Varicose Veins

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Basics

Description

  • Superficial venous disease causing a permanent dilatation, elongation, 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 and using the clinical, etiologic, anatomic, and pathologic (CEAP) classification:
    • Uncomplicated (cosmetic): corresponds to CEAP 0,1, and 2
    • With local symptoms (pain confined to the varices, not diffuse): corresponds to CEAP 2
    • With local complications (superficial thrombophlebitis, may rupture causing bleeding): corresponds to CEAP 2, 3, 4
    • Complex varicose disease (diffuse limb pain, swelling, skin changes/ulcer): corresponds to CEAP 4, 5, 6
  • 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)

Prevalence
  • Chronic vein abnormalities are present in approximately 50% of people; varicose veins are present in 10–30% of people
  • It is estimated that ~6 to 7 million Americans have chronic venous insufficiency
  • Prevalence of chronic venous disease varies among different populations (non-Hispanic Caucasians have more venous disease than African Americans, Asians, and Hispanics

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 (e.g., pregnancy, obesity)
  • 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.
  • Calf muscle pump failure
  • Obstruction (proximal)
  • Deep venous insufficiency can lead to secondary superficial varicosities via enlarging collaterals

Genetics
No gene has been identified; however, there does appear to be some inherited component.

Risk Factors

  • Increasing age
  • Family history
  • Pregnancy, especially multiple pregnancies
  • Prolonged standing
  • Obesity
  • Sedentary lifestyle
  • History of phlebitis or prior thrombosis
  • Lower extremity trauma
  • Ligament laxity
  • Female sex
  • Smoking
  • Congenital valvular dysfunction

General Prevention

  • Maintain a healthy body mass index
  • Regular exercise
  • Avoid sitting or standing for prolonged periods of time
  • Avoid smoking
  • Wear compression stockings

Commonly Associated Conditions

  • Stasis dermatitis
  • Lipodermatosclerosis
  • Venous ulceration (usually near medial malleolus/gaiter area

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Basics

Description

  • Superficial venous disease causing a permanent dilatation, elongation, 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 and using the clinical, etiologic, anatomic, and pathologic (CEAP) classification:
    • Uncomplicated (cosmetic): corresponds to CEAP 0,1, and 2
    • With local symptoms (pain confined to the varices, not diffuse): corresponds to CEAP 2
    • With local complications (superficial thrombophlebitis, may rupture causing bleeding): corresponds to CEAP 2, 3, 4
    • Complex varicose disease (diffuse limb pain, swelling, skin changes/ulcer): corresponds to CEAP 4, 5, 6
  • 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)

Prevalence
  • Chronic vein abnormalities are present in approximately 50% of people; varicose veins are present in 10–30% of people
  • It is estimated that ~6 to 7 million Americans have chronic venous insufficiency
  • Prevalence of chronic venous disease varies among different populations (non-Hispanic Caucasians have more venous disease than African Americans, Asians, and Hispanics

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 (e.g., pregnancy, obesity)
  • 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.
  • Calf muscle pump failure
  • Obstruction (proximal)
  • Deep venous insufficiency can lead to secondary superficial varicosities via enlarging collaterals

Genetics
No gene has been identified; however, there does appear to be some inherited component.

Risk Factors

  • Increasing age
  • Family history
  • Pregnancy, especially multiple pregnancies
  • Prolonged standing
  • Obesity
  • Sedentary lifestyle
  • History of phlebitis or prior thrombosis
  • Lower extremity trauma
  • Ligament laxity
  • Female sex
  • Smoking
  • Congenital valvular dysfunction

General Prevention

  • Maintain a healthy body mass index
  • Regular exercise
  • Avoid sitting or standing for prolonged periods of time
  • Avoid smoking
  • Wear compression stockings

Commonly Associated Conditions

  • Stasis dermatitis
  • Lipodermatosclerosis
  • Venous ulceration (usually near medial malleolus/gaiter area

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