para>Ulceration of varicose veins has a high rate of infection, which can lead to sepsis. é á
Geriatric Considerations
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Pregnancy Considerations
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EPIDEMIOLOGY
Incidence
- Predominant age: middle age
- Predominant gender: female > male (2:1)
- National Women 's Health Information Center estimates that 50% of women have varicose veins.
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
- 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 (1).
Genetics
Autosomal dominant with incomplete penetrance é á
RISK FACTORS
- Increasing age
- Pregnancy, especially multiple pregnancies
- Prolonged standing
- Obesity
- History of phlebitis (postthrombotic syndrome)
- Family history
- Female sex
- Increased height
- Congenital valvular dysfunction
COMMONLY ASSOCIATED CONDITIONS
- Stasis dermatitis
- Large varicose veins may lead to skin changes and eventual stasis ulceration.
DIAGNOSIS
HISTORY
- Symptoms range from minor annoyance/cosmetic problem to a lifestyle-limiting problem.
- Localized symptoms: pain, burning, itching
- Generalized symptoms
- Leg muscular cramp, aching
- Leg fatigue/swelling
- Pain if varicose ulcer develops
- Symptoms often worse at the end of the day, especially after prolonged standing.
- Women are more prone to symptoms due to hormonal influences: worse during menses.
- No direct correlation with the severity of varicose veins and the severity of symptoms
PHYSICAL EXAM
- Inspect lower extremities while the patient is standing. Varicose veins in the proximal femoral ring and distal portion of the legs may not be visible when the patient is supine.
- Varicose veins are the following:
- Dilated, tortuous, superficial veins, chiefly in the lower extremities
- Dark purple/blue in color, raised above the surface of the skin
- Often twisted, bulging, and can look like cords
- Most commonly found on the posterior/medial lower extremity
- Edema of the affected limb may be present.
- Skin changes may include the following:
- Eczema
- Hyperpigmentation
- Lipodermatosclerosis
- Spider veins (idiopathic telangiectases)
- Fine intracutaneous angiectasis
- May be extensive/unsightly
- Neurologic sensory and motor exam
- Peripheral arterial vasculature; pulses
- Musculoskeletal exam for associated rheumatologic/orthopedic issues
DIFFERENTIAL DIAGNOSIS
- Nerve root compression
- Arthritis
- Peripheral neuritis
- Telangiectasia: smaller, visible blood vessels that are permanently dilated
- Deep vein thrombosis
- Inflammatory liposclerosis
DIAGNOSTIC TESTS & INTERPRETATION
Duplex ultrasound: Noninvasive imaging duplex ultrasound will confirm the etiology, anatomy, and pathophysiology of segmental venous reflux. The severity of both symptoms and signs tends to correlate with the degree of venous reflux, which is identified by duplex ultrasound as retrograde or reversed flow of greater than 0.5 seconds duration (2). é á
Diagnostic Procedures/Other
Duplex scanning, venous Doppler study, photoplethysmography, light-reflection rheography, air plethysmography, and other vascular testing should be reserved for patients who have venous symptoms and/or large (>4 mm in diameter) vessels or large numbers of spider telangiectasia indicating venous HTN. é á
Test Interpretation
A clinical classification illustrating the current physical state is useful in clinical practice (1). é á
- 0: no visible or palpable signs of venous disease
- 1: spider veins or telangiectasias
- 2: varicose veins
- 3: edema
- 4: skin changes (pigmentation, eczema, lipodermatosclerosis, atrophie blanche)
- 5: healed ulcer
- 6: active ulcer
TREATMENT
- Conventional wisdom suggests conservative therapy (e.g., elevation, external compression, weight loss) as being helpful; while compression stockings improve the severity of varicose veins, they do not seem to improve quality of life (3)[B].
- There is insufficient, high-quality evidence to determine whether or not compression stockings are effective as the sole and initial treatment of varicose veins in people without healed or active venous ulceration, or whether any type of stocking is superior to any other type (4)[A].
- All the current modalities of endoluminal and open surgical treatment have similar short-term outcomes and risks (5)[A].
- Appropriate surgical treatment has the best long-term outcomes and evidence base (5)[A].
- Treatment of choice, however, depends on many factors, including local expertise (5)[A].
- When comparing quality of life, pain relief, and long-term relief, surgery is favored (6)[A].
- Endovenous laser ablation (EVLA); radiofrequency ablation, foam sclerotherapy, and surgical stripping for great saphenous varicose veins are all efficacious (7)[A].
- Endovenous ablation (radiofrequency and laser) is at least as effective as surgery in the treatment of great saphenous varicose veins and outcomes remain similar at 2 years (8)[A]; however, ultrasound-guided foam sclerotherapy has insufficient support from available data (7)[A].
