Epidemiology

Incidence & Prevalence
The incidence of varicose veins according to Western statistics is 52 /1000/ year in women and 39 / 1000/ year in men The Western statistics show a prevalence of 25% – 33 % of the females and 10% - 20% of the males have varicose veins. It therefore is a common problem. There are no studies that indicate the epidemiology of this condition in India.

 

Risk Factors

Gender : females are more prone than males to develop this condition
Pregnancies: prevalence of venous insufficiency increases during pregnancy. Greater the number of pregnancies / deliveries, greater the likelihood of developing varicose veins.
Heredity :if the parents have it there is a very high (49% in some studies) likelihood that the children will inherit the disorder.
Standing at work: individuals who have jobs which require long hours of standing such as policemen, surgeons, nurses, etc., have a greater chance of developing this condition.
Obesity: obese individuals are more prone to develop it than thinner gender & age matched counterparts.
Height : taller individuals are more prone to develop varicose veins than shorter ones
Chronic Constipation: is a recognised risk factor of varicose veins
Dietary Fibre intake : people who take low fibre diets are more prone to develop it than the ones who take high fibre diets.
Hormonal therapy : with oestrogen & / or progesterone are a well recognised risk factor for varicose veins.
Ethnicity: Caucasians are more prone than other races to develop varicose veins.

 

 

Clinical Features & Complications

  • The cardinal symptom and sign is prominent and tortuous veins, often cosmetically unappealing. In obese individuals this may not be as evident as in the thinner ones.
  • Patients may often complain of swelling in the ankles and legs, these are due to pooling and stasis of blood in the ankles owing to incompetence of venous valves. This can progress to hardening of skin and the lymphatics and this condition is known as lymphodermatosclerosis. Patients often say that the swelling is greater during day and often disappear after a few hours of rest at night or by lower limb elevation.
  • Patients often complain of cramps in the legs, especially at nights. The cramps less commonly may manifest on exertion mimicking claudication.
  • Itching and burning of the affected leg is also a well recognised feature.
  • There may later be discoloration and ulceration of the ankle and leg. Venous ulcers take a long time to heal and they tend to recur after healing, causing a lot of misery to the patient, it is one of the causes of a “non-healing” ulcer. Long standing venous ulcers rarely take a malignant transformation; this is termed as a Marjolin’s ulcer.
  • As the varicose veins are of large calibre and their walls thinned out and tend to form bulges (blow-outs) they tend to bleed on minimal trauma. The bleeding may often be a ghastly site and may not be easy to control, except in the hands of a specialist.
  • These veins also have a tendency to get inflamed and this condition is called thrombophlebitis. The inflammation can cause clots (thrombi) to form in them. They rarely migrate to the deep venous system and can provoke formation of more clots in them or can directly flow into the blood stream and then into the right side of the heart and then onto the lung circulation and can be responsible of a potentially fatal condition known as pulmonary embolism. Fortunately thrombi form the superficial veins causing pulmonary embolism is rare.
  • In summary, one could say that varicose veins cause a lot of misery to the patient.

 

Diagnosis

 

The site of dilated and tortuous veins gives away the diagnosis on the spot most of the time. Sometimes, in obese patients the varicosities may not be clearly visible. The clinical tests such as the tourniquet test and the Brodie-Trendelenberg test, etc., may sometimes be inaccurate in the identification of the precise level of incompetence. The tourniquet test when combined with a hand-held Doppler can give reasonably accurate information.

Colour coded duplex ultrasonography [CCDU] often known as “lower limb vein Doppler” is required to confirm the diagnosis, to ascertain the site(s) of incompetence and to map the lower limb venous system so as to plan and facilitate further management.

The gold standard test is the X-ray contrast venogram (venous angiogram). However CCDU when done properly by an experienced examiner gives results that are highly concurrent with the venous angiogram.

The advantages of CCDU over the venous angiogram are that it is non-invasive, relatively inexpensive and can be repeated and the results are reproducible. CCDU surpasses angiography in demonstrating reflux. Over the last few years, CCDU has become the diagnostic modality of choice to demonstrate varicose veins.

 

Normal Lower Limb Venous Doppler Spectral Pattern

Normal Lower Limb Venous Doppler Spectral Pattern Normal Lower Limb Venous Doppler Spectral Pattern

Colour Flow Map of a Competent Sapheno- femoral Junction

Colour Flow Map of a Competent Sapheno- femoral JunctionColour Flow Map of a Competent Sapheno- femoral Junction

 

Sapheno-femoral Junction Incompetence

 

Sapheno-femoral Junction IncompetenceSapheno-femoral Junction Incompetence

Sapheno-femoral Junction IncompetenceSapheno-femoral Junction Incompetence

 

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