A Patient with Dilated Leg Veins

Aaesha Javed
 CASE 1

History
35 year old lady, resident of Islamabad
Chief Complaints:
• Prominent veins in the right leg for past 2
years
• Pain and swelling in the right leg for 1 year
History of present illness:
• Patient was in usual state of health 2 years back
when she noticed prominent veins on the medial
aspect of the right calf and ankle.
• Gradually, the prominence went on increasing in size
and progressed towards mid-thigh. It aggravated on
prolonged standing and would disappear with rest
• It was associated with dull aching pain and swelling
in the right leg and ankle region which developed 1
year back.
• The pain and swelling was more in the evening hours,
especially after prolonged standing and relieved on
laying down with feet elevated.
• She also gave h/o night cramps, and itching and
pigmentation in right calf and ankle region for the last 1
year. There is no h/o any ulceration

ROS
• Not significant.

Past History:
• Not significant
• Drug History
She is taking Paracetamol 500mg for her lower limb pain and using
OCPs for contraception for past three years.

• Personal History:
Lecturer by profession
Mother of three children.
Non-smoker and non-alcoholic

• Family History:
Her sister developed similar dilated veins in her first pregnancy 7
years back, she got treated but it recurred.
Both her parents have diabetes and hypertension.
 General Physical Examination
A young, overweight lady, well oriented, sitting comfortably on
couch in no acute distress.
No obvious pallor, icterus, cyanosis, clubbing or
lymphadenopathy was noted.
Pedal edema+ (Right foot), JVP not raised.
Vital Signs:
• Pulse Rate- 82/min, regular good volume
• Blood Pressure- 130/80 mm Hg, right arm lying down position
• Respiratory Rate- 16/min
• Temperature- Afebrile
• BMI 30 kg/m2
 Local Examination

Inspection:
• Tortuous and dilated veins on the medial aspect of
right ankle extending up to mid-thigh,
hyperpigmentation around ankle area present but no
skin ulceration.
• No prominent veins in left leg
Palpation:
• Non-tender, dilated veins palpable on medial side of
the right ankle extending to mid-thigh region.
• There is thickening of skin in the right ankle region
• The veins collapse on elevation.
• Tourniquet test is positive at mid-thigh
• Trendelenburg test : +ve
• Perthe’s test : -ve
• Peripheral pulsations in right leg normal.
• Auscultation- No bruit heard over the prominent
veins.
• Opposite leg is normal on examination.
 Systemic Examination

• Unremarkable
• Differential Diagnosis?
– Varicose veins
• Investigations ?
– Doppler/Duplex USG
• Management ?
– Conservative/EVLA/RFA/Sclerotherapy/Surgery
 Review
Veins
• Deep veins: Femoral, Popliteal, Anterior and
Posterior Tibial
• Superficial veins: Greater and Lesser
Saphenous vein
Perforators
Connect the Deep and Superficial venous
systems
Perforators
• May or Kuster: Ankle region

• Cockett’s: 2, 4 and 6 inches

above the medial malleolus

• Boyd’s (Gastrocnemius): Just

below the tibial tubercle

• Dodd’s: Mid-thigh region

• Hunterian: Adductor canal

 VARICOSE VEINS

• Dilated, tortuous, subcutaneous veins, greater

than or equal to 3cm in diameter, measured in
an upright position with demonstrable reflux.
• Commonly referred to veins in the leg.
 Causes

Primary Secondary
• Obstruction to venous outflow
• Idiopathic
– Pregnancy
– Pelvic tumors
• Familial – Ascites
– Iliac vein thrombosis
• Weakness in vein wall – Abdominal
lymphadenopathy
 valve ring dilation
– Retroperitoneal fibrosis
• DVT
• Congenital absence of • AV fistula
valves
Pathophysiology
• Klippel-Trenaunay-Weber Syndrome
• Port wine stains
• Varicose veins
• Bony/soft tissue hypertrophy
 Risk factors
• Gender (25-30% in females, 15% in males)
• Age ( with age)
• Pregnancy ( estrogen and progesterone cause the
ligaments and smooth muscle to relax)
• Previous leg injuries
• Occupations and lifestyle (standing for long
periods)
• Increased BMI (abdominal obesity)
• History of DVT
• Positive family history
 Clinical features
Presentation
• Often asymptomatic
o Disfiguring look of the veins - cosmetic issue
• Symptoms exacerbated by prolonged periods of
standing
• Pain
• Dull ache
• Lower leg/calf
• Worsens throughout the day
• Relieved with rest or use of compression
stockings or elevation of leg
 History Questions
• Night cramps
• Itching
• Mild swelling of ankle
• Occurs at end of the day
• Acute superficial thrombophlebitis
• Red/painful/tender lumps
• Skin changes/ulcers
• Previous history of DVT or lower limb swelling during
pregnancy
• Family history in first degree relatives
 Examination
• Inspection
– Site/shape/size of visible veins
– Effect of elevation and dependency
– Edema
– Skin color (over medial aspect of ankle)

