Varicose Veins

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

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

• Post-thrombotic syndrome

• Pain or discomfort secondary to neuropathy

• Intermittent claudication

• Congenital malformation or atresia of the deep veins

Imaging Studies

• Duplex ultrasonography is modality of choice

General Measures

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

• Limb elevation when possible

Surgery

• Options for treating reflux arising from the great saphenous vein

  • Surgical vein stripping (removal)

  • Endovenous treatments using thermal devices (from a laser or radiofrequency catheter), cyanoacrylate glue injection, or foam sclerosant injection

    • Can often be performed with local anesthesia alone

    • Early success is equal to vein stripping

• Correction of reflux is performed at the same time as excision of the symptomatic varicose veins

Therapeutic Procedures

• Sclerotherapy

  • Obliterates and produces permanent fibrosis of the involved veins

  • Chemical irritants (eg, glycerin) or hypertonic saline are often used for reticular veins or telangiectasias < 4 mm in diameter

  • Foam sclerotherapy is used to treat the great saphenous vein, varicose veins > 4 mm and perforating veins

Complications

• Superficial thrombophlebitis of varicose veins is uncommon

• The risk of deep venous thrombosis or embolization is very low unless the thrombophlebitis extends into the great saphenous vein in the upper medial thigh

• Predisposing conditions for phlebitis

  • Pregnancy

  • Local trauma

  • Prolonged period of sitting

• Phlebitis, tissue necrosis, or infection may occur with sclerotherapy

Prognosis

• Long-term success is highest with vein stripping and thermal treatments while the long-term durability of cyanoacrylate glue and foam is unknown

• Excellent with surgical treatment of superficial vein reflux and excision of varicose veins

• 5-year success rate is 85–90%

• Simple excision (phlebectomy) or injection sclerotherapy without correction of reflux is associated with recurrence rates > 50%

• Even after adequate treatment, secondary tissue changes may persist

When to Refer

• Absolute indications for referral for saphenous ablation include thrombophlebitis and bleeding

• Pain and cosmetic concerns are responsible for the majority of referrals for ablation