History

Fact Explanation
Introduction Varicose vein is the presence of dilated, tortuous superficial veins. The varicose veins are predominant and clinically significant in lower limb veins. It is a common disease and in most patients runs with out progressing to complications. The incidence rate varies in different regions of the world between 15-45% and commoner in adult female patients. The venous return of the leg occurs via superficial and deep veins of the leg, which are inter connected with perforators (Superficial to deep) mainly at three points; above ankle perforator, below knee perforator and above knee perforator. The pathophysiology of varicose veins is due to incompetent valves, saphenofemoral valve or incompetent perforators which allow the back flow of venous blood. In normal individuals the venous return is towards the heart, but in patients with varicose veins there is a back flow of venous column which develops a venous hypertension in the superficial veins. This venous hypertension causes the symptoms and complications of the disease. So the pooling of venous blood in the superficial venous system causes the tortuousity and related complications. The definite two territories can be identified in varicose veins as greater saphenous (from the medial malleolus, medial side of the thigh and up to the saphenofemoral junction closer to the inguinal region) and lesser saphenous (from the lateral malleolus, lateral and posterior aspect of the thigh up to the posterior aspect of popliteal fossa where the saphenopopliteal junction is) territories[1][2].
Age The disease in commoner in adult population and also the complications also can be seen among them with long standing varicose veins[1][3][4].
Gender Females are more prone to get varicose veins than males, could be mainly due to the pregnancy related insufficient venous flow due to the gravid uterus[1].
The occupation Occupations which needs prolong standing (eg;securities, soldiers) does not cause varicose veins, but they can detect the disease early and the symptoms would affect the occupation. Because on prolonged standing they may develop the pain and itching over the malleolar region[5][6].
Dilated tortuous veins in the lower limb This the main presenting complain and the only symptom which is present in uncomplicated cases. Patient may complain than visible ugly worms like lumps in leg which are disappearing on lying down. In females and patients with cosmetic concerns this would be distressing and may present at early stage due to cosmetic reasons. The presentation could be unilateral or bilateral [1][2].
Pain over affected lower limb Patient will complain of pain over affected limb, especially following long standing. This occurs due to pooling of venous blood in limb for long time causing impairment of venous return leading to poor tissue perfusion. Typically the pain get relieved by elevating the limb or by walking[4][7].
Swelling of the limb in standing for a long period Due to reduced venous return the intravasular pressure goes up and causes extravasation of fluids[8][7].
Itchiness of the affected limb The increased venous pressure causes extravasation of fluid and accumulation of inflammatory agents which leads venous eczema[9][10].
Bleeding from dilated veins Due to the pressure effect and excessive scratching resulting in damage to skin and underlying superficial dilated veins this bleeding can take place. The blood would spurt out from the veins and bleeding points can be identified separately as a more prominent bluish point.[10][11].
Darkening of the skin in lower part mainly over the medial and lateral malleoli Due to the chronic venous pressure and extravasation of intravascular content the skin over the malleoli gets thickened and darkened. Hemosiderin causes staining over the affected skin[12][13].
Roughening of the skin Long standing venous hypertension would progress into lipodermatosclerosis causing skin changes.The mechanism of lipodermatosclerosis is multifactorial, involving leakage of proteins into the interstitium, tissue hypoxia, and leukocyte activation[12][13].
Chronic non healing/ recurrent ulcers Venous ulcer is the most distressing complication of varicose veins which takes a long time to heal. This is multifactorial, poor venous return and resulting tissue congestion, poor capillary perfusion and deficient removal or organisms. These ulcers are typically occur over the malleoli (gaiter area of the leg). They are discrete or circumferential in shape with slopping and irregular edges[25][26].
History suggestive of Deep Venous Thrombosis The deep venous thrombosis can lead to insufficient flow through the perforators. But the varicose veins does not lead to deep venous thrombosis. So the history of prolong immobilization, painful leg swelling should be asked[14][15].
Previous history of pelvic trauma or trauma to lower limb Pelvic trauma/ previous leg trauma can cause impedance to the venous drainage and could lead to varicose veins[16].
Alteration of bowel habits, constipation, anal lumps and per rectal bleeding, haematuria, bladder out flow symptoms. Bowel pathologies involving the rectum and and colon can increase the pelvic pressure and causes poor venous flow leading to varicose veins. Other than the bowel bladder and gynaecological pathologies also can cause the similar effect. In malignant pathologies the venous invasion of the tumour can cause venous obstruction leading to simple varicose veins. So the occurrence of simple varicose veins could be a manifestation of sinister bowel pathology[17].
In females gynaecological history such as per vaginal bleeding, pelvic pain, post coital bleeding, pelvic discharge As above gynaecological pathologies such as cervical carcinoma, endometrial carcinoma could lead to varicose veins due to increased pressure or vascular invasion[18][19].
cosmetic concerns Some patients even though the varicose veins are asymptomatic due to the cosmetic reasons they need interventions[1][2].
Effect on daily living Some times the symptoms of varicose veins like pain ant itching on standing could lead negative effect on day to day activities[20].
method of contraception As exogenous hormones (eg; estrogen and progesterone in oral contraceptive pills) can make all symptoms worse, it is important to identify the female patient's method of contraception. This mainly due to the relaxation of smooth muscles of the veins [23][24].
