Varicose Vein Surgery Clinical Presentation

Updated: Dec 14, 2017
  • Author: Wesley K Lew, MD; Chief Editor: Vincent Lopez Rowe, MD  more...
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Presentation

History

Patients with varicose veins may have a host of symptoms, but they are usually caused by venous hypertension rather than by the varicosities themselves.

Often, symptoms are purely aesthetic, and patients desire treatment of the unsightly nature of the tortuous, dilated varicosities. Complaints of pain, soreness, burning, aching, throbbing, heavy legs, cramping, muscle fatigue, pruritus, night cramps, and "restless legs" are usually secondary to the venous hypertension. Pain and other symptoms may worsen with the menstrual cycle, with pregnancy, and in response to exogenous hormonal therapy (eg, oral contraceptives).

In addition, pain associated with venous hypertension is usually a dull ache that is worsened by prolonged standing and is improved by walking or by elevating the legs. This is in contrast to the pain of arterial insufficiency, which worsens with ambulation and elevation.

Subjective symptoms are usually more severe early in the progression of disease, less severe in the middle phases, and more severe again with advancing age. Patients who have become acclimatized to their chronic disease may not volunteer information about symptoms. After treatment, patients are often surprised to realize how much chronic discomfort they had accepted as "normal."

The venous history should also include the following elements:

  • History of venous insufficiency (eg, date of onset of visible abnormal vessels, date of onset of any symptoms, any known prior venous diagnoses, any history of pregnancy-related varices)
  • Presence or absence of predisposing factors (eg, heredity, trauma to the legs, occupational prolonged standing, sports participation)
  • History of edema (eg, date of onset, predisposing factors, site, intensity, hardness, modification after a night's rest)
  • History of any prior evaluation of or treatment for venous disease (eg, medications, injections, surgery, compression)
  • History of superficial or deep thrombophlebitis (eg, date of onset, site, predisposing factors, sequelae)
  • History of any other vascular disease (eg, peripheral arterial disease, coronary artery disease, lymphedema, lymphangitis)
  • Family history of vascular disease of any type
Next:

Physical Examination

The physical examination of the venous system is fraught with difficulty. As mentioned earlier, the severity of symptoms does not necessarily correlate with the size or extent of visible varices or with the volume of reflux. Furthermore, most of the deep venous system cannot be directly inspected, palpated, auscultated, or percussed. In most areas of the body, examination of the superficial venous system must serve as an indirect guide to the deep system.

Inspection

Inspection should be performed in an organized manner, usually progressing from distal to proximal and from front to back. The perineal region, pubic region, and abdominal wall must also be inspected. The following items should be noted:

  • Surgical scars from prior intervention
  • Pigmentations and skin changes - Brownish darkening of the skin, resulting from extravasated blood that causes lipodermatosclerosis; this usually occurs in the medial ankle region but may extend to the leg and foot
  • Varicose veins – Visible, palpable veins in the subcutaneous skin greater than 3 mm in diameter (see the first image below)
  • Reticular veins (also called blue veins, subdermal varices, and venulectasias) – Visible, nonpalpable dilated bluish subdermal veins 1-3 mm in diameter (see the second image below)
  • Telangiectases (also called spider veins, hyphen webs, and thread veins) – Dilated intradermal venules greater than 1 mm in diameter (see the third image below)
  • Eczema – Erythematous dermatitis, which may progress to blistering, weeping, or scaling eruption of the skin of the leg.
  • Atrophie blanche (white atrophy) – Localized, often circular whitish and atrophic skin areas surrounded by dilated capillaries and sometimes hyperpigmentation (scars of healed ulceration are excluded from this definition)
  • Corona phlebectatica (also called malleolar flare and ankle flare) – Fan-shaped pattern of numerous small intradermal veins on the medial or lateral aspects of the ankle and foot.
  • Ulcers of the medial ankle – Most likely the result of underlying venous insufficiency; skin changes or ulcerations that are localized only to the lateral aspect of the ankle are more likely to be related to prior trauma or to arterial insufficiency than to pure venous insufficiency (see the fourth and fifth images below)
Varicose veins. Varicose veins.
Reticular veins. Reticular veins.
Telangiectasias. Telangiectasias.
Lipodermatosclerosis. Lipodermatosclerosis.
Venous stasis ulcer. Venous stasis ulcer.

Palpation

The entire surface of the skin is palpated lightly with the fingertips because dilated veins may be palpable even where they are not visible. Distal and proximal arterial pulses are also palpated. An ankle-brachial index (ABI) is useful if arterial insufficiency is suggested.

The anteromedial surface of the lower limb is the territory of the great saphenous vein (GSV). The arch of the vein may be palpated in some patients with healthy veins, but this segment of the vein is particularly well appreciated in patients with truncal reflux at the saphenofemoral junction (SFJ). It is best palpated two fingerbreadths below the inguinal ligament and just medial to the femoral artery. If reflux is present, a forced coughing maneuver may produce a palpable thrill or sudden expansion at this level.

The posterior surface of the calf is the territory of the small saphenous vein (SSV). This may be palpable in the popliteal fossa in some slender patients. Normal superficial veins above the foot are usually not palpable even after prolonged standing.

Palpation of an area of leg pain or tenderness may reveal a firm, thickened, thrombosed vein. These palpable thrombosed vessels are superficial veins, but an associated deep venous thrombosis (DVT) may exist in as many as 40% of patients with superficial phlebitis.

Varices of recent onset are easily distinguished from chronic varices by means of palpation. Newly dilated vessels sit on the surface of the muscle or bone; chronic varices erode into underlying muscle or bone, creating deep "boggy" or "spongy" pockets in the calf muscle and deep palpable bony notches, especially over the anterior tibia.

Palpation often reveals fascial defects in the calf along the course of an abnormal vein at sites where superficial tributaries emerge through openings in the superficial fascia. Incompetent perforating veins may connect the superficial and deep venous systems through these fascial defects, but the finding is neither sensitive nor specific for perforator incompetence.

Percussion

Percussion is useful in determining whether two venous segments are directly interconnected. With the patient in a standing position, a vein segment is percussed at one position while an examining hand feels for a "pulse wave" at another position. Percussion can be used to trace out the course of veins already detected by palpation, to discover varicose veins that could not be palpated, and to assess the relations between the various varicose vein networks. Valsalva maneuver or cough with the examiner's hand over the medial aspect of the knee can often elicit a palpable pulse wave with florid SFJ incompetence.

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