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Chronic venous disease (CVD), varicose vein disease, venous reflux disease, and superficial venous insufficiency are many times used interchangeably and reflect both the presence of visible varicose veins and the underlying cause of valvular reflux and venous insufficiency. Varicose veins are defined as bulging dilated or tortuous veins that are located superficially under the skin of the lower extremities and correspond to CEAP class C1 and C2 (classification to be explained later). Chronic venous insufficiency (CVI), on the other hand, involves symptoms and skin changes that are more extensive than just the presence of varicose veins and includes venous disease starting from CEAP class C3 and higher. They also reflect the presence of valvular reflux and insufficiency but of a more severe and chronic nature. Chronic venous insufficiency is discussed more specifically in Chapter 8, while this chapter will focus on superficial venous insufficiency and varicose veins.
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The prevalence of venous disease is greatly underestimated in the USA and worldwide. Twice more frequent than coronary heart disease, and as prevalent as diabetes, venous disease affects approximately 25 million Americans, with almost one million people in the United States having venous ulcers. The overall cost is estimated at $21 to $46 billion annually.1,2
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It has been proposed that humankind has been suffering from varicose veins ever since we started walking on two legs. Venous disease has similarly been recognized for a long time. The first documented case of varicose veins was recorded around 1550 BC in the papyrus of Ebers. Hippocrates noticed a connection between varicose veins and ulcers and started to treat varicose veins with compression and cautery. The first phlebectomy by mini-incisions was performed by Celsus (26 BC – 50 AD), but it was so painful that the patient reportedly refused further treatment. Vesalius described the anatomy of veins in 1543, Harvey then discovered the direction of venous flow to the heart, and Valsalva in 1710 described the pumping effect of muscles on venous flow. Risk factors for developing varicose veins, such as pregnancy and long travel, were identified by Paré in 1545. Fabricius first attributed varicose veins to valvular incompetence (1603) and a century later Dionis and Petit additionally attributed varices to proximal compression and obstruction. Rudolf Virchow in 1846 was the first to point out the hereditary tendency of varicose veins. In the 1880s, Briquet elucidated the role of abnormal flow from deep veins via the perforators in varicose vein pathogenesis. In terms of treatment, the first attempt at sclerotherapy was performed by Pravaz in the nineteenth century after the invention of the syringe and hypodermic needle but it was associated with numerous complications and was not further pursued. In 1884, Madelung proposed longitudinal incisions to perform phlebectomy but a less traumatic stripping technique was described by Charles Mayo in 1904. The hook phlebectomy, still in frequent use ...