Varicose Veins

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

• Post-thrombotic syndrome

• Pain or discomfort secondary to neuropathy

• Intermittent claudication

• Congenital malformation or atresia of the deep veins

Diagnosis

Imaging Studies

• Duplex ultrasonography is modality of choice

Treatment

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

Outcome