Varicose Veins

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Chapter 66 Varicose Veins

INTRODUCTION

Description: Varicose veins are dilated, elongated, and tortuous superficial veins with incompetent or congenitally absent valves. Although these may occur anywhere in the body, they are most common in the legs, where gravity produces reverse flow. Varicose veins are five times more common in women than in men.
Prevalence: Twenty percent of adults, one out of two people older than age 50.
Predominant Age: Middle age and beyond.
Genetics: Familial as an X-linked dominant condition.

ETIOLOGY AND PATHOGENESIS

Causes: Faulty or absent valves in one or more perforating veins that may result in secondary incompetence at the saphenofemoral junction. Other causes—deep vein thrombophlebitis, increased venous pressure from any source (e.g., obstruction by tumor, pregnancy, pelvic mass).
Risk Factors: Pregnancy, family history, prolonged standing.

CLINICAL CHARACTERISTICS

Signs and Symptoms

• Asymptomatic
• Leg pain or cramps (worse during menstruation)
• Dilated, tortuous superficial veins
• Spider veins (idiopathic telangiectases)
• Limb edema
• Superficial ulceration

DIAGNOSTIC APPROACH

Differential Diagnosis

• Radiculopathy (nerve root compression)
• Arthritis
• Peripheral neuritis

Associated Conditions: Stasis ulcers and dermatitis.

Workup and Evaluation

Laboratory: No evaluation indicated.
Imaging: Doppler studies may be used to evaluate the possibility of deep vein thrombosis but are generally not required for the diagnosis of varicose veins.
Special Tests: Trendelenburg-Brodie test (elevate leg, compress greater saphenous vein at mid-thigh, have patient stand: rapid refilling of vein indicates incompetent communicating veins).
Diagnostic Procedures: History and physical examination.

Pathologic Findings

Elongated, tortuous veins with medial fibrosis and absent or atrophic valves.

MANAGEMENT AND THERAPY

Nonpharmacologic

General Measures: Frequent rest, elevation of affected limb, lightweight compression (hosiery), avoidance of proximal compression (girdles).
Specific Measures: Superficial veins may be eliminated with intracapillary injection of hypertonic saline (20% to 25%) or 1% to 3% solution of sodium tetradecyl sulfate (must be followed by compression for up to 3 weeks). Ligation or stripping of the saphenous veins should be considered in patients with pain, ulcers, recurrent phlebitis, or significant cosmetic problems.
Diet: No specific dietary changes indicated. Weight loss when appropriate.
Activity: Active exercise routines including walking, use of elastic stockings (applied before arising), avoidance of prolonged standing or inactivity.
Patient Education: Education about risk factors and avoidance; American College of Obstetricians and Gynecologists Patient Education Pamphlet AP119 (Exercise During Pregnancy), AP045 (Exercise and Fitness: A Guide for Women).

Drug(s) of Choice

None.
Precautions: Some authors suggest that oral contraceptives not be used within 6 weeks of sclerotherapy.

Alternative Drugs

Antibiotic therapy for infected ulcers.

FOLLOW-UP

Patient Monitoring: Normal health maintenance, evaluation for progression of disease or emergence of complications (skin ulcers).
Prevention/Avoidance: Avoidance of prolonged standing or inactivity, use of compression stockings, exercise, weight loss, leg elevation when at rest.
Possible Complications: Petechial hemorrhages, chronic edema, superficial ulceration and infection, chronic pigment change, eczema.
Expected Outcome: Generally a chronic condition with control possible through treatment.

MISCELLANEOUS

Pregnancy Considerations: No effect on pregnancy. Pregnancy often worsens existing disease and increases the risk of future occurrence. Use of compression stockings should be encouraged for those at increased risk.
ICD-9-CM Codes: 454.1.

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REFERENCES

Level I

Lorenz D, Gabel W, Redtenbacher M, et al. Randomized clinical trial comparing bipolar coagulating and standard great saphenous stripping for symptomatic varicose veins. Br J Surg. 2007;94:434.

Michaels JA, Brazier JE, Campbell WB, et al. Randomized clinical trial comparing surgery with conservative treatment for uncomplicated varicose veins. Br J Surg. 2006;93:175.

Level III

American College of Obstetricians and Gynecologists. Prevention of deep vein thrombosis and pulmonary embolism. ACOG Practice Bulletin 21. Washington, DC: ACOG, 2000.

Baccaglini U, Spreafico G, Castoro C, Sorrentino P. Sclerotherapy of varicose veins of the lower limbs. Consensus paper. North American Society of Phlebology. Dermatol Surg. 1996;22:883.

Green D. Sclerotherapy for the permanent eradication of varicose veins: theoretical and practical considerations. J Am Acad Dermatol. 1998;38:461.

Eberhardt RT, Raffetto JD. Chronic venous insufficiency. Circulation. 2005;111:2398.

Helmerhorst FM, Bloemenkamp KW, Rosendaal FR, Vandenbroucke JP. Oral contraceptives and thrombotic disease: risk of venous thromboembolism. Thromb Haemost. 1997;78:327.

Hobson J. Venous insufficiency at work. Angiology. 1997;48:577.

Houghton AD, Panayiotopoulos Y, Taylor PR. Practical management of primary varicose veins. Br J Clin Pract. 1996;50:103.

Rajendran S, Rigby AJ, Anand SC. Venous leg ulcer treatment and practice—Part 4: Surgery and pharmaceutical therapies. J Wound Care. 2007;16:155.

Ramelet AA. Complications of ambulatory phlebectomy. Dermatol Surg. 1997;23:947.

Sapira JD. The art and science of bedside diagnosis. Baltimore: Williams & Wilkins, 1990;368.

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