History of previous treatments, if the patient is a diagnosed patient Detailed history about past history of varicose veins is very important as it can recur. Duration, previous treatments given are important[21][22].
Family history In some the varicose veins run in families[7][19].
Obstetric history In pregnancy varicose veins in lower limbs is a common complain. This is due to the hormonal changes (progesterone causes vascular smooth muscle relaxation) and increased intra-abdominal pressure by gravid uterus causing reduction of pelvic venous return. Due to the same reasons Vulval varices (dilatation of vulval veins and venous pooling) also commonly arise during pregnancy causing pelvic discomfort and vulval itchiness.
References
  1. EVANS CJ, FOWKES FG, RUCKLEY CV, LEE AJ. Prevalence of varicose veins and chronic venous insufficiency in men and women in the general population: Edinburgh Vein Study J Epidemiol Community Health [online] 1999 Mar, 53(3):149-153 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1756838
  2. WEDDELL JM. Varicose veins pilot survey, 1966. Br J Prev Soc Med [online] 1969 Aug, 23(3):179-186 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1059193
  3. TISI PV. Varicose veins Clin Evid (Online) [online] :0212 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3217733
  4. BRADBURY A, EVANS C, ALLAN P, LEE A, RUCKLEY CV, FOWKES FG. What are the symptoms of varicose veins? Edinburgh vein study cross sectional population survey BMJ [online] 1999 Feb 6, 318(7180):353-356 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC27720
  5. TUCHSEN F, HANNERZ H, BURR H, KRAUSE N. Prolonged standing at work and hospitalisation due to varicose veins: a 12 year prospective study of the Danish population Occup Environ Med [online] 2005 Dec, 62(12):847-850 [viewed 07 October 2014] Available from: doi:10.1136/oem.2005.020537
  6. CHEN CL, GUO HR. Varicose veins in hairdressers and associated risk factors: a cross-sectional study BMC Public Health [online] , 14(1):885 [viewed 07 October 2014] Available from: doi:10.1186/1471-2458-14-885
  7. OMBRELLINO M, KABNICK LS. Varicose Vein Surgery Semin Intervent Radiol [online] 2005 Sep, 22(3):185-194 [viewed 07 October 2014] Available from: doi:10.1055/s-2005-921951
  8. MUSSA FF, PEDEN EK, ZHOU W, LIN PH, LUMSDEN AB, BUSH RL. Iliac Vein Stenting for Chronic Venous Insufficiency Tex Heart Inst J [online] 2007, 34(1):60-66 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1847929
  9. QUARTEY-PAPAFIO CM. Importance of distinguishing between cellulitis and varicose eczema of the leg BMJ [online] 1999 Jun 19, 318(7199):1672-1673 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1116023
  10. RE HARRIS M, DAVIES RJ, BROWN S, JONES SM, EYERS PS, CHESTER JF. Surgical Treatment of Varicose Veins: Effect of Rationing Ann R Coll Surg Engl [online] 2006 Jan, 88(1):37-39 [viewed 07 October 2014] Available from: doi:10.1308/003588406X82998
  11. LONDON NJ, NASH R. Varicose veins BMJ [online] 2000 May 20, 320(7246):1391-1394 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1118055
  12. WORTHINGTON-KIRSCH RL. Injection Sclerotherapy Semin Intervent Radiol [online] 2005 Sep, 22(3):209-217 [viewed 07 October 2014] Available from: doi:10.1055/s-2005-921954
  13. SPENTZOURIS G, LABROPOULOS N. The Evaluation of Lower-Extremity Ulcers Semin Intervent Radiol [online] 2009 Dec, 26(4):286-295 [viewed 07 October 2014] Available from: doi:10.1055/s-0029-1242204
  14. KAHN SR, SOLYMOSS S, LAMPING DL, ABENHAIM L. Long-term Outcomes After Deep Vein Thrombosis: Postphlebitic Syndrome and Quality of Life J Gen Intern Med [online] 2000 Jun, 15(6):425-429 [viewed 07 October 2014] Available from: doi:10.1046/j.1525-1497.2000.06419.x
  15. SUBRAMONIA S, LEES T. The Treatment of Varicose Veins Ann R Coll Surg Engl [online] 2007 Mar, 89(2):96-100 [viewed 07 October 2014] Available from: doi:10.1308/003588407X168271
  16. STEVENSON TD. Varicose Veins of the Lower Extremity Secondary to Traumatic Arteriovenous Fistula: Late Results of War Injuries Ann Surg [online] 1961 Feb, 153(2):314-320 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1613884
  17. CUMMINGS JH. Constipation, dietary fibre and the control of large bowel function. Postgrad Med J [online] 1984 Nov, 60(709):811-819 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2418066
  18. IGNACIO EA, DUA R IV, SARIN S, HARPER AS, YIM D, MATHUR V, VENBRUX AC. Pelvic Congestion Syndrome: Diagnosis and Treatment Semin Intervent Radiol [online] 2008 Dec, 25(4):361-368 [viewed 07 October 2014] Available from: doi:10.1055/s-0028-1102998
  19. CHEN CL, GUO HR. Varicose veins in hairdressers and associated risk factors: a cross-sectional study BMC Public Health [online] , 14(1):885 [viewed 07 October 2014] Available from: doi:10.1186/1471-2458-14-885
  20. CAMPBELL B. Varicose veins and their management BMJ [online] 2006 Aug 5, 333(7562):287-292 [viewed 07 October 2014] Available from: doi:10.1136/bmj.333.7562.287
  21. DORAN FS, BARKAT S. The management of recurrent varicose veins. Ann R Coll Surg Engl [online] 1981 Nov, 63(6):432-436 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2493956
  22. KHAIRA HS, PARNELL A, CROWSON MC. Colour flow duplex in the assessment of recurrent varicose veins. Ann R Coll Surg Engl [online] 1996 Mar, 78(2):139-141 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2502537
  23. SALVAGGIO HL, ZAENGLEIN AL. Examining the use of oral contraceptives in the management of acne Int J Womens Health [online] :69-76 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2971728
  24. BARSOUM MK, HEIT JA, ASHRANI AA, LEIBSON CL, PETTERSON TM, BAILEY KR. Is Progestin an Independent Risk Factor for Incident Venous Thromboembolism? A Population-Based Case-Control Study Thromb Res [online] 2010 Nov, 126(5):373-378 [viewed 07 October 2014] Available from: doi:10.1016/j.thromres.2010.08.010
  25. GREY JE, HARDING KG, ENOCH S. Venous and arterial leg ulcers BMJ [online] 2006 Feb 11, 332(7537):347-350 [viewed 07 October 2014] Available from: doi:10.1136/bmj.332.7537.347
  26. DUNN JM, COSFORD EJ, KERNICK VF, CAMPBELL WB. Surgical treatment for venous ulcers: is it worthwhile? Ann R Coll Surg Engl [online] 1995 Nov, 77(6):421-424 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2502466
  27. DODD H. Varicose Veins in Pregnancy Br Med J [online] 1965 Jul 31, 2(5456):304 [viewed 08 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1845790
  28. DODD H, WRIGHT HP. Vulval Varicose Veins in Pregnancy Br Med J [online] 1959 Mar 28, 1(5125):831-832 [viewed 08 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1992824

