II. Definition

  1. Twisted, dilated veins most commonly located on the legs

III. Epidemiology: Prevalence

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

IV. Pathophysiology

  1. Venous valvular dysfunction
    1. Venous wall loss of elasticity
    2. Valve leaflets fail to fit together
  2. Retrograde venous flow
    1. Pooling of blood in distal and superficial veins
  3. 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. Obesity
  3. Multiparous women
  4. Older age
  5. Family History of Varicose Veins
  6. Prolonged standing

VII. Symptoms

  1. Often asymptomatic
    1. Symptom severity does not correlate with Varicosity severity
    2. Symptoms are more often worse in women
  2. Characteristics
    1. Local symptoms overlying Varicose Vein
      1. Pain
      2. Burning
      3. Itching
    2. Generalized symptoms
      1. Leg Fatigue, heaviness or tension sensation
      2. Regional swelling or pain of the extremity
  3. Provocative
    1. Prolonged standing
  4. Palliative
    1. Sitting with legs elevated

VIII. Signs: Distribution

  1. Lower extremities (most common)
  2. Vulva
  3. Varicocele
  4. Hemorrhoids
  5. Esophageal Varices

IX. Exam: Specific Tests (highest efficacy tests)

  1. Venous Tap Test
    1. Specific for long saphenous vein reflux
  2. Perthes Test
    1. Identifies the site of Venous Insufficiency (above or below the knee)

X. Imaging

  1. Indications
    1. Evaluate for venous thrombosis and Thrombophlebitis
    2. Define reflux, vascular architecture, and valvular competence
  2. First-line tests
    1. Venous Duplex Doppler Ultrasound
  3. Other tests
    1. Venography
    2. Light reflex rheography
    3. Ambulatory venous pressure measurements
    4. Plethysmography

XI. Management: Conservative Measures

  1. External compression
    1. Elastic Compression stockings apply 20-30 mm Hg, with decreasing pressure proximally
    2. Bandages
    3. Intermittent pneumatic compression devices
  2. Elevate the affected extremity
  3. Weight loss
  4. Avoid prolonged standing or straining
  5. Get regular Exercise
  6. Medications (use with caution - most are unproven and may worsen edema)
    1. Horse chestnut seed extract (may improve edema)
      1. Diehm (1996) Lancet 347(8997):292-4 [PubMed]
    2. Butcher's Broom (no proven efficacy)
    3. Avoid Diuretics (ineffective)

XII. Management: Endovenous therapies

  1. Endovenous obliteration of saphenous vein
    1. Thin catheter insterted percutaneously into vein
    2. Catheter delivers energy to collapse and sclerose the vein
    3. 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 <0.5 mm diameter (also improves veins 0.5 to 1 mm)
    3. Reichert (1998) Dermatol Surg 24(7):737-40 [PubMed]
  3. Venous sclerotherapy
    1. Sclerosing agent injected into vein lumen - scars vein into closure
    2. Most effective for small to moderate sized veins (<5 mm diameter)

XIII. Management: Surgery

  1. Background
    1. Higher complication rate and cost
    2. Better efficacy longterm than with conservative measures alone or with sclerotherapy
    3. Endovenous obliteration is too new for longterm comparison with surgery outcomes
      1. Barwell (2004) Lancet 363:1854-9 [PubMed]
  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

XIV. Complications

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Ontology: Varicosity (C0042345)

Definition (MEDLINEPLUS)

Varicose veins are swollen, twisted veins that you can see just under the skin. They usually occur in the legs, but also can form in other parts of the body. Hemorrhoids are a type of varicose vein.

Your veins have one-way valves that help keep blood flowing toward your heart. If the valves are weak or damaged, blood can back up and pool in your veins. This causes the veins to swell, which can lead to varicose veins.

Varicose veins are very common. You are more at risk if you are older, a female, obese, don't exercise or have a family history. They can also be more common in pregnancy.

Doctors often diagnose varicose veins from a physical exam. Sometimes you may need additional tests.

