Varicose Veins

Key Features

Essentials of Diagnosis

• Dilated, tortuous superficial veins in the legs

• Asymptomatic or there may be 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

• Treatment options for reflux arising from the great saphenous vein include

  • Surgical vein stripping (removal)

  • Thermal endovascular treatments using laser or radiofrequency catheter

  • Cyanoacrylate glue injection

  • Foam sclerosant injection

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

• One major complication of thermal treatments includes endothermal heat-induced thrombosis of the deep vein and may require prolonged anticoagulation

Therapeutic Procedures