Examination

Fact Explanation
General condition of the patient like in pain/ discomfort, weight, height The obese patients are more prone to get varicose veins than lean ones. At general glance we can see whether patient is in discomfort while sitting with itching of the limbs like that[1][2][3][4].
Inspection of the lower limb 1. Nature of the varicose veins 2. saphina varix 3. Ankle swelling 4. Darkening of the overlying skin 5. Superficial thrombophlebitis 6. Eczema 7. Bleeding points 8. Ulceration 9. Any evidence of associated deep vein thrombosis 1. Nature of the varicose veins Tortuous dilated palpable superficial veins can be identified. They are compressible and can empty by compression. Left leg is more likely to affect than right. Veins are more prominent on standing. Affected territory must be checked. When greater saphenous is affected veins can be seen over thighs while lesser saphenous is affected, veins will be visible over popliteal fossa to below. usually greater saphenous vein is more affected than lesser. Previous surgical scars must be checked as it can be a recurrence[5][6][7]. 2. saphina varix This is a large dilated vein which can be seen in the antero lateral aspect of the thigh. There will be a vibratory sensation over( following turbulent flow) this and cough impulse will be present[10]. 3. Ankle swelling Due to reduced venous return the intravasular pressure goes up and causes extravasation of fluids[2][16]. 4. Darkening of the overlying skin There would be a skin thickening over the medial and lateral malleolar regions which is named as greator area. This is mainly multi-factorial and due to the fluid and plasma proteins extravasation (fibrin) which leads to sub cutaneous inflammation which is named as lipodermatosclerosis. Due to the subcutaneous inflammation and fibrous tissue formation the swelling would be less pitting. The overlying skin would be darkened due to the deposition of hemosiderin and other pigments[12][13]. 5. Superficial thrombophlebitis The veins would be inflamed with redness and tenderness over that[17][18]. 6. Eczema The so called venous eczema would be due to the long standing back pressure. Scratch marks will also be obvious in symptomatic patients[16][19]. 7. Bleeding points As another complications some dilated veins would rupture and start to bleed and there will be spurting of blood. This is mainly due to the venous pressure as well as due the weakened skin due to frequent scratching [18][19]. 8. Ulceration Venous ulcer is the most distressing complication of varicose veins which takes a long time to heal. Long standing venous hypertension would progress into lipodermatosclerosis and then in to venous ulcer. These wounds are typically over the malleoli (gaiter area of the leg). They are discrete or circumferential in shape with slopping and irregular edges[2][21]. 9. Any evidence of associated deep vein thrombosis Generalized assymetrical painful limb swelling without features of cellulitis would suggest deep vein thrombosis[22][23].
Palpation of the lower limb 1. Compressibility 2. Tap test 3. Tourniquet test 4. Peripheral pulse and evidence of peripheral vascular disease The varicose veins disappear on lying down position and on standing position the get compressed and get refilled with the release of pressure. That is called compressibility[8]. 2. Tap test Tapping over the one upper end of the dilated veins will transmit the impulse to the down end of the vein following valve incompetence[9][10][11]. 3. Tourniquet test This will be useful in identifying the incompetent territory. Trendelenburg's test- this test will assess the valvular compitence[9][11][12][13]. Perthes' manoeuvre- this is useful in assessing deep venous patency[10]. 4. Peripheral pulse and evidence of peripheral vascular disease Peripheral pulse and evidence of peripheral vascular disease (cold periphery, absent pulse, pale skin and ulcers with necrotic surrounding) is very important in deciding the method of treatment. Pressure graded stockings will aggregate the symptoms in the absence of pulse/ presence of peripheral vascular disease, so need to be avoid[27][28].
Abdominal examination For presence of previous surgical scars suggestive of pelvic surgeries. Any abdominal and pelvic masses causing venous obstruction[24].
Digital examination of the rectum and vagina This just to exclude clinically detectable colonic and gynaecological malignancies[25][26].
References
  1. BRADBURY A, EVANS C, ALLAN P, LEE A, RUCKLEY CV, FOWKES FG. What are the symptoms of varicose veins? Edinburgh vein study cross sectional population survey BMJ [online] 1999 Feb 6, 318(7180):353-356 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC27720
  2. OMBRELLINO M, KABNICK LS. Varicose Vein Surgery Semin Intervent Radiol [online] 2005 Sep, 22(3):185-194 [viewed 07 October 2014] Available from: doi:10.1055/s-2005-921951
  3. FAN CM. Venous Pathophysiology Semin Intervent Radiol [online] 2005 Sep, 22(3):157-161 [viewed 07 October 2014] Available from: doi:10.1055/s-2005-921949
  4. COHEN J. Obesity: a review. J R Coll Gen Pract [online] 1985 Sep, 35(278):435-441 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1960248