Exercising, losing weight, elevating your legs when resting, and not crossing them when sitting can help keep varicose veins from getting worse. Wearing loose clothing and avoiding long periods of standing can also help. If varicose veins are painful or you don't like the way they look, your doctor may recommend procedures to remove them.

NIH: National Heart, Lung, and Blood Institute

Definition (NCI) A vascular abnormality characterized by the presence of enlarged and tortuous veins, particularly in the legs.
Definition (NCI_NCI-GLOSS) A condition in which a vein, most often in the legs, becomes permanently enlarged, twisted, and painful. This may be caused by valves in the vein that don't work properly or by weakness in the vein walls.
Definition (MSH) Enlarged and tortuous VEINS.
Definition (CSP) dilated tortuous vein, usually in subcutaneous tissues of the leg; incompetency of venous valves is associated.
Concepts Disease or Syndrome (T047)
MSH D014648
ICD10 I83.90
SnomedCT 12856003, 155468006, 155482006, 234053000, 266331000, 276504003, 128060009, 399989005
English Varices, Varicose Veins, Varix, Vein, Varicose, Veins, Varicose, VEIN VARICOSE, VARICOSE VEINS, varicosities, Uneven venous ectasia, Varicose veins NOS, VV - Varicose veins, VVs - Varicose veins, Vein varicose, Varicose Veins [Disease/Finding], venous ectasia, enlarged tortuous blood vessel, Venous varicosities, varicose veins of lower extremities (diagnosis), varicose veins lower extremities, varicose veins (diagnosis), varicose veins, Varicose veins NOS (disorder), Varices (disorder), Varicosities, varicose vein, Varicose vein, Phlebectasia, Varicose veins, Venous varices, Uneven venous ectasia (morphologic abnormality), Venous ectasia (morphologic abnormality), Venous ectasia, Venous varices (disorder), phlebectasia, varices, varix, Varix, NOS, Varices [Ambiguous], Varix (morphologic abnormality), Varicose Vein, Varicosity
Spanish VENAS VARICOSAS, Varicosidad, Venas varicosas, Venas varicosas NEOM, Varicose veins NOS, várices, SAI (trastorno), várices, SAI, várices (trastorno), venas varicosas, varicosidades, ectasia venosa (anomalía morfológica), ectasia venosa, flebectasia, vena varicosa, várice (anomalía morfológica), várices venosas (trastorno), várices venosas, várices, várice, Venas varicosas y complicaciones, Vena varicosa, Várices, Venas Varicosas
Italian Varici venose, Vena varicosa, Vene varicose non specificate, Varicosità, Varice, Varici, Vene varicose
Dutch spataders, varicose, varices NAO, spataderen, varices, veneuze spataderen, Ader, spat-, Aderen, spat-, Spatader, Spataderen, Varix
French Varicosité, Veine variqueuse, Veines variqueuses, Varices SAI, VARICE VEINEUSE, Phlébectasies, Varice, Varices
German Varizen NNB, Varikositaet, VARIKOSE, Varizen, Venoese Varizellen, Krampfadern, Variköse Venen
Portuguese Veia varicosa, Veias varicosas NE, Veias varicosas, Varicosidade, VARICOSIDADE VENOSA, Varizes venosas, Variz, Varizes, Veias Varicosas
Japanese 静脈瘤NOS, ジョウミャクリュウ, ジョウミャクリュウNOS, 静脈瘤, 拡張蛇行静脈
Swedish Åderbråck
Czech varixy, Křečové žíly NOS, Varikózní žíla, Přítomnost varixů, Křečové žíly, Žilní varixy, Křečová žíla, varices, varix, žilní městky, křečové žíly, varikózní žíly
Finnish Suonikohjut
Polish Żylaki, Choroba żylakowa
Hungarian Varicosus venák k.m.n., Vénás varixok, Varicosus venák, Visszértágulat, visszér, Varicositas, Varicosus vena
Norwegian Varicer, Åreknuter, Varix