Varicose veins are swollen and enlarged veins that usually occur on the legs and feet. They may be blue or dark purple, and are often lumpy, bulging or twisted in appearance.
Varicose veins develop in the lower extremities. Periods of high venous pressure related to prolonged standing or heavy lifting are contributing factors, but the highest incidence occurs in women after pregnancy. Varicosities develop in over 20% of all adults.
This combination of progressive venous reflux and venous hypertension is the hallmark of chronic venous disease. The superficial veins are involved, typically the great saphenous vein and its tributaries, but the short saphenous vein (posterior lower leg) may also be affected. Distention of the vein prevents the valve leaflets from coapting, creating incompetence and reflux of blood toward the foot.
Focal venous dilation and reflux leads to increased pressure and distention of the vein segment below that valve, which in turn causes progressive failure of the next lower valve. Perforating veins that connect the deep and superficial systems may become incompetent, allowing blood to reflux into the superficial veins from the deep system, increasing venous pressure and distention.
Secondary varicosities can develop as a result of obstructive changes and valve damage in the deep venous system following thrombophlebitis, or rarely as a result of proximal venous occlusion due to neoplasm or fibrosis. Congenital or acquired arteriovenous fistulas or venous malformations are also associated with varicosities and should be considered in young patients with varicosities.
Signs and symptoms
Symptom severity is not correlated with the number and size of the varicosities; extensive varicose veins may produce no subjective symptoms, whereas minimal varicosities may produce many symptoms.
Dull, aching heaviness or a feeling of fatigue of the legs brought on by periods of standing is the most common complaint.
Itching from venous eczema may occur either above the ankle or directly overlying large varicosities.
Dilated, tortuous veins of the thigh and calf are visible and palpable when the patient is standing.
Longstanding varicose veins may progress to chronic venous insufficiency with associated ankle edema, brownish skin hyperpigmentation, and chronic skin induration or fibrosis.
A bruit or thrill is never found with primary varicose veins and when found, alerts the clinician to the presence of an arteriovenous fistula or malformation.
The identification of the source of venous reflux that feeds the symptomatic veins is necessary for effective surgical treatment. Duplex ultrasonography by a technician experienced in the diagnosis and localization of venous reflux is the test of choice for planning therapy. In most cases, reflux will arise from the greater saphenous vein.
Varicose veins due to primary superficial venous reflux should be differentiated from those secondary to previous or ongoing obstruction of the deep veins (post-thrombotic syndrome). Pain or discomfort secondary to neuropathy should be distinguished from symptoms associated with coexistent varicose veins. Similarly, vein symptoms should be distinguished from pain due to intermittent claudication, which occurs after a predictable amount of exercise and resolves with rest. In adolescent patients with varicose veins, imaging of the deep venous system is obligatory to exclude a congenital malformation or atresia of the deep veins. Surgical treatment of varicose veins in these patients is contraindicated because the varicosities may play a significant role in venous drainage of the limb.
Nonsurgical treatment is effective. Elastic graduated compression stockings (20–30 mm Hg pressure) reduce the venous pressure in the leg and may prevent the progression of disease. Good control of symptoms can be achieved when stockings are worn daily during waking hours and legs are elevated, especially at night. Compression stockings are well-suited for elderly patients or patients who do not want surgery.
Direct injection of a sclerosing agent induces permanent fibrosis and obliteration of the target veins. Chemical irritants (eg, glycerin) or hypertonic saline are often used for small, less-than-4-mm reticular veins or telangiectasias. Foam sclerotherapy is used to treat the great saphenous vein, varicose veins larger than 4 mm, and perforating veins, often with local anesthesia alone. Injection of a cyanoacrylate adhesive is also available for treating the great saphenous vein.
Foam sclerotherapy and cyanoacrylate adhesive therapy have similar clinical results as saphenous vein thermal ablation or stripping, although the long-term success rate may be lower and systemic embolization remains a concern. Complications such as phlebitis, tissue necrosis, or infection may occur with any sclerosing agent.
Treatment with endovenous thermal ablation (with either radiofrequency or laser) or, less commonly, with great saphenous vein stripping is effective for reflux arising from the great saphenous vein. Less common sources of reflux include the small saphenous vein (for varicosities in the posterior calf) and incompetent perforator veins arising directly from the deep venous system. Correction of reflux is performed at the same time as excision of the symptomatic varicose veins.
Phlebectomy without correction of reflux results in a high rate of recurrent varicosities, as the uncorrected reflux progressively dilates adjacent veins. Concurrent reflux detected by ultrasonography in the deep system is not a contraindication to treatment of superficial reflux because the majority of deep vein dilatation is secondary to volume overload in this setting, which will resolve with correction of the superficial reflux.
Superficial thrombophlebitis of varicose veins is uncommon. The typical presentation is acute localized pain with tender, firm veins. The process is usually self-limiting, resolving within several weeks. The risk of deep venous thrombosis (DVT) or embolization is very low unless the thrombophlebitis extends into the great saphenous vein in the upper medial thigh. Predisposing conditions include pregnancy, local trauma, or prolonged periods of sitting.
In older patients, superficial varicosities may bleed with even minor trauma. The amount of bleeding can be alarming as the pressure in the varicosity is high.