  5. CAMPBELL B. Varicose veins and their management BMJ [online] 2006 Aug 5, 333(7562):287-292 [viewed 07 October 2014] Available from: doi:10.1136/bmj.333.7562.287
  6. DORAN FS, BARKAT S. The management of recurrent varicose veins. Ann R Coll Surg Engl [online] 1981 Nov, 63(6):432-436 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2493956
  7. KHAIRA HS, PARNELL A, CROWSON MC. Colour flow duplex in the assessment of recurrent varicose veins. Ann R Coll Surg Engl [online] 1996 Mar, 78(2):139-141 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2502537
  8. GHATAK T, SINGH RK, BARONIA AK. Spontaneous central vein thrombosis in a patient with activated protein C resistance and dengue infection: An association or causation? J Anaesthesiol Clin Pharmacol [online] 2013, 29(4):547-549 [viewed 07 October 2014] Available from: doi:10.4103/0970-9185.119145
  9. BHASIN N, SCOTT D. How Should a Candidate Assess Varicose Veins in the MRCS Clinical Examination? A Vascular Viewpoint Ann R Coll Surg Engl [online] 2006 May, 88(3):309-312 [viewed 07 October 2014] Available from: doi:10.1308/003588406X98595
  10. KRISHNAN S, NICHOLLS SC. Chronic Venous Insufficiency: Clinical Assessment and Patient Selection Semin Intervent Radiol [online] 2005 Sep, 22(3):169-177 [viewed 07 October 2014] Available from: doi:10.1055/s-2005-921961
  11. KIM J, RICHARDS S, KENT PJ. Clinical examination of varicose veins--a validation study. Ann R Coll Surg Engl [online] 2000 May, 82(3):171-175 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2503433
  12. STEINER CA, PALMER LH. A Simplification of the Diagnosis of Varicose Veins Ann Surg [online] 1948 Feb, 127(2):362-371 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1513782
  13. SHERMAN RS. Varicose Veins: Further Findings based on Anatomic and Surgical Dissections Ann Surg [online] 1949 Aug, 130(2):218-232 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1616302
  14. WORTHINGTON-KIRSCH RL. Injection Sclerotherapy Semin Intervent Radiol [online] 2005 Sep, 22(3):209-217 [viewed 07 October 2014] Available from: doi:10.1055/s-2005-921954
  15. SPENTZOURIS G, LABROPOULOS N. The Evaluation of Lower-Extremity Ulcers Semin Intervent Radiol [online] 2009 Dec, 26(4):286-295 [viewed 07 October 2014] Available from: doi:10.1055/s-0029-1242204
  16. MUSSA FF, PEDEN EK, ZHOU W, LIN PH, LUMSDEN AB, BUSH RL. Iliac Vein Stenting for Chronic Venous Insufficiency Tex Heart Inst J [online] 2007, 34(1):60-66 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1847929
  17. CAMPBELL B. Thrombosis, phlebitis, and varicose veins. BMJ [online] 1996 Jan 27, 312(7025):198-199 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2349999
  18. LONDON NJ, NASH R. Varicose veins BMJ [online] 2000 May 20, 320(7246):1391-1394 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1118055
  19. RE HARRIS M, DAVIES RJ, BROWN S, JONES SM, EYERS PS, CHESTER JF. Surgical Treatment of Varicose Veins: Effect of Rationing Ann R Coll Surg Engl [online] 2006 Jan, 88(1):37-39 [viewed 07 October 2014] Available from: doi:10.1308/003588406X82998
  20. GREY JE, HARDING KG, ENOCH S. Venous and arterial leg ulcers BMJ [online] 2006 Feb 11, 332(7537):347-350 [viewed 07 October 2014] Available from: doi:10.1136/bmj.332.7537.347
  21. DUNN JM, COSFORD EJ, KERNICK VF, CAMPBELL WB. Surgical treatment for venous ulcers: is it worthwhile? Ann R Coll Surg Engl [online] 1995 Nov, 77(6):421-424 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2502466
  22. SUBRAMONIA S, LEES T. The Treatment of Varicose Veins Ann R Coll Surg Engl [online] 2007 Mar, 89(2):96-100 [viewed 07 October 2014] Available from: doi:10.1308/003588407X168271
  23. KAHN SR, SOLYMOSS S, LAMPING DL, ABENHAIM L. Long-term Outcomes After Deep Vein Thrombosis: Postphlebitic Syndrome and Quality of Life J Gen Intern Med [online] 2000 Jun, 15(6):425-429 [viewed 07 October 2014] Available from: doi:10.1046/j.1525-1497.2000.06419.x
  24. CHALLA R, IRION KL, HOCHHEGGER B, SHACKLOTH M, ELSAYED H, GOSNEY JR, BINUKRISHNAN S, MARCHIORI E, CARDINAL DA SILVA V. Large pulmonary masses containing varicose veins: a rare presentation of benign metastasising leiomyomas Br J Radiol [online] 2010 Nov, 83(995):e243-e246 [viewed 07 October 2014] Available from: doi:10.1259/bjr/49938718
  25. IGNACIO EA, DUA R IV, SARIN S, HARPER AS, YIM D, MATHUR V, VENBRUX AC. Pelvic Congestion Syndrome: Diagnosis and Treatment Semin Intervent Radiol [online] 2008 Dec, 25(4):361-368 [viewed 07 October 2014] Available from: doi:10.1055/s-0028-1102998
  26. CHEN CL, GUO HR. Varicose veins in hairdressers and associated risk factors: a cross-sectional study BMC Public Health [online] , 14(1):885 [viewed 07 October 2014] Available from: doi:10.1186/1471-2458-14-885
  27. SHAMMAS NW. Epidemiology, classification, and modifiable risk factors of peripheral arterial disease Vasc Health Risk Manag [online] 2007 Apr, 3(2):229-234 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1994028
  28. LAWRENCE RN, MARSTON A, MICHAELS JA. Peripheral vascular disease. BMJ [online] 1989 Nov 18, 299(6710):1283-1284 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1838124