• Palpation
– Palpate the trunks of Great and Short saphenous veins
– Cough impulse
– Sapheno-femoral junction (2.5cm inferolateral to pubic tubercle)
– Sapheno-popliteal junction (popliteal fossa)
– Feel texture of skin and subcutaneous tissues
– Temperature
– Pitting edema
 Examination
• Percussion
– Percussion wave upwards or downwards
– Retrograde(downward) percussion wave- incompetent
valves while the patient is standing
• Auscultation
– Listen for bruits over the varices
• Machinery murmur – AV fistula
• Tourniquet (Trendelenburg) tests
• Failure of veins to collapse on elevation- venous hypertension
or AV fistula
• Assess by Perthe’s walking test
Tourniquet test
 Perthe’s test

• Empty vein
• Apply tourniquet just below
knee
• Ask the patient to stand up
and down on their toes
repeatedly
• Failure to achieve superficial
vein emptying indicates deep
vein obstruction or reflux
through incompetent valves in
deep veins or perforators
• Painful and rarely used
 Chronic Venous Insufficiency

• Pigmentation
• Eczema
• Chronic cellulitis
• Bleeding
• Cutaneous infarction (atrophie blanche)
• Ulceration
• Superficial thrombophlebitis
 Prognosis
• Without correction of the underlying cause,
venous insufficiency is inexorably progressive
• As many as 50% of patients with untreated
varicose veins develop superficial
thrombophlebitis at some time.
• Venous insufficiency syndromes can lead to
bleeding from lower-extremity varicosities which
can be fatal
• Non healing ulceration
 Telangiectasia/Reticular veins
Telangiectasia Reticular Veins
• Intradermal venules. • Subdermal
• Less than 1mm. • 1-3mm
• Do not indicate severity but a • Do not indicate severity but a
cosmetic issue cosmetic issue
 Saphena varix

• Groin varicosity at the

saphenofemoral
junction
• Palpable thrill when
coughing
• Emergent on standing
and disappears on lying
down
 Corona phlebectatica

• Fan shaped
intradermal veins on
the medial or lateral
aspect of the foot
• Ankle or malleolar
flare
• Severe venous HTN
 Lipodermatosclerosis
Chronic inflammation of the skin and
subcutaneous tissue leading to fibrosis
Sign of severe disease
 Eczema and Ulceration

Eczema is an
erythematous dermatitis
which may progress to
blistering, weeping or
scaling eruption

Ulceration is a full
thickness epidermal
defect
 CASE 2
44 year old lady presented with a swollen ulcerated
left leg. The ulcer began with an abrasion from a
minor injury six months ago. She had a moderately
swollen leg for many years following an episode of
pulmonary embolism 5 years back. O/E, the ulcer
has sloping edges, measuring 8x15cm, over the
medial malleolus. In addition, there are numerous
dilated leg veins in the left leg which is 5cm greater
in circumference compared to the right leg at both
the ankle and calf level.
• Differential Diagnosis?
• Investigations ?
• Management ?
 Venous Ulceration
• 50% are associated with primary varicose veins
• 50% due to post-thrombotic deep vein damage

HISTORY
• Onset usually after trauma/may also be from itching
• Prolonged history of venous disease
• Females > males
• Painful/painless
• Smelly discharge
• Previous history of ulcers/DVT
 EXAMINATION (Bilateral)

• Usually on medial aspect of lower leg (medial malleolus)

• Variable shape/size
• Sloping edges with granulation tissue
• Base-granulation tissue (healing phase)
• Depth-shallow
• Discharge-seropurulent/blood stained
• Surrounding tissues- lipodermatosclerosis/old scars/dilated
veins/cellulitis/equinus deformity
• Lymph nodes – usually not enlarged
– If enlarged it may suggest a malignancy-Marjolin’s ulcer
 INVESTIGATIONS

1. Hand held doppler

2. Duplex ultrasound imaging: Mainstay of treatment
3. Magnetic resonance venography: Useful when lower
limb varicosities seem to arise from the pelvic vein
incompetence.
4. Varicography: Contrast directly injected in the
superficial veins. Detailed mapping of varices to their
termination.
5. Abdominal USG: to rule out obstructive pathology
 Doppler Ultrasound
Used to assess the speed and direction of blood flow

• Probe placed over sapheno-femoral/sapheno-popliteal junction while the thigh/calf is

squeezed

• Uniphasic-one way flow. Single ‘whoosh’

• Biphasic-2 way flow (forward/reverse flow) ‘Whoosh’ with compression and upon
release of calf. Seen in valve incompetence
Advantages Disadvantages

