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  • Valluvanad Hospital,
  • Kanniyampuram, Ottapalam, Kerala
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How Do We Evaluate Varicose Veins?

Table of Contents

Proper evaluation is essential for diagnosing and managing varicose veins, especially in advanced cases like venous ulcers. A structured approach involving history, clinical examination, imaging, and classification ensures optimal treatment.

History Taking

A detailed history provides critical insights into the progression of venous disease. Key aspects include:

  • Symptoms: Patients may report heaviness, swelling, pain, itching, or night cramps. Symptoms often worsen after prolonged standing and improve with elevation.
  • Ulcer History: Chronicity, recurrence, previous treatments, and healing response. Venous ulcers often have a long-standing history, unlike arterial ulcers.
  • Risk Factors:
    • Family history of varicose veins.
    • Previous deep vein thrombosis (DVT) or trauma.
    • Pregnancy, obesity, or prolonged standing occupation.
    • Past venous interventions.
  • Associated Skin Changes: Hyperpigmentation, lipodermatosclerosis, eczema, or atrophie blanche suggest chronic venous insufficiency.

Physical Examination

A. Limb Examination (Performed in Supine and Standing Positions)

1. Inspection
  • Assess the entire limb to visualize the extent of varicose veins.
  • Identify the type of edema: pitting (venous insufficiency) vs. non-pitting (lymphedema).
  • Look for venous eczema, hyperpigmentation, lipodermatosclerosis, and atrophie blanche.
  • Evaluate the presence of hemosiderin deposits or induration around the ankle.
2. Palpation:
  • Assess the entire limb to visualize the extent of varicose veins.
  • Identify the type of edema: pitting (venous insufficiency) vs. non-pitting (lymphedema).
  • Look for venous eczema, hyperpigmentation, lipodermatosclerosis, and atrophie blanche.
  • Evaluate the presence of hemosiderin deposits or induration around the ankle.

B. Venous Ulcer Evaluation

1. Location
  • Venous ulcers are most commonly found over the medial malleolus (gaiter region).
  • Less commonly, lateral malleolus or anterior shin may be involved.
2. Ulcer Characteristics
  • Margins: Irregular and sloping edges.
  • Base: Shallow with granulation tissue, may have fibrinous slough.
  • Base: Shallow with granulation tissue, may have fibrinous slough.
3. Surrounding Skin
  • Hyperpigmentation due to hemosiderin deposition.
  • Lipodermatosclerosis (woody induration).
  • Stasis dermatitis (venous eczema with erythema and scaling).
  • Atrophie blanche (white scar-like patches).
4. Pain Assessment
  • Typically mild to moderate pain, worsened by dependency and relieved by elevation.
  • Severe pain suggests superadded infection or arterial involvement.
5. Signs of Infection
  • Increased warmth, erythema, foul-smelling discharge.
  • Presence of cellulitis or secondary bacterial colonization.

Ultrasound Doppler Examination

Color Doppler ultrasound (CDUS) is the gold standard for evaluating venous reflux and ulcer-related venous insufficiency.

  • Superficial Venous Reflux: Great saphenous vein (GSV), small saphenous vein (SSV), and perforators.
  • Deep Venous Reflux or Obstruction: To rule out post-thrombotic syndrome (PTS).
  • Perforator Vein Incompetence: Perforators >3.5 mm with reflux are significant.

Advanced Imaging in Chronic Ulcers

If deep venous obstruction or iliac vein compression is suspected:

  • CT Venography (CTV) or MR Venography (MRV): To evaluate May-Thurner Syndrome or venous outflow obstruction and pelvic congestion syndrome in non-healing ulcers.

Planning the Treatment

Treatment focuses on ulcer healing, preventing recurrence, and addressing underlying venous reflux.

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