Differential Diagnoses

Fact Explanation
Pedal edema due to systemic causes The systemic causes leading pedal edema are heart failure, renal failure, liver failure and hypothyroidism. In these conditions the manifestation is usually bilateral. They does not show dilated tortuous veins in relation to varicose veins. The edema is more pitting nature in these causes except in hypothyroidism. Other features of heart failure ; history of ischaemic heart disease, orthopnea, paroxysmal nocturnal dyspnoea, on examination increased Jugular venous pressure, gallop heart sound, tender hepatomegaly and 2D echocardiogram would help to diagnose heart failure. Features of renal failure ; long standing diabetes, hypertension, alteration of urine output, frothy urine, on examination anaemia, scaly dry skin, urine proteins and increased serum funtion tests would suggest renal failure. History of alcoholism, yellowish sclera, hematamesis, on examination gynaecomastia, spider naevi, jaundice, abdominal free fluid, altered albumin globulin ration and ultra sound scan of the abdomen would suggest liver diseases. History of goiter, thyroid surgeries, constipation, horse voice, dry skin and thyroid function tests would suggest hypothyroidism[1][2][3].
Arterio vascular malformations such as Klippel-Trenaunay-Weber Syndrome In these patients the affected limb would be giant, the dilated vessels would be pulsatile, the affected leg would be warmer. Duplex scan and angiogram would conclude the diagnosis. Though the condition can be manifested during childhood lot of patients presents during early adult hood but younger than the patients with varicose veins[4][5][6].
Dermatological conditions like dermatitis or eczema The cases the patients would have itchy eruptive lesions for a long time which appears in time to time. may be having associated hypereosinophilic features such as bronchial asthma, rhinitis and food allergy. Many give a history of contact with a culprit substance such as rubber or leather causing contact dermatitis[7][8].
Lymphoedema The lymphoedema can be congenital or acquired as well as it can be benign or malignant. There want be dilated veins but the limb would be edematous with less pitting nature. Lymph nodes will be palpable. Stammer's sign (when picking the dorsal skin of a toe the thickness of the sub cutaneous tissue can be felt. Duplex would be normal and lymphocyntigram conclude the diagnosis[9][10][15][16].
Arterial and neuropathic ulcers Patients with arterial ulcers will give a history of arterial claudication and the pulses are diminished on examination. The arterial ulcers will have an pale nature with sharp edges. Arterial duplex will show the arterial insufficiency. Neuropathic ulcers will give a history of burning sensation of limbs, numbness, long standing diabetes and the ulcers would be over the pressure points. Nerve conduction studies will conclude the diagnosis[11][12].
Leg cellulitis Leg cellulitis is an inflammatory condition of the lower limb following an infection occur in dermis and subcutaneous tissues, common with Streptococcus or Staphylococcus. Patient will have significant limb selling, redness, pain with fever and other constitutional symptoms. In varicose veins patient will not have fever and inflammatory changes at the site of leg swelling/ ulcer, unless it is infected[13][14].
References
  1. AHMED A. DEFEAT - Heart Failure: A Guide to Management of Geriatric Heart Failure by Generalist Physicians Minerva Med [online] 2009 Feb, 100(1):39-50 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2914573
  2. ANAND IS, CHANDRASHEKHAR Y, FERRARI R, POOLE-WILSON PA, HARRIS PC. Pathogenesis of oedema in chronic severe anaemia: studies of body water and sodium, renal function, haemodynamic variables, and plasma hormones. Br Heart J [online] 1993 Oct, 70(4):357-362 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1025332
  3. SHETTY R, VIVEK G, NAHA K, TUMKUR A, RAJ A, BAIRY KL. Excellent Tolerance to Cilnidipine in Hypertensives with Amlodipine - Induced Edema N Am J Med Sci [online] 2013 Jan, 5(1):47-50 [viewed 07 October 2014] Available from: doi:10.4103/1947-2714.106203
  4. KARIM T, SINGH U, NANDA NS. A rare presentation of Klippel-Trenaunay syndrome Indian Dermatol Online J [online] 2014, 5(2):154-156 [viewed 07 October 2014] Available from: doi:10.4103/2229-5178.131086
  5. SERMSATHANASAWADI N, HONGKU K, WONGWANIT C, RUANGSETAKIT C, CHINSAKCHAI K, MUTIRANGURA P. Endovenous Radiofrequency Thermal Ablation and Ultrasound-Guided Foam Sclerotherapy in Treatment of Klippel-Trenaunay Syndrome Ann Vasc Dis [online] 2014, 7(1):52-55 [viewed 07 October 2014] Available from: doi:10.3400/avd.oa.13-00111
  6. LINDENAUER SM. The Klippel-Trenaunay Syndrome: Varicosity, Hypertrophy and Hemangioma with No Arteriovenous Fistula Ann Surg [online] 1965 Aug, 162(2):303-314 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1476812
  7. KRAFCHIK BR. Eczema Paediatr Child Health [online] 2000 Mar, 5(2):101-105 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2817760
  8. BOGUNIEWICZ M, LEUNG DY. Atopic Dermatitis: A Disease of Altered Skin Barrier and Immune Dysregulation Immunol Rev [online] 2011 Jul, 242(1):233-246 [viewed 07 October 2014] Available from: doi:10.1111/j.1600-065X.2011.01027.x
  9. QUERCI DELLA ROVERE G, AHMAD I, SINGH P, ASHLEY S, DANIELS IR, MORTIMER P. An audit of the incidence of arm lymphoedema after prophylactic level I/II axillary dissection without division of the pectoralis minor muscle. Ann R Coll Surg Engl [online] 2003 May, 85(3):158-161 [viewed 07 October 2014] Available from: doi:10.1308/003588403321661299
  10. PEREIRA DE GODOY JM, AZOUBEL LM, DE FáTIMA GUERREIRO DE GODOY M. INTENSIVE TREATMENT OF LEG LYMPHEDEMA Indian J Dermatol [online] 2010, 55(2):144-147 [viewed 07 October 2014] Available from: doi:10.4103/0019-5154.62745
  11. SPENTZOURIS G, LABROPOULOS N. The Evaluation of Lower-Extremity Ulcers Semin Intervent Radiol [online] 2009 Dec, 26(4):286-295 [viewed 07 October 2014] Available from: doi:10.1055/s-0029-1242204
  12. ALEXIADOU K, DOUPIS J. Management of Diabetic Foot Ulcers Diabetes Ther [online] 2012 Dec, 3(1):4 [viewed 07 October 2014] Available from: doi:10.1007/s13300-012-0004-9
  13. DUPUY A, BENCHIKHI H, ROUJEAU JC, BERNARD P, VAILLANT L, CHOSIDOW O, SASSOLAS B, GUILLAUME JC, GROB JJ, BASTUJI-GARIN S. Risk factors for erysipelas of the leg (cellulitis): case-control study BMJ [online] 1999 Jun 12, 318(7198):1591-1594 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC28138
  14. BRAEUNLING FM, MACKEY PM, WRIGHT C, KLIMACH OE, RAMANADEN DN. Cellulitis of the right thigh, with gas J R Soc Med [online] 2003 Nov, 96(11):553-554 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC539631
  15. TORRES LACOMBA M, YUSTE SáNCHEZ MJ, ZAPICO GOñI Á, PRIETO MERINO D, MAYORAL DEL MORAL O, CEREZO TéLLEZ E, MINAYO MOGOLLóN E. Effectiveness of early physiotherapy to prevent lymphoedema after surgery for breast cancer: randomised, single blinded, clinical trial BMJ [online] 2010:b5396 [viewed 07 October 2014] Available from: doi:10.1136/bmj.b5396
  16. PEREIRA DE GODOY JM, AZOUBEL LM, DE FáTIMA GUERREIRO DE GODOY M. INTENSIVE TREATMENT OF LEG LYMPHEDEMA Indian J Dermatol [online] 2010, 55(2):144-147 [viewed 07 October 2014] Available from: doi:10.4103/0019-5154.62745

