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ESSENTIALS OF DIAGNOSIS

  • Dilated, tortuous superficial veins in the legs.

  • May be asymptomatic or associated with aching discomfort or pain.

  • Often hereditary.

  • Increased frequency after pregnancy.

GENERAL CONSIDERATIONS

Varicose veins develop in the lower extremities. Periods of high venous pressure related to prolonged standing or heavy lifting are contributing factors, but the highest incidence occurs in women after pregnancy. Varicosities develop in over 20% of all adults.

The combination of progressive venous reflux and venous hypertension is the hallmark of chronic venous disease. The superficial veins are involved, typically the great saphenous vein and its tributaries, but the short saphenous vein (posterior lower leg) may also be affected. Distention of the vein prevents the valve leaflets from coapting, creating incompetence and reflux of blood toward the foot. Focal venous dilation and reflux leads to increased pressure and distention of the vein segment below that valve, which in turn causes progressive failure of the next lower valve. Perforating veins that connect the deep and superficial systems may become incompetent, allowing blood to reflux into the superficial veins from the deep system, increasing venous pressure and distention.

Secondary varicosities can develop as a result of obstructive changes and valve damage in the deep venous system following thrombophlebitis, or rarely as a result of proximal venous occlusion due to neoplasm or fibrosis. Congenital or acquired arteriovenous fistulas or venous malformations are also associated with varicosities and should be considered in young patients with varicosities.

CLINICAL FINDINGS

A. Symptoms and Signs

Symptom severity is not correlated with the number and size of the varicosities; extensive varicose veins may produce no subjective symptoms, whereas minimal varicosities may produce many symptoms. Dull, aching heaviness or a feeling of fatigue of the legs brought on by periods of standing is the most common complaint. Itching from venous eczema may occur either above the ankle or directly overlying large varicosities.

Dilated, tortuous veins of the thigh and calf are visible and palpable when the patient is standing. Longstanding 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 is never found with primary varicose veins and when found, alerts the clinician to the presence of an arteriovenous fistula or malformation.

B. Imaging

The identification of the source of venous reflux that feeds the symptomatic veins is necessary for effective surgical treatment. Duplex ultrasonography by a technician experienced in the diagnosis and localization of venous reflux is the test of choice for planning therapy. In most cases, reflux will arise from the greater saphenous vein.

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 ...

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