Veins in the leg are soft, thin-walled tubes that return blood back to the heart. This is accomplished
by the presence of one-way valves and the action of the calf pump. Superficial venous insufficiency develops when venous return is impaired by valvular incompetence, obstruction, or calf muscle pump failure.
Varicose veins, the most common clinical manifestation of chronic venous disease, are bulging (>3 mm in diameter), tortuous conduits. Reticular veins, often called “feeder veins,” are bluish subdermal veins about 1 to 3 mm in diameter that give rise to telangiectasia. Spider veins or telangiectasias are very small (≤1 mm in diameter) thread veins found commonly in clusters on the surface of the skin.
PREVALENCE: One large U.S. cohort study found the biannual incidence of varicose veins was 3% in women and 2% in men. The prevalence of varicose veins in Western populations was estimated in one study to be
about 25% to 30% in women and 10% to 20% in men.
Genetics: family history of varicose veins Increasing age ,Multiple pregnancies.
• Chronic vein disease is the result of the introduction of high pressures into a normal low-pressure superficial venous system.
• This increased pressure or venous hypertension causes superficial veins to distend to such a degree that vein valves fail to close, causing reflux and pooling of blood in surface veins.
• Manifested clinically by two syndromes:
1. Junctional: failure of the terminal valve at the intersection between the saphenous vein trunks and the deep system. If the great saphenous vein is involved, large varicose veins are found mainly above medial knee or calf. When the small saphenous vein is involved, large varicose veins are found in posterior knee or calf area. If the anterior accessory of great saphenous vein is involved, large varicose veins are found mainly in anterior or lateral thigh.
2. Perforator: failure of valves located in perforating vein. Large varicose veins are found most commonly in medial calf and proximal thigh region.
Chronic venous disease can now be classified using the Clinical-Etiology-Anatomy- Pathophysiology (CEAP) criteria to allow a precise description of the type of venous disease being discussed and provide an orderly framework for decision making.
• The underlying etiology of varicose veins remains uncertain.
• Important structural changes that occur: failure of vein valve function and vein wall dilation from fragmentation of the muscle layer.
• Superficial venous thrombophlebitis (SVT): a very common disorder with an incidence of 125,000 new cases per year in the U.S. The most frequent predisposing risk factors are varicose veins. The clinical findings include
the presence of erythema, tenderness, and a palpable cord. Pain, increased warmth, and swelling are also present. Diagnosis is made by ultrasonography, which is useful to identify associated deep vein thrombosis that can
occur in approximately 15% of patients. The location of the SVT determines the course of treatment; if the proximal great saphenous vein (GSV) is involved, a 1-mo course of sion stockings has been found to be more effective than vein ligation. If SVT involves branch varicosities, treatment is usually symptomatic (control of pain).
• Bleeding is a more common complication than traditionally suspected. It is associated with thin-walled ectatic veins known as “blue blebs” that are found predominantly in the medial lower calf and ankle region. The best emergency treatment consists of pressure wrapping and not suture ligation, which results in delayed healing of the bleeding site. Sclerotherapy of these veins is the definitive treatment to prevent further bleeding.
Other conditions that cause leg pain:
• Stress fracture
• Arthritis hip/knee joint
• Degenerative disk disease of lower back
• Intermittent claudication secondary to peripheral arterial disease (PAD)
• Medications such as allopurinol and statins Other conditions that cause leg swelling:
• Soft tissue injury to leg/ankle/foot
• Aerobic exercise regularly for 30 min a day.
• Elevate legs above heart level to reduce swelling.
• Flex ankles frequently at work and during air travel or long car travel.
• Maintain proper weight.
• Graduated compression stockings (below knee) to alleviate symptoms in patients who are not candidates or do not desire to undergo treatment of their varicose veins.
• Small- to medium-sized varicose veins such as spider veins and reticular varices in the absence of reflux in saphenous trunks are best treated with liquid sclerotherapy.
• The three principal sclerosants used in the U.S. are hypertonic saline, sodium tetradecylsulfate, and the newly FDA-approved solution, polidocanol.
• These agents are injected into vessels using 27-gauge or 30-gauge needles at concentrations of 23.4%, 0.1%, or 0.5%, respectively, causing injury to the endothelium with the resultant disappearance of the vein over period of time (usually 8-12 wk).
• A procedure in which large varicose vein branches are removed with special hook instruments through a small puncture— incisions are made with an 18-gauge needle or No. 11 blade
• Performed safely under local anesthesia in an office setting and offers excellent cosmetic results and relief of symptoms
• Most commonly performed in conjunction with endovenous ablation procedures
• Ablation of diseased saphenous vein trunks, large incompetent tributaries, or perforating veins can be achieved by using:
1. Radiofrequency energy
2. Laser energy
3. Ultrasound-guided foam sclerotherapy.
• The first two accomplish thermal injury to the vein in situ via an intraluminal catheter or bare-tipped laser wire. Chemical ablation uses a solution (polidocanol or sodium tetradecyl sulfate) that is injected directly into the
vein in the form of foam.
• Endovenous ablation can be performed in an office setting using local anesthesia. Patients can return to their normal daily activities immediately.
• The efficacy of these endovenous ablation procedures has been borne out by numerous published reports with occlusion rates over 95% and reflux free rates over 5-yr follow-up of 86%. A recent trial comparing ultrasoundguided
foam sclerotherapy and endovenous laser ablation revealed that quality of life measures were generally similar among the study groups, with the exception of a slightly worse disease-specific quality of life in the foam group than in the surgery group. Both treatments had similar efficacy, but complications were less frequent after laser treatment
and ablation rates were lower after foam treatment.