Cleveland Clinic Journal of MedicineVaricose Veins

Chronic Venous Insufficiency: Unraveling the Complex Interplay of Valvular Dysfunction and Venous Pressure in Lower-Limb Varicosities

Lower-limb varicosities, a common manifestation of chronic venous disease, affect millions worldwide. This article presents a case study of a 60-year-old man with a 20-year history of worsening varicose veins, highlighting the clinical presentation, diagnostic approach, and treatment options. The comprehensive overview emphasizes the importance of proper evaluation and management, from conservative measures to surgical interventions, in addressing both symptomatic relief and cosmetic concerns.

Key Points:

• Varicose veins are defined as subcutaneous dilated veins ≥ 3 mm in diameter, typically involving the great and small saphenous veins and their branches.
• Etiology involves elevated venous pressure due to incompetent valves, obstruction, or a combination of both, impairing venous return.
• Risk factors include occupations requiring prolonged standing or walking and history of venous thrombosis.
• The Clinical, Etiologic, Anatomic, Pathophysiologic (CEAP) classification grades chronic venous disorders, with varicose veins classified as C2.
• Symptoms may include leg pain, heaviness, swelling, dryness, itching, skin changes, and ulceration.
• Evaluation of varicosity patterns is crucial, as certain patterns may indicate underlying conditions:
  • Suprapubic or abdominal wall varicosities: Consider iliofemoral venous obstruction
  • Medial thigh or vulvar varicosities: Evaluate for pelvic venous insufficiency
  • Scrotal varicosities: May suggest gonadal vein incompetence, nutcracker syndrome, or other conditions
• Color duplex ultrasound is the first-line diagnostic test to confirm the absence of deep and superficial venous thrombosis.
• Differential diagnoses include lymphedema, congestive heart failure, and renal disease.
• Treatment options:
  1. Conservative measures:
     • Moderate-pressure compression stockings (20–30 mm Hg)
     • Lifestyle modifications (weight loss, leg elevation)
  2. Surgical interventions:
     • Endovenous therapy (laser or radiofrequency ablation, sclerotherapy)
     • Open venous surgery (ligation, phlebectomy, venous stripping)
• Compression stockings can improve symptoms and control edema but have low compliance rates (as low as 37%) due to discomfort.
• Referral to vascular surgery may be indicated for refractory cases or symptomatic varicose veins with axial reflux.
• Radiofrequency ablation shows approximately 70% cosmetic improvement, with optimal results when patients wear compression stockings for 7-10 days post-treatment and ambulate early.
• Potential complications of radiofrequency ablation include deep vein thrombosis, heat-induced thrombus extension, or rarely, pulmonary embolism.
• Postprocedural duplex scanning within 1 week is routinely recommended after radiofrequency ablation.

A study of 3,822 adults in the Framingham Study found that varicose veins were more common in women than men, with no clear age-related differences. Women with varicose veins were more likely to be obese, less physically active, and had higher blood pressure compared to women without varicose veins. They also tended to experience menopause later in life. (American Journal of Preventative Medicine)

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