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  • Reverse venous flow (reflux) is exceedingly common in the general population.

  • Age, pregnancy, body mass, and a family history of varicose leg veins all increase the incidence of venous reflux in patients.

  • Duplex ultrasound examination can rapidly, effectively, and reproducibly map the superficial venous pathways of the lower extremities and identify sources of reflux in a noninvasive fashion.

  • Sclerotherapy is the gold standard treatment for spider veins, although lasers may play an important adjuvant or alternative role.

  • Varicose veins are often treated with a combination of endovenous ablation and sclerotherapy or phlebectomy, depending on their underlying cause.

Abnormal lower-extremity veins, from unsightly telangiectasias (“spider veins”) to symptomatic varicose veins, affect millions of people worldwide. Although telangiectasias and reticular veins are often considered solely a cosmetic nuisance, they are, like varicose veins, an early manifestation of chronic venous disease (CVD) and may foreshadow the development of advanced CVD, termed chronic venous insufficiency (CVI). Signs and symptoms of CVI have high socioeconomic costs, including reduced quality of life and millions of work days lost per year, in the United States and Western Europe.1,2

While telangiectasias and reticular veins may be treated with sclerotherapy or long-pulsed vascular lasers, varicose veins require sclerotherapy (typically with the aid of duplex ultrasound guidance), ambulatory phlebectomy, or endovenous thermal ablation. Successful treatment of lower-extremity venous disease is predicated on the fundamental understanding of venous anatomy, physiology, and patterns of insufficiency; methods of diagnosing venous disease; uses and actions of sclerosing solutions; and the proper use of posttreatment compression.


The venous system of the lower extremities is an intricate, variable network of vessels divided into 3 compartments (superficial, deep, and perforating) that allow for outflow of blood back to the heart and local tissue drainage and thermoregulation (Fig. 212-1). One-way valves are present in veins of all 3 systems, ensuring unidirectional blood flow against gravity, toward the heart.

Figure 212-1

Superficial and (pertinent) deep venous system anatomy of the lower extremity. n, Nerve; SSV, small saphenous vein; v, vein. (Reproduced with permission from UT Health Science Center at San Antonio. © UTHSCSA.)


The veins of the deep venous compartment lie beneath muscular (aka deep aponeurotic) fascia and act as a conduit for approximately 90% of venous return from the leg. Deep venous blood flow is regulated by the physiologic alternate contraction–relaxation of the calf flexor–extensor skeletal muscles that act as a peristaltic pump. During calf muscle contraction, rising pressure in the deep compartment (up to 250 mm Hg) propels blood through the deep system in a proximal direction with an ejection fraction of 65%.3 This and the fact that these high pressures close valves of deep and perforating veins prevent ...

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