Definition distention of tortuous superficial veins resulting from incompetent valves in the deep, superficial, or perforator systems
distribution: greater saphenous vein and tributaries (most common), esophagus, anorectum, scrotum
Etiology
Primary
main factor: inherited structural weakness of valves
contributing factors: increasing age, female gender, OCP use, occupations requiring long hours of standing, pregnancy, obesity
secondary
malignant pelvic tumors with venous compression
congenital anomalies, arteriovenous fistulae
Pathogenesis: gravity → blood congestion → ↑ pressure → valve insufficiency → structural change
Dynamics of venous flow in response to calf muscle contraction in a normal limb.
Dynamics of venous flow in response to calf muscle contraction in a postthrombotic limb with residual deep venous obstruction, incompetent valves, and secondary varicose veins. Blood ow in perforating veins is bidirectional.
Dynamics of venous flow in response to calf muscle contraction in a limb with primary varicose veins.
Epidemiology
primary varicose veins are the most common form of venous disorder of lower extremity
10-20% of population
Clinical Features
diffuse aching, fullness/tightness, nocturnal cramping
aggravated by prolonged standing (end of day), premenstrual
visible long, dilated and tortuous superficial veins along thigh and leg
ulceration, hyperpigmentation, and induration (secondary varicosities)
Brodie-Trendelenburg test (valvar competence test)
with patient supine, raise leg and compress saphenous vein at thigh, have patient stand – if veins fill quickly from top down then incompetent valves; use multiple tourniquets to localize incompetent veins
Complications
• recurrent superficial thrombophlebitis
• hemorrhage: external or subcutaneous
• ulceration, eczema, lipodermatosclerosis, and hyperpigmentation
Treatment
largely a cosmetic problem
conservative: elevation of leg and/or elastic compression stockings
surgical: high ligation and stripping of the long saphenous vein and its tributaries, ultrasound- guided foam sclerotherapy, endovenous laser therapy (EVLT)
indications for surgery: symptomatic varix (pain, bleeding, recurrent thrombophlebitis), tissue changes (hyperpigmentation, ulceration), failure of conservative treatment, cosmetics
Prognosis
• benign course with predictable complications
• almost 100% symptomatic relief with treatment if varicosities are primary
• good cosmetic results with treatment
• significant post-operative recurrence, especially with sclerosing agent injection