Varicose Veins

• • 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

Primary

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

  • Most cases of isolated superficial venous insufficiency are primary

Secondary

• • 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

Epidemiology

• • 10-20% of population affected

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

Symptoms and Signs

• • 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

Rule Out

• • 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

• • 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

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

  • Avoid prolonged sitting/standing

Surgery

• • 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

Indications

• • Persistent or disabling pain

  • Recurrent superficial thrombophlebitis

  • Erosion of overlying skin with bleeding

Complications

• • Hematoma formation

  • Infection

  • Saphenous nerve irritation

Prognosis

• • 10% recurrence after treatment

References