Varicose Veins

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.