvular incompetence at the common and superficial femoral, long and short saphenous, popliteal, posterior tibial, and perforator veins.
Treatment
Surgery is indicated in people with saphenofemoral incompetence and in those with significant symptoms such as superficial thrombophlebitis, bleeding from varicosities, or skin changes. This entails identifying the saphenofemoral junction in the groin and ligating it. The long saphenous vein is then disconnected in the groin and stripped to remove its tributaries. Isolated varicosities in the leg can be removed through small incisions (avulsion).
Sclerotherapy can be effective in treating small varicose veins without reflux. If reflux occurs at the saphenofemoral junction the surgeon should correct this first. Sclerotherapy entails marking varices while the patient is standing and then injecting a sclerosant, such as sodium tetradecylsulfate, into the lumen of larger veins to cause an inflammatory reaction. Compression stockings are worn after sclerotherapy.
Conservative management may include:
Reassurance and advice
Weight reduction
Exercise and avoidance of long periods of sitting or standing
Elevation of the legs
Compression stockings may be used to manage chronic venous insufficiency, with the greatest compression at the ankle. However, people with peripheral vascular disease should not wear compression stockings unless an ankle brachial pressure index is satisfactory.
Notes
Originally published as: Student BMJ 2004;12:448
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