Varicose Veins

Venous Reflux Disease

Anatomic Definitions

  • Varicose veins: are palpable veins 4 mm or greater in diameter that do not discolor skin
  • Reticular veins: are dilated but nonpalpable, blue dermal veins less than 4 mm
  • Perforators
    • Diameter greater than 4 mm almost always refluxing
    • Diameter less than 2 mm – unlikely to reflux and treatment is usually of little clinical significance
    • If perforator is > 3.5 mm and is near and active or healed ulcer, it is considered a pathologic perforator

Hemodynamics

Ambulatory venous pressure (AVP) is measured by sticking a 21g needle in the dorsal foot vein. 10 tiptoe movements is done and the lowest pressure is recorded at the end of exercise.

  • AVP < 30 mmHg usually do not have ulceration
  • AVP > 90 mmHg is almost always associated with venous ulcers

Venous refilling time (VRT) is the time required to fill the venous system to 90% of baseline. VRT is very short, or rapid, in reflux disease.

Air plethysmography (APG) measures the calf volume changes. Venous volume (VV) is measured as patient stands from supine and leg elevated position. After 10 tiptoes, the EF is calculated. Residual volume (RV) is also known. VRT is noted base on time 90% VV is achieved.

The parameter venous filling index is calculated by:

VFI = 90%VV/VRT

  • VFI of 5 mL/s ~ 0% incidence of ulceration.
  • VFI of 10 mL/s ~ 58% ulceration

Reflux Time

  • Superficial and deep calf veins > 0.5 seconds
  • Perforating veins >0.35 seconds, although some texts states 0.5 seconds
  • Femoral-popliteal veins > 1.0 second
  • Deep femoral vein > 0.5 seconds
  • Of note, the reflux venous flow velocity should be greater than 30 cm/s. At less than 30 cm/s, the elicited reflux flow may be to slow to produce valve closure, even if the valve is physiologically competent, thus producing a false positive insufficiency.

Radiofrequency Ablation

Sizes above 2 mm and below 15 mm in diameter

Endovenous Heat Induced Thrombosis (EHIT)

  1. EHIT I: Thrombosis up to saphenofemoral junction (SFJ)
    No treatment needed
  2. EHIT II: Thrombosis into common femoral vein (CFV) with <50% cross sectional area
    Variable management, but typically short term anticoagulation with repeat ultrasound in 1-2 weeks to monitor resolution
  3. EHIT III: Thrombosis into common femoral vein with >50% cross sectional area
    Anticoagulation for 3 months
  4. EHIT IV: Complete thrombosis of common femoral vein
    Anticoagulation for 3 months