Varicose veins examination

Varicose veins examination

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.

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