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varicose vein (varix)

Distended, lengthened or tortuous vein(s). The superficial veins of the legs (saphenous veins) are most commonly affected. Other sites include the rectum (hemorrhoids), the testes (varicocele), the esophagus (esophageal varices) & the retina. Etiology: 1) inefficient or defective venous valves 2) risk factors a) female gender b) history of deep venous thrombosis (DVT) c) pregnancy d) local trauma e) familial history of varicose veins Epidemiology: 1) 30-60% of adults 2) females affected more frequently than males 3) incidence increases with age Clinical manifestations: 1) dilated superficial veins 2) achy & burning legs generally worse with: a) warm weather b) prolonged standing c) pregnancy d) following sexual intercourse e) with exogenous hormone therapy 3) night cramps 4) restless legs 5) leg edema 6) cutaneous & venous ulceration 7) cutaneous pigmentation 8) venous stasis, stasis dermatitis Laboratory: 1) continuous wave Doppler 2) exercise plethysmography 3) photoplethysmography 2) laboratory tests as indicated to rule out DVT, diabetes Complications: 1) increased risk for deep vein thrombosis (RR=5.3) [4] - lesser risk for pulmonary embolism (RR=1.7) & peripheral arterial disease (RR=1.7) 2) phlebitis 3) hemorrhage Differential diagnosis: 1) deep venous thrombosis (DVT) 2) arterial occlusive disease Management: 1) elastic support (compression stockings) a) greatest compression at ankle, less higher b) continuous use while upright c) patient compliance is an issue 2) surgery a) surgical ligation & avulsion (stripping, phlebectomy) b) luminal (endovenous radio-frequency laser ablation) [2] c) foam sclerotherapy - surgical ligation or laser ablation better [3] d) VenaSeal (closure with adhesive) see VenaSeal e) laser ablation or surgical ligation/stripping with slightly better disease-specific quality of life at 6 months vs foam sclerotherapy [5] 3) elevation of extremities 4) good skin care

Related

varus deformity venous stasis; venous hypertension

Specific

esophageal varices gastric varices hemorrhoids (piles) varicocele; cirsocele; pampinocele

General

venous disease; venopathy peripheral vascular disease (PVD) abnormal morphologic structure (malformation)

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 276-77
  2. Rass K et al Comparable Effectiveness of Endovenous Laser Ablation and High Ligation With Stripping of the Great Saphenous Vein Arch Dermatol. Published online September 19, 2011 PMID: 21931012 http://archderm.ama-assn.org/cgi/content/abstract/archdermatol.2011.272
  3. Brittenden J et al A Randomized Trial Comparing Treatments for Varicose Veins. N Engl J Med 2014; 371:1218-1227. September 25, 2014 PMID: 25251616 http://www.nejm.org/doi/full/10.1056/NEJMoa1400781
  4. Chang SL, Huang YL, Lee MC et al Association of Varicose Veins With Incident Venous Thromboembolism and Peripheral Artery Disease. JAMA. 2018;319(8):807-817. February 27, 2018 PMID: 29486040 https://jamanetwork.com/journals/jama/article-abstract/2673551
  5. Brittenden J, Cooper D, Dimitrova M et al. Five-year outcomes of a randomized trial of treatments for varicose veins. N Engl J Med 2019 Sep 5; 381:912 PMID: 31483962 https://www.nejm.org/doi/10.1056/NEJMoa1805186
  6. Raetz J, Wilson M, Collins K. Varicose Veins: Diagnosis and Treatment. Am Fam Physician. 2019 Jun 1;99(11):682-688. PMID: 31150188 Free article. Review.
  7. Barstow C, Kassop D. Cardiovascular disease: chronic venous insufficiency and varicose veins. FP Essent. 2019;479:16-20. PMID: 30995000