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Essential Features

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  • • Dilated, tortuous superficial veins in lower extremities, usually bilateral

    • Pigmentation, ulceration, edema suggest concomitant venous stasis disease

    • Classified as primary or secondary

    • Risk factors for varicose veins (VV) include:

    • –Female gender

      –Pregnancy

      –Family history

      –Prolonged standing

      –History of phlebitis

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Primary

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  • • Due to genetic or developmental defects in vein wall causing valvular incompetence

    • Most cases of isolated superficial venous insufficiency are primary

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Secondary

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  • • Destruction or dysfunction of valves caused by trauma, deep venous thrombosis (DVT), AV fistula, proximal venous obstruction (pregnancy, pelvic tumor, etc)

    • Disruption of valves results in chronic venous stasis changes

    • Long-standing venous dysfunction leads to chronic skin changes leading to infection

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Epidemiology

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  • • 10–20% of population affected

    • Highest incidence in women 40- to 50-years-old

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Clinical Findings

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Symptoms and Signs

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  • • Variable presentation

    • Many patients are asymptomatic

    • Localized pain (ache or heaviness with prolonged standing), phlebitis

    • Predominantly located medially (saphenous vein)

    • Small, flat blue-green reticular and spider veins indicates venous dysfunction

    • Secondary VV can cause edema, hyperpigmentation, dermatitis, ulcers

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Diagnostic Considerations

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Rule Out

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  • • Chronic deep venous insufficiency

    • Klippel-Trénaunay syndrome: Unilateral VV, limb hypertrophy, cutaneous birthmark (port wine stain/venous malformation)

    • –Therapy: Graduated support stockings, avoid saphenous vein stripping as deep veins often absent

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Work-up

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  • • Brodie-Trendelenburg test

    • –Identifies saphenofemoral dysfunction: Elevate leg until varicosities collapse, place tourniquet around mid thigh to occlude reflux from saphenofemoral incompetence

      –If veins fill, implies perforator incompetence

      –If veins remain collapsed, implies saphenofemoral dysfunction

    • Duplex US is test of choice

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Treatment and Management

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  • • First manage venous insufficiency: Elastic stockings, leg elevation, exercise

    • Avoid prolonged sitting/standing

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Surgery

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  • • Operative therapy:

    • 1. Remove entire saphenous vein (for incompetent saphenofemoral junction, varicosities along entire length)

      2. Selective VV removal with stab-avulsion technique

      3. Combined technique

    • Inject small volume of sclerosing solution (0.2% sodium tetradecyl sulfate) into varix, telangiectasia, spider vein; maintain direct pressure for 1 wk with stockings

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Indications
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  • • Persistent or disabling pain

    • Recurrent superficial thrombophlebitis

    • Erosion of overlying skin with bleeding

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Complications

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  • • Hematoma formation

    • Infection

    • Saphenous nerve irritation

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Prognosis

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  • • 10% recurrence after treatment

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Resources

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References

Belcaro G et al. Endovascular sclerotherapy, surgery, and surgery plus sclerotherapy in superficial venous incompetence: a randomized, 10 year follow-up trial - final results. Angiology. 2000;51:529.  [PubMed: 10917577]
Gohel MS et al: Randomized clinical trial of compression plus surgery versus compression alone in chronic venous ulceration (ESCHAR ...

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