Varicose Veins
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Direct answer
Varicose veins are dilated, tortuous superficial veins of the lower limb, usually primary from valvular incompetence at the saphenofemoral or saphenopopliteal junctions and at perforators, and occasionally secondary to deep vein thrombosis. Clinical tests localise the incompetence and colour duplex ultrasound is the investigation of choice. Management runs from compression stockings for symptom control to endovenous laser or radiofrequency ablation or surgery, and the complications — especially the medial gaiter venous ulcer — are exam favourites.
What you must remember
- Lower limb venous return depends on the calf muscle pump, competent valves and the deep fascia; incompetence at the saphenofemoral junction floods the great saphenous system, at the saphenopopliteal junction the short system, and at calf perforators the superficial system directly over the gaiter area.
- The Trendelenburg test with a tourniquet localises the leaking point — reflux filling the veins after a controlled tourniquet release or reapplication identifies saphenofemoral versus perforator incompetence; the Perthes test checks deep vein patency by filling the veins and exercising, and deep vein obstruction contraindicates ablating the superficial system.
- Duplex ultrasound is the investigation of choice, mapping reflux at junctions and perforators and confirming deep patency before any intervention.
- The CEAP classification grades clinical signs from C0 to C6 — telangiectasia, varicosity, oedema, skin changes of pigmentation and eczema, healed ulcer and active ulcer.
- Complications: superficial thrombophlebitis, haemorrhage from eroded varices (elevate and compress first), chronic venous eczema and lipodermatosclerosis, and venous ulceration characteristically in the gaiter area above the medial malleolus.
- Treatment: graduated compression stockings and lifestyle measures for milder disease; endovenous laser ablation, radiofrequency ablation, foam sclerotherapy or open surgery — saphenofemoral ligation with stripping of the great saphenous vein and perforator interruption — for advanced disease.
- A venous ulcer is managed conservatively first with wound dressings and sustained compression after arterial insufficiency has been excluded, with surgery of the reflux reserved for non-healing ulcers; never apply compression to an ischaemic limb.
Common confusion
Primary varicose veins must be separated from secondary: a young patient with unilateral varicosities or a history of deep vein thrombosis should have the deep system imaged before ablation, because removing the superficial escape route decompensates the limb. Candidates also mix up the test purposes — Trendelenburg-type tests localise reflux, Perthes-type tests check the deep veins — and forget that a medial gaiter ulcer with pigmentation is venous, while a punched-out painful ulcer over the foot or toes suggests arterial disease.
Exam-focused takeaway
FMGE varicose vein questions run on three habits: name the test from its purpose (localise incompetence versus assess deep patency); name the investigation of choice, duplex ultrasound; and name the complication from its description — bleeding varicosity managed by elevation and compression, the gaiter ulcer by dressings and compression once pulses are confirmed. CEAP grades, the saphenofemoral junction as the commonest reflux point and endovenous ablation as the modern definitive treatment complete the marks.
Frequently asked questions
Which is the investigation of choice for varicose veins?
Colour duplex ultrasound, which maps reflux at the junctions and perforators and confirms deep vein patency.
What does the Trendelenburg test assess?
The site of valvular incompetence — saphenofemoral junction or perforators — by controlled release of a tourniquet during refilling.
What is the Perthes test for?
Deep vein patency; obstruction of the deep system on this test is a contraindication to ablating or ligating the superficial veins.
Where does a venous ulcer occur?
Classically in the gaiter area just above the medial malleolus, with surrounding pigmentation and lipodermatosclerosis.
What are the modern definitive treatments?
Endovenous laser or radiofrequency ablation and foam sclerotherapy, alongside traditional saphenofemoral ligation with stripping.
How is a bleeding varicose vein managed first?
Immediately by elevation and direct pressure with a compression bandage, before definitive treatment of the reflux.