Introduction

Essentials of Diagnosis

• Dilated, tortuous superficial veins in the lower extremities.
• May be asymptomatic or associated with fatigue, aching discomfort, bleeding, or localized pain.
• Edema, pigmentation, and ulceration suggest concomitant venous stasis disease.
• Increased frequency after pregnancy.

General Considerations

Abnormally dilated veins develop in several locations, giving rise to varicoceles, esophageal varices, and hemorrhoids. However, varicose veins are most commonly found in the legs as abnormally dilated, elongated, and tortuous alterations in the saphenous veins and their tributaries. Fifteen percent of adults develop saphenous vein varicosities. Risk factors include female gender, pregnancy, family history, prolonged standing, and history of phlebitis.

The long saphenous vein and its tributaries are most commonly involved, but the short saphenous vein may also be affected. These vessels lie immediately beneath the skin and superficial to the deep fascia.

An inherited vein wall or valvular defect appears to play a role in the development of most primary varicosities. Secondary varicosities may result from valve damage following thrombophlebitis, trauma, Deep venous thrombosis, arteriovenous fistula, or nontraumatic proximal venous obstruction (pregnancy, pelvic tumor). Venous reflux caused by valvular incompetence is characteristic of both primary and secondary varicose veins. At the saphenofemoral junction and the perforating veins of the medial calf and thigh, the superficial and deep veins of the leg communicate; valve incompetence in these segments permits blood flow to be bidirectional. Thus, high venous pressures (< 300 mm Hg) from within the deep system that occur during calf compression associated with walking are transmitted to these superficial veins, which dilate. With long-standing disease, the surrounding tissue and skin may develop secondary changes such as fibrosis, chronic edema, and skin pigmentation and atrophy.

Clinical Findings

A. Symptoms
The severity of the symptoms is not necessarily correlated with the number and size of the varicosities. Dull, aching heaviness or a feeling of fatigue brought on by periods of standing is the most common complaint. Itching from an associated eczematoid dermatitis may occur above the ankle.

B. Signs
Dilated, tortuous, elongated veins on the medial aspect of the thigh and leg are usually readily visible with the patient standing, though in very obese patients palpation may be necessary to detect their presence and location. Smaller, flat, blue-green reticular veins, telangiectasias, and spider veins may accompany varicose veins and are further evidence of venous dysfunction. Secondary tissue changes may be absent even in the presence of extensive large varicosities; however, with deep venous insufficiency and long-standing varicose veins signs of chronic venous insufficiency appear. These may include brownish pigmentation and thinning of the skin above the ankle, edema, fibrosis, scaling dermatitis, and venous ulceration. Duplex ultrasonography is used to detect the precise location of incompetent valves. The Brodie-Trendelenburg test is less accurate but can help differentiate saphenofemoral valve incompetence from perforator vein incompetence. With the patient lying supine, the leg is elevated until all varicosities collapse. A tourniquet is placed at the mid thigh to exclude reflux secondary to incompetence at the saphenofemoral junction. With the tourniquet in place, the patient is asked to stand. If the varicosities stay collapsed, this implies valvular insufficiency at the saphenofemoral junction. However, if the varicosities rapidly refill, perforator vein incompetence is implicated. The tourniquet can then be moved more distally to identify the location of the incompetent perforator.

Differential Diagnosis
Primary varicose veins should be differentiated from secondary varicose veins to exclude the possibility of chronic venous insufficiency of the deep system of veins, obstruction of the pelvic veins, arteriovenous fistula (congenital or acquired), or congenital venous malformation. If extensive varicose veins are encountered in a young patient -  especially if unilateral and in an atypical distribution (lateral leg)  -  Klippel-Trenaunay syndrome must be considered. The classic triad of Klippel-Trenaunay syndrome is varicose veins, limb hypertrophy, and a cutaneous birthmark (port wine stain or venous malformation). Because the deep veins are often anomalous or absent, saphenous vein stripping is contraindicated. Standard treatment for patients with Klippel-Trenaunay syndrome is graduated support stockings and surgery for correction of leg length discrepancy.

Pain or discomfort secondary to arthritis, radiculopathy, or arterial insufficiency should be distinguished from symptoms associated with coexistent varicose veins.

Complications

Complications of varicose veins include secondary ulceration, bleeding, chronic stasis dermatitis, superficial venous thrombosis, and thrombophlebitis.

Treatment

A. Nonsurgical Measures
Knee-high or thigh-high elastic graduated compression stockings give external support to the superficial veins. For most patients, a gradient of compression of 20-30 mm Hg is appropriate. The stockings are worn all day to reduce venous hypertension due to pooling of blood and are removed at night. Periodic leg elevation and regular exercise are encouraged. In many patients, this program may provide relief of symptoms and discourage progression of disease sufficient to avoid surgery.

Small venous ulcers generally heal with leg elevation and compression bandages (Ace wrap or Unna boot). Varicose vein excision should be postponed until infection and edema are controlled.

B. Surgical Measures
Indications for surgical treatment include persistent or disabling pain, recurrent superficial thrombophlebitis, erosion of the overlying skin with bleeding, and manifestations of chronic venous insufficiency (particularly ulceration).

The operative plan is dependent on determination of the competency of the deep and perforating veins and the location of sites of venous reflux. Preoperative duplex ultrasound is essential in identification of incompetent perforating veins and in assessment of the saphenofemoral junction. Surgery can then be tailored to the pattern of disease. Stab avulsion surgery is combined with prevention of reflux by high ligation of the saphenofemoral junction or ligation of perforator branches. Endovenous radiofrequency ablation of the proximal saphenous vein alone or combined with stab avulsion of calf varicosities is under evaluation. Stripping of the entire saphenous system is rarely required and may be complicated by hematoma formation, infection, and saphenous nerve irritation.

C. Compression Sclerotherapy
Compression sclerotherapy can be used for telangiectasias, spider veins, and small (> 4 mm) varicosities that persist after vein stripping. With patients in supine position, small volumes of a sclerosing solution (23.4% hypertonic saline or 2.5% sodium morrhuate) are injected, and direct pressure is then maintained with compression stockings. The goal is to obliterate the abnormal vein by inducing localized endothelial destruction and fibrosis. More than one treatment is often required. Complications -  including allergic reactions, thrombophlebitis, neoangiogenesis, skin necrosis, or hyperpigmentation -  are rare.

Prognosis

With careful patient selection and properly selected operative techniques, most patients experience relief of symptoms, and the recurrence rate is about 10%. Patients should be informed that this is a chronic disease and that prevention of new varicosities is dependent on continued use of the compression stockings, leg elevation, and exercise. If extensive varicosities reappear after surgery, the completeness of the high ligation should be questioned, and reexploration of the saphenofemoral area may be necessary. Even after adequate treatment, secondary tissue changes may not regress.

Bradbury A et al: The relationship between lower limb symptoms and superficial and deep venous reflux on duplex ultrasonography: the Edinburgh Vein Study. J Vasc Surg 2000;32:921.

Lurie F et al: Prospective randomized study of endovenous radiofrequency obliteration (closure procedure) versus ligation and stripping in a selected patient population (EVOLVeS Study). J Vasc Surg 2003;38:207.