Investigations - for Diagnosis

Fact Explanation
Hand-held Doppler This is a simple non invasive test use to assess the presence of varicose veins. It will assess the venous dilatation and the direction of the blood flow alone the superficial veins. also useful in measurement of ankle-brachial pressure index (ABPI)[1][2][3].
Duplex ultrasound imaging This is a combined investigation of both doppler studies and ultrasound scanning. it assess the anatomy of the veins and the extend of varicose veins. This also useful in excluding the associated deep vein thrombosis[4][5].
Colour-flow imaging In here the results of doppler studies are seen through the colour images. It is more sensitive and can be used to detect valve incompetence in small veins[6][7].
Magnetic resonance venography This is useful in finding out the other causes which can leads to similer symptoms by anatomical obstruction[8][9].
Plethysmography Plethysmography measures the volume changes of the venous system of the leg. This is useful in measuring maximum venous outflow, muscle pump ejection fraction and Venous refilling time. These indicators give an idea about the severity of disease and possible complications[10][11].
Ultrasound scan of the abdomen and pelvis This is important in assessing the presence of any intra abdominal/ pelvic masses which leads to development of varicose veins following venous out flow obstruction[12].
References
  1. CAMPBELL B. Clinical and hand-held Doppler examination of primary varicose veins. Ann R Coll Surg Engl [online] 2001 Jul, 83(4):287-288 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2503384
  2. KIM J, RICHARDS S, KENT PJ. Clinical examination of varicose veins--a validation study. Ann R Coll Surg Engl [online] 2000 May, 82(3):171-175 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2503433
  3. SIMON DA, DIX FP, MCCOLLUM CN. Management of venous leg ulcers BMJ [online] 2004 Jun 5, 328(7452):1358-1362 [viewed 07 October 2014] Available from: doi:10.1136/bmj.328.7452.1358
  4. KENT PJ, WESTON MJ. Duplex scanning may be used selectively in patients with primary varicose veins. Ann R Coll Surg Engl [online] 1998 Nov, 80(6):388-393 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2503157
  5. CAMPBELL WB, HALIM AS, AERTSSEN A, RIDLER BM, THOMPSON JF, NIBLETT PG. The place of duplex scanning for varicose veins and common venous problems. Ann R Coll Surg Engl [online] 1996 Nov, 78(6):490-493 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2502872
  6. KHAIRA HS, PARNELL A, CROWSON MC. Colour flow duplex in the assessment of recurrent varicose veins. Ann R Coll Surg Engl [online] 1996 Mar, 78(2):139-141 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2502537
  7. KHILNANI NM, MIN RJ. Imaging of Venous Insufficiency Semin Intervent Radiol [online] 2005 Sep, 22(3):178-184 [viewed 07 October 2014] Available from: doi:10.1055/s-2005-921950
  8. SATO K, ORIHASHI K, TAKAHASHI S, TAKASAKI T, KUROSAKI T, IMAI K, ISHIFURO M, SUEDA T. Three-dimensional CT Venography: A Diagnostic Modality for the Preoperative Assessment of Patients with Varicose Veins Ann Vasc Dis [online] 2011, 4(3):229-234 [viewed 07 October 2014] Available from: doi:10.3400/avd.oa.11.00021
  9. STEINER CA, PALMER LH. A Simplification of the Diagnosis of Varicose Veins Ann Surg [online] 1948 Feb, 127(2):362-371 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1513782
  10. KRISHNAN S, NICHOLLS SC. Chronic Venous Insufficiency: Clinical Assessment and Patient Selection Semin Intervent Radiol [online] 2005 Sep, 22(3):169-177 [viewed 07 October 2014] Available from: doi:10.1055/s-2005-921961
  11. SALIBA JúNIOR OA, GIANNINI M, MóRBIO AP, SALIBA O, ROLLO HA. Pre- and Postoperative Evaluation by Photoplethysmography in Patients Receiving Surgery for Lower-Limb Varicose Veins Int J Vasc Med [online] 2014:562782 [viewed 07 October 2014] Available from: doi:10.1155/2014/562782
  12. IGNACIO EA, DUA R IV, SARIN S, HARPER AS, YIM D, MATHUR V, VENBRUX AC. Pelvic Congestion Syndrome: Diagnosis and Treatment Semin Intervent Radiol [online] 2008 Dec, 25(4):361-368 [viewed 07 October 2014] Available from: doi:10.1055/s-0028-1102998

Investigations - Fitness for Management

Fact Explanation
Hand-held Doppler This will useful in assessing the ankle-brachial pressure index (ABPI) which gives an idea about the arterial blood supply to the limb[1][2][3].
Duplex ultrasound imaging This also useful in assessing the disease condition[4][5].
FBC, ESR, CRP These blood test will assess the patients basic conditions of haemoglobin levels( to detect any associated anaemic condition), ongoing inflammatory conditions (presence of infections) and platelet levels (to assess the bleeding tendency before invasive procedures)[6].
Chest x ray This will helpful in preoperative assessment of the Patient's fitness before giving general anaesthesis[7][8].
ECG and if needed echo cardiogram These test also important in pre operative fitness assessment[9][10].
Clotting profile (PT/INR, APTT) Prior to surgery or other invasive procedures these test should be done to assess patients clotting status[11].
References
  1. CAMPBELL B. Clinical and hand-held Doppler examination of primary varicose veins. Ann R Coll Surg Engl [online] 2001 Jul, 83(4):287-288 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2503384
  2. KIM J, RICHARDS S, KENT PJ. Clinical examination of varicose veins--a validation study. Ann R Coll Surg Engl [online] 2000 May, 82(3):171-175 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2503433
  3. SIMON DA, DIX FP, MCCOLLUM CN. Management of venous leg ulcers BMJ [online] 2004 Jun 5, 328(7452):1358-1362 [viewed 07 October 2014] Available from: doi:10.1136/bmj.328.7452.1358
  4. KENT PJ, WESTON MJ. Duplex scanning may be used selectively in patients with primary varicose veins. Ann R Coll Surg Engl [online] 1998 Nov, 80(6):388-393 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2503157
  5. CAMPBELL WB, HALIM AS, AERTSSEN A, RIDLER BM, THOMPSON JF, NIBLETT PG. The place of duplex scanning for varicose veins and common venous problems. Ann R Coll Surg Engl [online] 1996 Nov, 78(6):490-493 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2502872
  6. NARCI H, TURK E, KARAGULLE E, TOGAN T, KARABULUT K. The Role of Mean Platelet Volume in the Diagnosis of Acute Appendicitis: A Retrospective Case-Controlled Study Iran Red Crescent Med J [online] 2013 Dec, 15(12):e11934 [viewed 07 October 2014] Available from: doi:10.5812/ircmj.11934
  7. SEYMOUR DG, PRINGLE R, SHAW JW. The role of the routine pre-operative chest X-ray in the elderly general surgical patient Postgrad Med J [online] 1982 Dec, 58(686):741-745 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2426605
  8. REES AM, ROBERTS CJ, BLIGH AS, EVANS KT. Routine preoperative chest radiography in non-cardiopulmonary surgery. Br Med J [online] 1976 May 29, 1(6021):1333-1335 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1640313
  9. FLEISHER LA. The Preoperative Electrocardiogram: What Is the Role in 2007? Ann Surg [online] 2007 Aug, 246(2):171-172 [viewed 07 October 2014] Available from: doi:10.1097/SLA.0b013e31811eb927
  10. SUBRAMANI S, TEWARI A. Pre-operative echocardiography: Evidence or experience based utilization in non-cardiac surgery? J Anaesthesiol Clin Pharmacol [online] 2014, 30(3):313-315 [viewed 07 October 2014] Available from: doi:10.4103/0970-9185.137258
  11. BENARROCH-GAMPEL J, SHEFFIELD KM, DUNCAN CB, BROWN KM, HAN Y, TOWNSEND CM JR, RIALL TS. Preoperative Laboratory Testing in Patients Undergoing Elective, Low-Risk Ambulatory Surgery Ann Surg [online] 2012 Sep, 256(3):518-528 [viewed 07 October 2014] Available from: doi:10.1097/SLA.0b013e318265bcdb