- The ambulatory conservative hemodynamic correction of venous insufficiency method (cure conservatrice et hemodynamique de l 'insuffisance veineuse en ambulatoire [CHIVA]) is a less-invasive approach based on venous hemodynamics with deliberate preservation of the superficial venous system. The CHIVA method reduces recurrence of varicose veins and produces fewer side effects than vein stripping (9)[A].
GENERAL MEASURES
Patients with unsightly varicose veins often seek treatment for cosmetic reasons. é á
MEDICATION
Superficial thrombophlebitis is not an infective condition and does not require antibiotic treatment. é á
ISSUES FOR REFERRAL
- Emergency: bleeding from a varicosity that has eroded the skin
- Urgent: varicosity that has bled and is at risk for bleeding again
- Soon: ulcer that is progressive/painful despite treatment
- Routine
- Active/healed ulcer/progressive skin changes that may benefit from surgery
- Recurrent superficial thrombophlebitis
- Troublesome symptoms attributable to varicose veins or patient and provider feel that the extent, site, and size of the varicosities are having a severe impact on quality of life.
ADDITIONAL THERAPIES
- Apply elastic stockings before lowering legs from the bed.
- Activity
- Frequent rest periods with legs elevated
- If standing is necessary, frequently shift weight from side to side.
- Appropriate exercise routine as part of conservative treatment
- Walking regimen after sclerotherapy is important to help promote healing.
- Never sit with legs hanging down.
- Physical therapy
SURGERY/OTHER PROCEDURES
- Surgery
- Improved quality-adjusted life-years and symptoms compared to conservative management at 2 years (1)[A]
- Surgery is indicated if there is pain, recurrent phlebitis, or skin changes/ulceration or for cosmetic improvement for severe cases.
- Minimally invasive techniques include the following:
- Radiofrequency ablation (RFA): compared with surgery provides a faster return to work; less pain, better short-term quality of life; less bruising and tenderness compared with endovenous laser therapy (1)[A]
- Endovenous microwave ablation (EMA) is an effective new technique for the treatment of varicose veins and had a more satisfactory clinical outcome than high ligation and stripping (HLS) in the short term (10)[A].
- EVLA is as effective as conventional surgery (CS) and superior to ultrasound-guided foam sclerotherapy (UGFS), according to occlusion on ultrasound duplex (11)[B].
- Quality of life improves after treatment in all groups (EVLA, CS, UGFS), significantly (11)[B].
- There is no significant difference between EVLA and open surgery in patients with great saphenous vein incompetence (12)[A].
- Sclerotherapy is a simple, safe, and particularly effective for smaller, early varicosities and also for residual veins after surgery (13)[C].
- Radiotherapy
- RFA takes longer to perform but has better early outcome than CS in patients with great saphenous varicose veins.
- Radiofrequency and laser treatments replace "stripping " Ł; however, most varicosities still require phlebectomy/sclerotherapy.
ONGOING CARE
DIET
- No special diet
- Weight-loss diet is recommended if obesity is a problem.
PATIENT EDUCATION
- Avoid long periods of standing and crossing legs when sitting.
- Exercise (walking, running) regularly to improve leg strength and circulation.
- Maintain an appropriate weight.
- Wear elastic support stockings.
- Avoid clothing that constricts legs.
- Surgery/sclerotherapy may not prevent development of varicosities, and the procedure may need to be repeated in later years.
- National Heart, Lung and Blood Institute, Communications and Public Information Branch, National Institutes of Health, Building 31, Room 41 " ô21, 9000 Rockville Pike, Bethesda, MD 20892; 301-496-4236. http://www.nhlbi.nih.gov/
- JAMA Patient Page | Treatment of Varicose Veins; http://jama.jamanetwork.com/article.aspx?articleid=1672241
PROGNOSIS
- Usual course: chronic
- Favorable with appropriate treatment
- Surgery has a nonsignificant reduction in the risk of varicose vein recurrence compared with liquid sclerotherapy and endoluminal interventions (6)[A].
- Increasing disease severity by venous clinical severity score (VCSS) is associated with reductions in quality of life (14)[B].
COMPLICATIONS
- Complications with sclerotherapy include hyperpigmentation, matting, local urticaria, cutaneous necrosis, microthrombi, accidental intra-arterial injection, phlebitis, deep vein thrombosis, thromboembolism, scintillating scotomas, nerve damage, and allergic reactions.
- Petechial hemorrhages
- Chronic edema
- Superimposed infection
- Varicose ulcers
- Pigmentation
- Eczema
- Recurrence after surgical treatment
- Scarring/nerve damage from stripping technique
- Neurologic complications after sclerotherapy are rare (6)[B].