•Noninvasive •Data dependent on skill of

•Cheap and easily available interpreter
•Direction and velocity of blood
flow
 Duplex Scanning Ultrasound
Combination of anatomic imaging by Traditional
USG and flow detection by Doppler shift
• Study of choice for the evaluation of venous insufficiency
syndromes
• Detection of stenosis, its degree and related flow
abnormalities
• Diagnostic/therapeutic
– USG guided sclerotherapy/EVLA
• PPV of 77% for diagnosing reflux
Color Doppler
 MRV

• Useful when lower limb varicosities appear to

arise from pelvic vein incompetence
• Most sensitive/specific test for deep and
superficial venous disease in the lower legs
and in the pelvis
• Unsuspected nonvascular causes for leg pain
and edema may often be observed on the
MRV scan
MRV
 Varicography

• Injection of contrast
directly into superficial
varicosities
• Detailed mapping of
varices till to their
termination
• Useful in cases with
complex anatomy or
recurrent varicose veins
 Management

Goal of treatment is the ablation of these reflux

pathways with resulting improvement of venous
circulation
Patients with asymptomatic varicose veins can be
reassured.
Indications for referral to a vascular surgeon
C3 to C6 disease
C2 with bleeding
Symptoms impairing QOL
Superficial thrombophlebitis
• C0- Conservatively

• C1 (Telangiectasia/reticular veins)
– Compression hosiery
– Sclerotherapy/Surface laser

• C2 (Varicose veins)
– Sclerotherapy/Excision

• C3-C6
– Extensive duplex examination
– Ablation/Surgery/Reconstruction
 Conservative

• Elevation of legs / exercises to promote blood

flow
• Compression stockings
• Topical dermatologic agents – skin changes
• Ulcer wound management
• Carry out medical management for at least 3
months before ablation is used
 Compression Hosiery
• Apply external
pressure to improve
venous return
• Classes 1-3 based on
the grades of
compression
• Improves symptoms
but patient compliance
is usually poor
• Incorrect use may lead
to pressure necrosis
 Ablation therapies
• Chemical / Thermal
• Indications:
• Symptom severity
• Response to medical treatment
• Patient expectations
• Manage hemorrhage
• Prevent proximal extension
• Treat recurrent symptoms in patients with superficial phlebitis

• Assess whether the incompetence is in superficial or deep venous

system
– Deep venous obstruction: ablation of varicosities results in worsening of
symptoms
 Sclerotherapy

• Ultrasound guided foam sclerotherapy

• Sclerosing substance is injected to produce endothelial
destruction, followed by formation of a fibrotic cord and
resorption of all vascular tissue layers
• High degree of skill needed for the procedure
• Used for telengiectasia, reticular veins, small varicose
veins
 Endovenous Laser Ablation

– Used for telangiectasia/reticular veins

– Extremely painful
– Endovenous lasers for small varicose veins
• Laser fiber placed inside the incompetent truncal vein
• Laser fiber tip is positioned at the saphenofemoral
junction just distal to the subterminal valve. Position is
confirmed by ultrasonography
• High volume local tumescent anesthetic is injected
around the vessel to be ablated
• Firm pressure is applied to collapse the vein around the
laser fiber, and the laser energy with settings sufficient
to cause irreversible thermal endothelial damage
 Radiofrequency ablation

• Like EVLA except for vein cannulation and method

of ablation but is less painful
• Uses Bipolar catheter to generate heat to ablate
the vein. RF catheter placed inside the vein.
Position of the tip is confirmed by ultrasonography
• Energy is delivered until the tissue temperature is
just sufficient to ensure endothelial ablation
• SE : thromboembolism, phlebitis, skin burns
Saphenectomy/Saphenous Strip
Avulsion
 Phlebectomy
emoval of short segments of varicose and reticular veins through tiny incisions
xtremely useful for treatment of residual clusters after saphenectomy and for
emoval of non-truncal tributaries when the saphenous vein is competent
uplex ultrasonography is used to map the locations of all refluxing vessels to be
emoved
hlebectomy hook is introduced into the microincision, and the vein is delivered
hrough the incision
o ligatures are used in the procedure, and no sutures are used to close the
microincisions
 Surgical Management
Indications Contraindications

1. Lack of response to medical 1. Pregnancy

therapy 2. Acute superficial/ deep vein
2. Extent of disease thrombosis
3. Patient expectations 3. Mod-severe PAD
4. Manage hemorrhage 4. Joint disease interfering with
5. Prevent proximal extension mobility
6. Treat recurrent symptoms in 5. Congenital venous
patients with superficial abnormality
phlebitis
 Complications after surgery

• Wound infection:
– Incidence due to prophylactic antibiotics
• Nerve injury:
– Damage to sural/saphenous/common peroneal
nerves
• Subcutaneous hematoma:
– Manage with warm compresses and NSAIDs
• DVT formation:
– 0.5% risk
 Post-op Care

• Compression stockings
• Maintain or increase activity level to prevent
DVT
• DVT prophylaxis
• Analgesia
• Prophylactic antibiotics