Varicose Vein

1. See Also
   1. Venous Insufficiency
2. Definition
   1. Twisted, dilated veins most commonly located on the legs
3. Epidemiology: Prevalence
   1. Men: 10-20%
   2. Women: 25-33%
4. Pathophysiology
   1. Venous valvular dysfunction
      1. Venous wall loss of elasticity
      2. Valve leaflets fail to fit together
   2. Retrograde venous flow
      1. Pooling of blood in distal and superficial veins
   3. Increased pressure in larger superficial veins
      1. Large veins become swollen, tortuous and elongated
5. Causes: Secondary
   1. See Venous Insufficiency
   2. Increased intravenous pressure (e.g. prolonged standing)
   3. Increased intraabdominal pressure
      1. Pregnancy
      2. Malignancy
      3. Obesity
      4. Constipation
      5. Chronic Cough
   4. Deep Vein Thrombosis
   5. Arteriovenous Shunting (uncommon)
6. Risk Factors
   1. Female gender
   2. Obesity
   3. Multiparous women
   4. Older age
   5. Family History of Varicose Veins
   6. Prolonged standing
7. Symptoms
   1. Often asymptomatic
      1. Symptom severity does not correlate with Varicosity severity
      2. Symptoms are more often worse in women
   2. Characteristics
      1. Local symptoms overlying Varicose Vein
         1. Pain
         2. Burning
         3. Itching
      2. Generalized symptoms
         1. Leg Fatigue, heaviness or tension sensation
         2. Regional swelling or pain of the extremity
   3. Provocative
      1. Prolonged standing
   4. Palliative
      1. Sitting with legs elevated
8. Signs: Distribution
   1. Lower extremities (most common)
   2. Vulva
   3. Varicocele
   4. Hemorrhoids
   5. Esophageal Varices
9. Exam: Specific Tests (highest efficacy tests)
   1. Venous Tap Test
      1. Specific for long saphenous vein reflux
   2. Perthes Test
      1. Identifies the site of Venous Insufficiency (above or below the knee)
10. Imaging
    1. Indications
       1. Evaluate for venous thrombosis and thrombophlebitis
       2. Define reflux, vascular architecture, and valvular competence
    2. First-line tests
       1. Venous Duplex Doppler Ultrasound
    3. Other tests
       1. Venography
       2. Light reflex rheography
       3. Ambulatory venous pressure measurements
       4. Plethysmography
11. Management: Conservative Measures
    1. External compression
       1. Elastic Compression stockings apply 20-30 mm Hg, with decreasing pressure proximally
       2. Bandages
       3. Intermittent pneumatic compression devices
    2. Elevate the affected extremity
    3. Weight loss
    4. Avoid prolonged standing or straining
    5. Get regular Exercise
    6. Medications (use with caution - most are unproven and may worsen edema)
       1. Horse chestnut seed extract (may improve edema)
          1. Diehm (1996) Lancet 347(8997):292-4
       2. Butcher's Broom (no proven efficacy)
       3. Avoid Diuretics (ineffective)
12. Management: Endovenous therapies
    1. Endovenous obliteration of saphenous vein
       1. Thin catheter insterted percutaneously into vein
       2. Catheter delivers energy to collapse and sclerose the vein
       3. Min (2003) J Vasc Interv Radiol 14(8):991-6
    2. External venous laser therapy (esp. long-pulsed lasers)
       1. Thermocoagulation-based therapy
          1. Hemoglobin Absorbs transcutaneous laser delivered wave lengths
       2. Most effective for small veins <0.5 mm diameter (also improves veins 0.5 to 1 mm)
       3. Reichert (1998) Dermatol Surg 24(7):737-40
    3. Venous sclerotherapy
       1. Sclerosing agent injected into vein lumen - scars vein into closure
       2. Most effective for small to moderate sized veins (<5 mm diameter)
13. Management: Surgery
    1. Background
       1. Higher complication rate and cost
       2. Better efficacy longterm than with conservative measures alone or with sclerotherapy
       3. Endovenous obliteration is too new for longterm comparison with surgery outcomes
          1. Barwell (2004) Lancet 363:1854-9
    2. Venous ligation
       1. Vein tied off along its course via small incisions
    3. Phlebectomy
       1. With patient standing, Varicose Vein mapped (may use doppler ultrasound)
       2. Small incisions made every few centimeters over the course of the vein
       3. Saphenous vein ligated at proximal site
       4. Vein pulled through incisions, extracted proximal to distal
    4. Vein stripping
       1. Greater saphenous vein ligated at proximal site
       2. Vein stripper inserted into venous lumen at knee and moved proximally toward thigh
14. Complications
    1. See Venous Insufficiency
15. References
    1. Jones (2008) Am Fam Physician 78(11): 1289-94
    2. Sardick (2005) Dermatol Clin 23: 443-55
    3. Teruya (2004) Surg Clin North Am 84: 1397-417