REFERENCES
11 Hamdan é áA. Management of varicose veins and venous insufficiency. JAMA. 2012;308(24):2612 " ô2621.22 Coleridge-Smith é áP, Labropoulos é áN, Partsch é áH, et al. Duplex ultrasound investigation of the veins in chronic venous disease of the lower limbs " öUIP consensus document. Part I. Basic principles. Eur J Vasc Endovasc Surg. 2006;31(1):83 " ô92.33 Nandhra é áS, El-sheikha é áJ, Carradice é áD, et al. A randomized clinical trial of endovenous laser ablation versus conventional surgery for small saphenous varicose veins. J Vasc Surg. 2015;61(3):741 " ô746.44 Shingler é áS, Robertson é áL, Boghossian é áS, et al. Compression stockings for the initial treatment of varicose veins in patients without venous ulceration. Cochrane Database Syst Rev. 2013;(12):CD008819.55 Wright é áN, Fitridge é áR. Varicose veins " önatural history, assessment and management. Aust Fam Physician. 2013;42(6):380 " ô384.66 Kistner é áRL, Eklof é áB, Masuda é áEM. Diagnosis of chronic venous disease of the lower extremities: the "CEAP " Ł classification. Mayo Clin Proc. 1996;71(4):338 " ô345.77 Nesbitt é áC, Eifell é áRK, Coyne é áP, et al. Endovenous ablation (radiofrequency and laser) and foam sclerotherapy versus conventional surgery for great saphenous vein varices. Cochrane Database Syst Rev. 2011;(10):CD005624.88 Sell é áH, Vikatmaa é áP, Alb â Ąck é áA, et al. Compression therapy versus surgery in the treatment of patients with varicose veins: a RCT. Eur J Vasc Endovasc Surg. 2014;47(6):670 " ô677.99 Bellmunt-Montoya é áS, Escribano é áJM, Dilme é áJ, et al. CHIVA method for the treatment of chronic venous insufficiency. Cochrane Database Syst Rev. 2013;(7):CD009648.1010 Yang é áL, Wang é áXP, Su é áWJ, et al. Randomized clinical trial of endovenous microwave ablation combined with high ligation versus conventional surgery for varicose veins. Eur J Vasc Endovasc Surg. 2013;46(4):473 " ô479.1111 Biemans é áAA, Kockaert é áM, Akkersdijk é áGP, et al. Comparing endovenous laser ablation, foam sclerotherapy, and conventional surgery for great saphenous varicose veins. J Vasc Surg. 2013;58(3):727 " ô734.e1.1212 Rasmussen é áL, Lawaetz é áM, Bjoern é áL, et al. Randomized clinical trial comparing endovenous laser ablation and stripping of the great saphenous vein with clinical and duplex outcome after 5 years. J Vasc Surg. 2013;58(2):421 " ô426.1313 Subbarao é áNT, Aradhya é áSS, Veerabhadrappa é áNH. Sclerotherapy in the management of varicose veins and its dermatological complications. Indian J Dermatol Venereol Leprol. 2013;79(3):383 " ô388.1414 Lozano S â ínchez é áFS, S â ínchez Nevarez é áI, Gonz â ílez-Porras é áJR, et al. Quality of life in patients with chronic venous disease: influence of the socio-demographical and clinical factors. Int Angiol. 2013;32(4):433 " ô441.