Investigations - Followup

Fact Explanation
Duplex ultrasound imaging This will be useful in assessing the patients condition during follow up[1][2].
renal function tests like urine for protein urea, serum creatinine and blood urea As patient can develop ankle oedema renal failure need to be excluded[4].
Echocardiogram As patient can develop ankle oedema heart failure also need to be excluded[5].
Liver function tests like AST,ALT, Serum protein Similerly renal disease also need to be excluded[6].
Swab from ulcer for culture and ABST As venous ulcers are chronic and at risk of getting infected, this will be useful[7].
Full blood count, ESR, CRP These basic blood tests will assess the patients haemoglobin level and any evidence of ongoing inflammatory condition[3].
References
  1. KENT PJ, WESTON MJ. Duplex scanning may be used selectively in patients with primary varicose veins. Ann R Coll Surg Engl [online] 1998 Nov, 80(6):388-393 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2503157
  2. CAMPBELL WB, HALIM AS, AERTSSEN A, RIDLER BM, THOMPSON JF, NIBLETT PG. The place of duplex scanning for varicose veins and common venous problems. Ann R Coll Surg Engl [online] 1996 Nov, 78(6):490-493 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2502872
  3. NARCI H, TURK E, KARAGULLE E, TOGAN T, KARABULUT K. The Role of Mean Platelet Volume in the Diagnosis of Acute Appendicitis: A Retrospective Case-Controlled Study Iran Red Crescent Med J [online] 2013 Dec, 15(12):e11934 [viewed 07 October 2014] Available from: doi:10.5812/ircmj.11934
  4. TEDLA FM, BRAR A, BROWNE R, BROWN C. Hypertension in Chronic Kidney Disease: Navigating the Evidence Int J Hypertens [online] :132405 [viewed 07 October 2014] Available from: doi:10.4061/2011/132405
  5. AHMED A. DEFEAT - Heart Failure: A Guide to Management of Geriatric Heart Failure by Generalist Physicians Minerva Med [online] 2009 Feb, 100(1):39-50 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2914573
  6. LOSOWSKY MS, SCOTT BB. Ascites and oedema in liver disease. Br Med J [online] 1973 Aug 11, 3(5875):336-338 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1586440
  7. BOWLER PG, DUERDEN BI, ARMSTRONG DG. Wound Microbiology and Associated Approaches to Wound Management Clin Microbiol Rev [online] 2001 Apr, 14(2):244-269 [viewed 07 October 2014] Available from: doi:10.1128/CMR.14.2.244-269.2001

Investigations - Screening/Staging

Fact Explanation
Hand-held Doppler This is useful as a screening test for identifying varicose veins and pheripheral vasculr disease using ankle-brachial pressure index (ABPI)[1][2][3].
Clinical, etiological, anatomic, pathophysiological (CEAP) classification from the American Venous Forum( 2004) Clinical classification C0: no visible or palpable signs of venous disease C1: telangiectasies or reticular veins C2: varicose veins C3: edema C4a: pigmentation or eczema C4b: lipodermatosclerosis or atrophie blanche C5: healed venous ulcer C6: active venous ulcer S: symptomatic, including ache, pain, tightness, skin irritation, heaviness, and muscle cramps, and other complaints attributable to venous dysfunction A: asymptomatic Etiologic classification Ec: congenital Ep: primary Es: secondary (postthrombotic) En: no venous cause identified Anatomic classification As: superficial veins Ap: perforator veins Ad: deep veins An: no venous location identified Pathophysiologic classification Pr: reflux Po: obstruction Pr,o: reflux and obstruction Pn: no venous pathophysiology identifiable[4][5]
References
  1. CAMPBELL B. Clinical and hand-held Doppler examination of primary varicose veins. Ann R Coll Surg Engl [online] 2001 Jul, 83(4):287-288 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2503384
  2. KIM J, RICHARDS S, KENT PJ. Clinical examination of varicose veins--a validation study. Ann R Coll Surg Engl [online] 2000 May, 82(3):171-175 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2503433
  3. SIMON DA, DIX FP, MCCOLLUM CN. Management of venous leg ulcers BMJ [online] 2004 Jun 5, 328(7452):1358-1362 [viewed 07 October 2014] Available from: doi:10.1136/bmj.328.7452.1358
  4. MEISSNER MH. Lower Extremity Venous Anatomy Semin Intervent Radiol [online] 2005 Sep, 22(3):147-156 [viewed 07 October 2014] Available from: doi:10.1055/s-2005-921948
  5. SERRA R, GALLELLI L, CONTI A, DE CARIDI G, MASSARA M, SPINELLI F, BUFFONE G, CALIò FG, AMATO B, CEGLIA S, SPAZIANO G, SCARAMUZZINO L, FERRARESE AG, GRANDE R, DE FRANCISCIS S. The effects of sulodexide on both clinical and molecular parameters in patients with mixed arterial and venous ulcers of lower limbs Drug Des Devel Ther [online] :519-527 [viewed 07 October 2014] Available from: doi:10.2147/DDDT.S61770

Management - General Measures

Fact Explanation
Health education Patient should be educated about the condition, symptoms, complications, treatment options and prognosis[6][7].
reassurance If the patient is asymptomatic and not concerning it as a cosmetic problem reassurance can be done by modifying causative factors[8][9].
lifestyle modifications maintain body weight by diet control, taking balanced diet and by regular physical exercise (avoid sedentary lifestyles). Reduction in obesity will be useful in primary, secondary and tertiary prevention. Reduced time of long standing will help in improving the symptoms. Maintaining good bowel habits, taking more fruits and fiber containing diet will help in improving the constipation. Stop smoking also important in prevention[1][2].
Compression stockings Presence of peripheral vascular disease should be excluded before deciding this treatment option as it can aggravate the ischemia. this will nor improve the condition but will minimize the progression. various types of stockings are available and type will decide individually according to the patients current condition. According to the available evidence this has been shown to reduce the occurrence of venous ulcers[10][11].
post operative care and look for post operative complications Especially following the surgerry, patient is at risk of developing DVT and pulmonary embolus. So prophylactic phophilactic measures are important. eg; well hydration, adequate mobilization of the patient, limb physiotherapy, thrombo embolic detergenic stocking and low molecular weight heparin in high risk patients. As patient can develop pulmonary embolism need close monitoring for any recent symptoms of acute breathlessness, pleuritic type chest pain, haemoptysis, dizziness and syncopy. There will be numbness over the limb in areas supplying sensation by sural nerve/ saphenous nerve. This can be due to the damage during the surgery. Haematomas and bruising can occur over the surgical sites. as they are superficial will resolve spontaneously. if the haematoma is very large evacuation will be needed. Other than these specific complications common post operative complications can occur like wound site infections, chest infections. So strict aseptic precautions will be needed in handling the patient and post operative prophylactic antibiotics will be helpful[3][4][5].
References
  1. EVANS CJ, FOWKES FG, RUCKLEY CV, LEE AJ. Prevalence of varicose veins and chronic venous insufficiency in men and women in the general population: Edinburgh Vein Study J Epidemiol Community Health [online] 1999 Mar, 53(3):149-153 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1756838
  2. FAN CM. Venous Pathophysiology Semin Intervent Radiol [online] 2005 Sep, 22(3):157-161 [viewed 07 October 2014] Available from: doi:10.1055/s-2005-921949
  3. ADLER MW, WALLER JJ, CREESE A, THORNE SC. Randomised controlled trial of early discharge for inguinal hernia and varicose veins. J Epidemiol Community Health [online] 1978 Jun, 32(2):136-142 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1060932
  4. HEALTH QUALITY ONTARIO. Endovascular Radiofrequency Ablation for Varicose Veins: An Evidence-Based Analysis Ont Health Technol Assess Ser [online] , 11(1):1-93 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3377553
  5. MILLER GV, LEWIS WG, SAINSBURY JR, MACDONALD RC. Morbidity of varicose vein surgery: auditing the benefit of changing clinical practice. Ann R Coll Surg Engl [online] 1996 Jul, 78(4):345-349 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2502581
  6. EVANS CJ, FOWKES FG, RUCKLEY CV, LEE AJ. Prevalence of varicose veins and chronic venous insufficiency in men and women in the general population: Edinburgh Vein Study J Epidemiol Community Health [online] 1999 Mar, 53(3):149-153 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1756838
  7. ABRAMSON JH, HOPP C, EPSTEIN LM. The epidemiology of varicose veins. A survey in western Jerusalem. J Epidemiol Community Health [online] 1981 Sep, 35(3):213-217 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1052160
  8. CAMPBELL B. Varicose veins and their management BMJ [online] 2006 Aug 5, 333(7562):287-292 [viewed 07 October 2014] Available from: doi:10.1136/bmj.333.7562.287
  9. LONDON NJ, NASH R. Varicose veins BMJ [online] 2000 May 20, 320(7246):1391-1394 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1118055
  10. MORRIS RJ, WOODCOCK JP. Evidence-Based Compression: Prevention of Stasis and Deep Vein Thrombosis Ann Surg [online] 2004 Feb, 239(2):162-171 [viewed 07 October 2014] Available from: doi:10.1097/01.sla.0000109149.77194.6c
  11. TISI PV. Varicose veins Clin Evid (Online) [online] :0212 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3217733

