Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 12-13: Varicose Veins + Key Features Download Section PDF Listen +++ +++ 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 Download Section PDF Listen +++ +++ 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 Download Section PDF Listen +++ +++ Imaging Studies ++ Duplex ultrasonography is modality of choice + Treatment Download Section PDF Listen +++ +++ 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 Download Section PDF Listen +++ +++ 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 + References Download Section PDF Listen +++ + +Brittenden J et al. A randomized trial comparing treatments for varicose veins. N Engl J Med. 2014 Sep 25;371(13):1218–27. [PubMed: 25251616] + +DePopas E et al. Varicose veins and lower extremity venous insufficiency. Semin Intervent Radiol. 2018 Mar;35(1):56–61. [PubMed: 29628617] + +Hamann SAS et al. Editor's Choice—Five-year results of great saphenous vein treatment: a meta-analysis. Eur J Vasc Endovasc Surg. 2017 Dec;54(6):760–70. [PubMed: 29033337]