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Key Features

Essentials of Diagnosis

  • Dilated, tortuous superficial veins in the legs

  • May be asymptomatic or associated with aching discomfort or pain

  • Often hereditary, with patients reporting a family member with similar lesions

  • Increased frequency after pregnancy

General Considerations

  • The superficial veins are involved, typically the great saphenous vein and its tributaries

  • However, the short saphenous vein (posterior lower leg) may also be affected

  • Secondary varicosities can develop as a result of

    • Obstructive changes and valve damage in the deep venous system following thrombophlebitis

    • Proximal venous occlusion due to neoplasm (rarely)

  • Congenital or acquired arteriovenous fistulas or venous malformations are also associated with varicosities and should be considered in young patients with varicosities

Demographics

  • Highest incidence in women after pregnancy

  • Develop in over 20% of all adults

Clinical Findings

Symptoms and Signs

  • Extensive varicose veins may produce no subjective symptoms, whereas minimal varicosities may produce many symptoms

  • Dull, aching heaviness or a feeling of fatigue

  • Itching from a venous eczema

  • Dilated, tortuous veins beneath the skin in the thigh and leg are generally visible in the standing individual

  • However, palpation may be necessary in very obese patients

  • Long-standing varicose veins may progress to chronic venous insufficiency with associated ankle edema, brownish skin hyperpigmentation and chronic skin induration or fibrosis

  • A bruit or thrill

    • Never found with primary varicose veins

    • When found, alerts the clinician to the presence of an arteriovenous fistula or malformation

Differential Diagnosis

  • Varicose veins due to primary superficial venous reflux should be differentiated from those secondary to previous or ongoing obstruction of the deep veins (post-thrombotic syndrome)

  • Pain or discomfort secondary to neuropathy should be distinguished from symptoms associated with coexistent varicose veins

  • Vein symptoms should be distinguished from pain due to intermittent claudication, which occurs after a predictable amount of exercise and resolves with rest

  • In adolescent patients with varicose veins, imaging of the deep venous system is obligatory to exclude a congenital malformation or atresia of the deep veins

Diagnosis

Imaging Studies

  • Duplex ultrasonography is modality of choice

Treatment

Surgery

  • Endovenous ablation (with either radiofrequency or laser)

  • Greater saphenous vein stripping less common

  • Excision of the symptomatic varicose veins; correction of reflux done at same time

  • Phlebectomy without correction of reflux results in a high rate of recurrent varicosities

  • Concurrent reflux detected by ultrasonography in the deep system is not a contraindication to treatment of superficial reflux

Therapeutic Procedures

  • Elastic graduated compression stockings (20–30 mm Hg pressure)

  • Limb elevation when possible

  • Sclerotherapy

    • Obliterates and produces permanent fibrosis of the involved veins

    • Chemical irritants (eg, glycerin) or hypertonic saline are often used for reticular ...

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