Varicose Veins

Anatomy

• Major lower extremity superficial veins incl.

  • Greater saphenous vein (GSV)

  • Lesser saphenous vein (LSV)

  • Common variations incl.

    • accessory saphenous veins (anterior or posterior)

    • thigh extension of LSV

• Major lower extremity perforating veins incl.

  • femoral canal perforators

  • proximal paratibial perforators

  • posterior tibial perforators

• Major lower extremity deep veins incl.

  • common femoral vein (CFV)

  • deep femoral vein (profunda femoris)

  • femoral vein

  • popliteal vein

  • tibial veins (anterior, posterior, peroneal)

  • Common variations incl.

    • duplicated popliteal & femoral veins

Physiology

• venous valves

  • direct flow distal-to-proximal & superficial-to-deep

  • increase in number in direct relation to hydrostatic pressure

    • ex. every 2 cm in distal deep veins

• venous "pump"

  • leg muscle contraction → sub-fascial pressure exceeds intra-muscular vein hydrostatic pressure → flow

  • valves prevent retrograde flow back into superficial system

  • normal superficial venous pressure 20-30 mmHg

Pathophysiology

• inciting factors

  • incompetent venous valves (usually present, but it is unclear if cause or effect)

  • venous obstruction (ie DVT)

• venous hypertension

  • pressure 60-90 mmHg

• initiates changes structural weakening of the vein wall

  • variation in wall thickness, increases in type 1 collagen, decreases in type 3 collagen, degradation of extracellular matrix, reductions in number of smooth muscle cells, etc.

Risk Factors & Etiology

• advancing age

• FHx venous disease

• prolonged standing

• obesity

• smoking

• lower extremity trauma

• DVT (< 33% pts have hx of DVT)

• hereditary conditions

• high estrogen states (i.e., pregnancy)

Clinical

• lower extremity pain/edema

• worse after prolonged standing

• heaviness in the lower extremities

Diagnosis

• Clinical signs & symptoms (superficial lower extremity veins dilated ≥ 3 mm diameter when standing)

• Venous duplex US

  • confirms pathologic venous reflux

  • ≥ 500 ms retrograde flow in superficial/perforator system

  • ≥ 1000 ms retrograde flow in deep system