CODES
ICD10
- I83.90 Asymptomatic varicose veins of unspecified lower extremity
- I83.009 Varicose veins of unsp lower extremity w ulcer of unsp site
- I83.10 Varicose veins of unsp lower extremity with inflammation
- I83.819 Varicose veins of unspecified lower extremities with pain
- I83.222 Varicos vn of l low extrem w ulc of calf and inflammation
- I83.219 Varicos vn of r low extrem w ulc of unsp site and inflam
- I83.218 Varicos vn of r low extrem w ulc oth prt low extrm & inflam
- I83.221 Varicos vn of l low extrem w ulc of thigh and inflammation
- I83.215 Varicos vn of r low extrem w ulc oth part of foot and inflam
- I83.223 Varicos vn of l low extrem w ulc of ankle and inflammation
- I83.213 Varicos vn of r low extrem w ulc of ankle and inflammation
- I83.813 Varicose veins of bilateral lower extremities with pain
- I83.211 Varicos vn of r low extrem w ulc of thigh and inflammation
- I83.93 Asymptomatic varicose veins of bilateral lower extremities
- I83.214 Varicos vn of r low extrem w ulc of heel & midft and inflam
- I83.224 Varicos vn of l low extrem w ulc of heel & midft and inflam
- I83.225 Varicos vn of l low extrem w ulc oth part of foot and inflam
- I83.228 Varicos vn of l low extrem w ulc oth prt low extrm & inflam
- I83.229 Varicos vn of l low extrem w ulc of unsp site and inflam
- I83.812 Varicose veins of left lower extremities with pain
- I83.209 Varicos vn unsp low extrm w ulc of unsp site and inflam
- I83.891 Varicose veins of right low extrm w oth complications
- I83.892 Varicose veins of left lower extremities w oth complications
- I83.893 Varicose veins of bi low extrem w oth complications
- I83.899 Varicose veins of unsp lower extremities w oth complications
- I83.91 Asymptomatic varicose veins of right lower extremity
- I83.92 Asymptomatic varicose veins of left lower extremity
- I83.208 Varicos vn unsp low extrm w ulc oth prt low extrm and inflam
- I83.811 Varicose veins of right lower extremities with pain
- I83.014 Varicose veins of r low extrem w ulcer of heel and midfoot
- I83.205 Varicos vn unsp low extrm w ulc oth part of foot and inflam
- I83.212 Varicos vn of r low extrem w ulc of calf and inflammation
- I83.001 Varicose veins of unsp lower extremity with ulcer of thigh
- I83.002 Varicose veins of unsp lower extremity with ulcer of calf
- I83.003 Varicose veins of unsp lower extremity with ulcer of ankle
- I83.004 Varicos vn unsp lower extremity w ulcer of heel and midfoot
- I83.005 Varicos vn unsp lower extremity w ulcer oth part of foot
- I83.008 Varicos vn unsp low extrm w ulcer oth part of lower leg
- I83.011 Varicose veins of right lower extremity with ulcer of thigh
- I83.013 Varicose veins of right lower extremity with ulcer of ankle
- I83.015 Varicose veins of r low extrem w ulcer oth part of foot
- I83.018 Varicose veins of r low extrem w ulcer oth part of lower leg
- I83.019 Varicose veins of right lower extremity w ulcer of unsp site
- I83.12 Varicose veins of left lower extremity with inflammation
- I83.204 Varicos vn unsp low extrm w ulc of heel and midft and inflam
- I83.203 Varicos vn unsp low extrm w ulc of ankle and inflammation
- I83.012 Varicose veins of right lower extremity with ulcer of calf
- I83.201 Varicos vn unsp low extrm w ulc of thigh and inflammation
- I83.021 Varicose veins of left lower extremity with ulcer of thigh
- I83.11 Varicose veins of right lower extremity with inflammation
- I83.029 Varicose veins of left lower extremity with ulcer of unspecified site
- I83.028 Varicose veins of l low extrem w ulcer oth part of lower leg
- I83.025 Varicose veins of l low extrem w ulcer oth part of foot
- I83.024 Varicose veins of l low extrem w ulcer of heel and midfoot
- I83.023 Varicose veins of left lower extremity with ulcer of ankle
- I83.022 Varicose veins of left lower extremity with ulcer of calf
- I83.202 Varicos vn unsp low extrm w ulc of calf and inflammation
ICD9
- 454.9 Asymptomatic varicose veins
- 454.0 Varicose veins of lower extremities with ulcer
- 454.1 Varicose veins of lower extremities with inflammation
- 454.8 Varicose veins of lower extremities with other complications
- 454.2 Varicose veins of lower extremities with ulcer and inflammation
SNOMED
- 128060009 venous varices (disorder)
- 72866009 Varicose veins of lower extremity (disorder)
- 195445008 varicose veins of the leg with ulcer (disorder)
- 313254003 Varicose vein of leg with phlebitis (disorder)
- 12237511000119100 Varicose veins of right lower limb (disorder)
- 12237471000119109 Varicose veins of left lower limb (disorder)
- 297713002 Varicose veins of lower extremity without ulcer AND without inflammation (disorder)
- 24366001 Varicose veins of lower extremity with inflammation (disorder)
CLINICAL PEARLS
- Long-term safety and efficacy of surgery for the treatment of varicose veins is supported by low-quality evidence. Less-invasive treatments, which are associated with less periprocedural disability and pain, are supported by short-term studies (4)[A].
- Endovascular treatment of varicose veins is safe and effective and has a rapid recovery (7)[A]. Insufficient evidence exists to prefer sclerotherapy over surgery (6)[A].
- The efficacy of sclerotherapy is not significantly affected by the choice of sclerosant, dose, formulation (foam vs. liquid), local pressure dressing, or degree and length of compression (6)[A].