Management - Specific Treatments

Fact Explanation
Sclerotherapy (Injection sclerotherapy, Ultrasound guided form sclerotherapy) Sclerotherapy destroy the endothelium causing inducing clot formation finally leading to block and destroy the veins. Sclerosants are used like Sodium tetradecyl sulfate and polidocanol . This is useful in treating small veins[3][4][5].
endovascular ablation (Endovenous laser ablation and Radiofrequency ablation) In Endovenous laser ablation thrombosis and permanent endothelial damage is induced using heat. In radio-frequency ablation, saphenous vein is blocked using radiofrequency thermal energy. Vein diameter should be more than 4.5mm for endovascular ablation. These are done with an endovenous catheter under the guidance of ultrasound scan[2][7][8].
Ambulatory phlebectomy Remove all affected veins except proximal part of the long saphenous vein. This is being done with local anesthesia as an outpatient procedure[9][10].
Transilluminated powered phlebectomy The surgical procedure is similer to ambulatory phlebectomy but it is done using a small surgical device. This needs general anesthesia[11][12].
Saphenofemoral junction ligation and greater saphenous stripping or Saphenopopliteal junction ligation and lesser saphenous stripping The type of ligation and stripping is depend on the affected territory of the superficial veins. This is the final option of treatment following failing of other consecutive treatment options. In greater Saphenofemoral junction ligation and greater saphenous stripping, First put small cut over groin and identify the femoral vein and Saphenofemoral junction. Then stripping is being done using various devices (eg: Mayo stripper, babcock device, keller device). In saphenopopliteal junction ligation and lesser saphenous stripping, saphenopopliteal junction identified using an ultrasound scan and ligation done. then similerly stripping is done. This is associated with the risk of damaging to the vessels and nerves in the popliteal fossa[6][9][12].
Subfascial endoscopic perforator vein surgery This is a minimally invasive surgical procedure use in varicose veins to prevent complications[1][12].
References
  1. WHIDDON LL. Advances in the treatment of superficial venous insufficiency of the lower extremities Proc (Bayl Univ Med Cent) [online] 2007 Apr, 20(2):136-139 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1849874
  2. TISI PV. Varicose veins Clin Evid (Online) [online] :0212 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3217733
  3. SHOULER PJ, RUNCHMAN PC. Varicose veins: optimum compression after surgery and sclerotherapy. Ann R Coll Surg Engl [online] 1989 Nov, 71(6):402-404 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2499037
  4. SCURR JH, COLERIDGE-SMITH P, CUTTING P. Varicose veins: optimum compression following sclerotherapy. Ann R Coll Surg Engl [online] 1985 Mar, 67(2):109-111 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2498276
  5. CAMPBELL B. Varicose veins and their management BMJ [online] 2006 Aug 5, 333(7562):287-292 [viewed 07 October 2014] Available from: doi:10.1136/bmj.333.7562.287
  6. LONDON NJ, NASH R. Varicose veins BMJ [online] 2000 May 20, 320(7246):1391-1394 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1118055
  7. HEALTH QUALITY ONTARIO. Endovascular Radiofrequency Ablation for Varicose Veins: An Evidence-Based Analysis Ont Health Technol Assess Ser [online] , 11(1):1-93 [viewed 07 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3377553
  8. NIEDZWIECKI G. Endovenous Thermal Ablation of the Saphenous Vein Semin Intervent Radiol [online] 2005 Sep, 22(3):204-208 [viewed 07 October 2014] Available from: doi:10.1055/s-2005-921953
  9. OMBRELLINO M, KABNICK LS. Varicose Vein Surgery Semin Intervent Radiol [online] 2005 Sep, 22(3):185-194 [viewed 07 October 2014] Available from: doi:10.1055/s-2005-921951
  10. KABNICK LS, OMBRELLINO M. Ambulatory Phlebectomy Semin Intervent Radiol [online] 2005 Sep, 22(3):218-224 [viewed 07 October 2014] Available from: doi:10.1055/s-2005-921955
  11. FRANZ RW, HARTMAN JF, WRIGHT ML. Treatment of Varicose Veins by Transilluminated Powered Phlebectomy Surgery: A 9-Year Experience Int J Angiol [online] 2012 Dec, 21(4):201-208 [viewed 07 October 2014] Available from: doi:10.1055/s-0032-1330229
  12. SUBRAMONIA S, LEES T. The Treatment of Varicose Veins Ann R Coll Surg Engl [online] 2007 Mar, 89(2):96-100 [viewed 07 October 2014] Available from: doi:10.1308/003588407X168271