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Conservative management of varicose veins.

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VOL: 101, ISSUE: 04, PAGE NO: 51

Debbie Ruff, BSc, is vascular nurse specialist, Pennine Acute Hospitals NHS Trust, Oldham, Lancashire

Classification

Classification
Varicose veins can be classified as trunk, reticular, or telangiectasia.

Trunk varicose veins are varicosities in the long or short saphenous vein (veins of the leg) or their major branches (Fig 1A).

Reticular varicose veins are dilated tortuous subcutaneous veins that do not belong to the main branches of the long or short saphenous veins (Fig 1B).

Telangiectasia are referred to as spider veins, thread veins or starbursts. They are a localised collection of distended capillaries that are visible under the skin surface (Fig 1C).

Varicose veins are also described as being primary or secondary:

- Primary veins - the underlying cause is unknown;

- Secondary veins - those that have occurred following a particular illness or event. For example: after a deep-vein thrombosis; in a patient with pelvic tumours; or during or after pregnancy.

Causes
The underlying causes of varicose veins have been the subject of considerable debate. There is some evidence that primary genetic defects affect the valves, while other evidence refers to an abnormality affecting the vein wall, which results in dilation, so preventing the valve from functioning effectively (Callam, 1999).

There are several predisposing factors. These are summarised in Box 1.

Symptoms
Some people with varicose veins are asymptomatic, while others complain of a range of symptoms in the affected limb. These include aches and pains, heaviness, itching, swelling, restless legs, cramps and tingling (Bradbury et al, 1999).

The symptoms are more common in women than men and tend to increase with age. Cosmetic appearance is often a significant factor in requests for treatment.

Complications
The aim of early treatment of varicose veins is to reduce the risks associated with venous incompetence. These include haemorrhage, oedema, atrophie blanche (abnormality of skin scar formation - the white scar tissue is dotted with the red dots of dilated capillaries), lipodermatosclerosis (areas of induration that result from fibrosis of the subcutaneous fat), thrombophlebitis (inflammation of the wall of the vein), skin pigmentation, varicose eczema, and venous ulceration (London and Nash, 2000).

Patient assessment
Initially, a full medical history should be recorded in conjunction with a physical examination of the limbs. The patient should then undergo a vascular assessment, which should include measuring the ankle brachial pressure index using a hand-held Doppler so as to exclude any underlying arterial impairment (Vowden and Vowden, 2001). Once any arterial impairment has been excluded, the practitioner may then discuss the most appropriate treatment for the patient.

Clinical management
Most patients who present to their GP with varicose veins can be managed effectively in primary care. However, specialist advice should be sought if they are experiencing certain symptoms (Box 2).

Conservative management: Most varicose veins do not require any treatment, in which case the role of health-care professionals in primary care is to provide reassurance and education, including advice on exercise and weight reduction if necessary (NICE, 2001). Staff should also be involved in making recommendations for compression hosiery and skin care.

Compression hosiery
Classifications: To assist in identifying the most appropriate level of compression for each individual, hosiery is divided into three categories. These are classified as class I, II and III depending on the performance of the materials and the indications for their use (Table 1). It should be noted, however, that the European and British standards for the recommended levels of compression are different: the European standards are higher than the British ones.

Hosiery selection
The underlying pathology and patient compliance may influence the class of hosiery that is prescribed. That in classes l and ll has been shown to be beneficial for treating venous congestion and venous hypertension (Weiss and Duffy, 1999). Patient compliance can be improved by education about the role of compression hosiery in preventing and treating varicose veins (Dale and Gibson, 1992). Involving patients in the selection of hosiery will help ensure that the chosen product is suited to their needs and preferences.

Measurement: Accurate patient assessment and measurement are vital to ensure that the hosiery fits comfortably and produces an effective gradation in pressure (Box 3).

Contraindications for compression hosiery: There are a number of contraindications for using compression hosiery, including:

- Advanced peripheral arterial occlusive disease;

- Congestive cardiac failure;

- Advanced peripheral neuropathy;

- Known sensitivities to the fabric of the stocking.

Note: Caution is advised when considering compression hosiery for people with diabetes and rheumatoid arthritis because of the possibility of their having microvascular disease (see p47).

Patient education
Teaching patients to apply their compression hosiery is essential. Application can often be difficult and a number of aids such as the Actiglide or Medivalet (Fig 2, and see footnote) may be used to help with application. Hosiery may be removed at night but must be reapplied first thing in the morning before the limb swells. Emollients or moisturisers should be used daily to maintain healthy skin under the hosiery.

Conclusion
GPs are frequently faced with patients complaining of varicose veins. In some cases the problem is cosmetic, while in many cases patients are symptomatic and the varicose veins are a precursor to chronic venous insufficiency (Callam, 1999).

The development of varicose veins occurs over several years, offering many opportunities for early treatment. The GP should assess all patients presenting with varicose veins in order to identify those with a significant problem who will require referral to a specialist.

NICE (2001) recommends that most patients should now be managed conservatively in primary care in nurse-led clinics that offer advice on compression hosiery and skin care.

Points for reflection
- Think of a patient whom you have nursed who had varicose veins

- How would you explain what varicose veins are?

- Did the patient have predisposing factors for the development of varicose veins?

- With what symptoms did the patient present?

- What lifestyle advice should you give?

- Did you consider compression hosiery?

- How did you assess your patient for hosiery?

- What are the contraindications for using compression hosiery on a patient?

- When would you refer your patient for specialist advice?

Foot note
The Actiglide can be purchased through a local pharmacy or from The Leg Care Company. Tel: 01288 359 599.

The Medivalet can be purchased by telephoning 01432 373 500.

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