Varicose Veins

Varicose Veins is a topic covered in the 5-Minute Clinical Consult.

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Basics

Description

  • Superficial venous disease causing a permanent dilatation and tortuosity of superficial veins ≥3 mm in diameter usually occurring in the legs and feet; caused by systemic weakness in the vein wall and may result from congenitally incomplete valves or valves that have become incompetent
  • Affects legs where reverse flow occurs when dependent
  • Truncal varices involve the great and small saphenous veins; branch varicosities involve the saphenous vein tributaries.
  • Categorized as the following:
    • Uncomplicated (cosmetic)
    • With local symptoms (pain confined to the varices, not diffuse)
    • With local complications (superficial thrombophlebitis, may rupture causing bleeding)
    • Complex varicose disease (diffuse limb pain, swelling, skin changes/ulcer)
  • System(s) affected: cardiovascular; skin

ALERT
Ulceration of varicose veins has a high rate of infection, which can lead to sepsis.

Geriatric Considerations
  • Common; usually valvular degeneration but may be secondary to chronic venous insufficiency
  • Elastic support hose and frequent rests with legs elevated rather than ligation and stripping
Pregnancy Considerations
  • Frequent problem
  • Elastic stockings are recommended for those with a history of varicosities or if prolonged standing is involved.

Epidemiology

Incidence
  • Predominant age: middle age
  • Predominant gender: female > male (2:1)
  • National Women’s Health Information Center estimates that 50% of women have varicose veins.

Etiology and Pathophysiology

  • Varicose veins are caused by venous insufficiency from faulty valves in ≥1 perforator veins in the lower leg, causing secondary incompetence at the saphenofemoral junction (valvular reflux).
  • Valvular dysfunction causing venous reflux and subsequently venous hypertension (HTN)
  • Failed valves allow blood to flow in the reverse direction (away from the heart), from deep to superficial and from proximal to distal veins.
  • Deep thrombophlebitis
  • Increased venous pressure from any cause
  • Congenital valvular incompetence
  • Trauma (consider arteriovenous fistula; listen for bruit)
  • Presumed to be due to a loss in vein wall elasticity with failure of the valve leaflets
  • An increase in venous filling pressure is sufficient to promote varicose remodeling of veins by augmenting wall stress and activating venous endothelial and smooth muscle cells.

Genetics
Autosomal dominant with incomplete penetrance

Risk Factors

  • Increasing age
  • Pregnancy, especially multiple pregnancies
  • Prolonged standing
  • Obesity
  • History of phlebitis (postthrombotic syndrome)
  • Family history
  • Female sex
  • Increased height
  • Congenital valvular dysfunction

Commonly Associated Conditions

  • Stasis dermatitis
  • Large varicose veins may lead to skin changes and eventual stasis ulceration.

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