II. Definition

  1. Varicose Veins
    1. Twisted, dilated veins (3 mm diameter or more when patient standing) most commonly located on the legs

III. Epidemiology: Prevalence

  1. Men: 10-20%
  2. Women: 25-33%

IV. Pathophysiology

  1. Varicose Veins are on a continuum of Chronic Venous Disease
    1. On the mild end of the continuum, Telangiectasias and reticular veins
    2. Following Varicose Veins, edema develops and then secondary Stasis Dermatitis
    3. In severe cases, Venous Stasis Ulcers may form
  2. Venous valvular dysfunction
    1. Venous wall loss of elasticity
    2. Increased venous pressure
    3. Valve leaflets fail to fit together and allow for venous fluid reflux (opposite the normal distal to proximal flow)
  3. Retrograde venous flow
    1. Pooling of blood in distal and superficial veins
  4. Increased pressure in larger superficial veins
    1. Large veins become swollen, tortuous and elongated

V. Causes: Secondary

  1. See Venous Insufficiency
  2. Increased intravenous pressure (e.g. prolonged standing)
  3. Increased intraabdominal pressure
    1. Pregnancy
    2. Malignancy
    3. Obesity
    4. Constipation
    5. Chronic Cough
  4. Deep Vein Thrombosis
  5. Arteriovenous Shunting (uncommon)

VI. Risk Factors

  1. Female gender
  2. Family History of Varicose Veins
  3. Older age
  4. Prolonged standing
  5. Deep Vein Thrombosis (Post-Thrombotic Syndrome)
  6. Arteriovenous shunting
  7. Chronically incrfeased intra-abdominal pressure
    1. Obesity
    2. Multiparous women
    3. Chronic Constipation
    4. Intraabdominal mass

VII. Symptoms

  1. Often asymptomatic
    1. Symptom severity does not correlate with Varicosity severity
    2. Symptoms are more often worse in women
  2. Distribution
    1. Unilateral or bilateral
    2. Legs are most often affected
  3. Characteristics
    1. Local symptoms overlying Varicose Vein
      1. Pain
      2. Burning
      3. Itching
    2. Generalized symptoms
      1. Leg Fatigue, heaviness, cramping, throbbing, restlessness, swelling or tension Sensation
      2. Regional swelling or pain of the extremity
  4. Timing
    1. Typically worse at the end of the day
  5. Provocative
    1. Prolonged standing
  6. Palliative
    1. Sitting with legs elevated

VIII. Signs

  1. Findings associated with more severe, advanced disease
    1. Ankle region, fan-shaped Varicose Veins (corona phlebectatica)
    2. Atrophie blanche (dilated capillaries surrounded by circular region of white scar)
    3. Lipodermatosclerosis
  2. Distribution
    1. Lower extremities (most common)
      1. Great saphenous vein, small saphenous vein and tributaries
    2. Other regions (consider pelvic vein incompetence or obstruction)
      1. Vulva
      2. Varicocele
      3. Hemorrhoids
      4. Esophageal Varices

IX. Exam: Documentation

  1. Size, distribution of Varicose Veins
  2. Edema
  3. Skin Discoloration or ulcerations

X. Exam: Specific Tests (poor sensitivity and Specificity)

  1. Venous Tap Test
    1. Palpate for retrograde transmitted impulse at saphenofemoral junction from the long saphenous vein
    2. Specific for long saphenous vein reflux
  2. Cough Test
    1. Transmission of thrill or impulse with coughing at the saphenofemoral junction
  3. Perthes Test
    1. Identifies the site of Venous Insufficiency (above or below the knee)

XI. Imaging

  1. Indications
    1. Evaluate for Deep Vein Thrombosis and Superficial Thrombophlebitis
    2. Define reflux, vascular architecture, and valvular competence
  2. First-line tests
    1. Venous Duplex Doppler Ultrasound
  3. Interpretation: Reflux criteria
    1. Retrograde flow lasting >350 ms in perforating veins
    2. Retrograde flow lasting >500 ms in superficial and deep calf vein
    3. Retrograde flow lasting >1000 ms in the femoropopliteal veins
  4. Other tests
    1. Venography
    2. Light reflex rheography
    3. Ambulatory venous pressure measurements
    4. Plethysmography

XII. Management: Conservative Measures

  1. External compression (may relieve discomfort)
    1. Indicated as first line therapy in pregnancy, or if other interventions as below are ineffective
    2. Elastic Compression Stockings apply 20-30 mm Hg, with decreasing pressure proximally
    3. Other measures
      1. Bandages
      2. Intermittent pneumatic compression devices
  2. Elevate the affected extremity
  3. Weight loss (in obese patients)
  4. Avoid prolonged standing or straining
  5. Get regular Exercise
  6. Avoid restrictive clothing
  7. Medications (use with caution - most are unproven and may worsen edema)
    1. Numerous formulations (known as phlebotonics)
    2. Horse chestnut seed extract 300 mg(or 50 mg of escin) orally twice daily
      1. May improve edema, but no longterm data
      2. Diehm (1996) Lancet 347(8997):292-4 [PubMed]
    3. Other medications include Rutin, Diosmin, Hidrosmin, disodium flavodate, grape seed extract
    4. Butcher's Broom (no proven efficacy)
    5. Avoid Diuretics (ineffective)

XIII. Management: Endovenous therapies

  1. Endovenous obliteration via thermal ablation of saphenous vein (first-line in non-pregnant patients)
    1. Thin catheter insterted percutaneously into vein under Local Anesthesia
    2. Used for larger veins, including the greater saphenous vein
    3. Catheter delivers energy to collapse and sclerose the vein
    4. May be associated with local nerve injury in up to 7% of patients (usually transient)
    5. Same day procedure, with early return to work and activities
    6. Min (2003) J Vasc Interv Radiol 14(8):991-6 [PubMed]
  2. External venous laser therapy (esp. long-pulsed lasers)
    1. Thermocoagulation-based therapy
      1. Hemoglobin Absorbs transcutaneous laser delivered wave lengths
    2. Most effective for small veins and Telangiectasias <0.5 mm diameter (also improves veins 0.5 to 1 mm)
    3. Reichert (1998) Dermatol Surg 24(7):737-40 [PubMed]
  3. Endovenous sclerotherapy
    1. Sclerosing agent (e.g. Hypertonic Saline, Sodium tetradecyl, polidocanol)
      1. Injected into vein lumen, forming a foam, and scars vein into closure
    2. Most effective for small to moderate sized veins (<5 mm diameter)
      1. However, less overall effectiveness than other measures (thermal ablation, laser, surgery)

XIV. Management: Surgery

  1. Background
    1. Higher complication rate and cost
    2. Surgical methods have been refined for less invasive measures
    3. Better efficacy longterm than with conservative measures alone or with sclerotherapy
    4. Other non-surgical measures (thermal ablation, laser) are as effective, with fewer adverse effects
  2. Venous ligation
    1. Vein tied off along its course via small incisions
  3. Phlebectomy
    1. With patient standing, Varicose Vein mapped (may use Doppler Ultrasound)
    2. Small incisions made every few centimeters over the course of the vein
    3. Saphenous vein ligated at proximal site
    4. Vein pulled through incisions, extracted proximal to distal
  4. Vein stripping
    1. Greater saphenous vein ligated at proximal site
    2. Vein stripper inserted into venous lumen at knee and moved proximally toward thigh

XV. Complications

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