Cardiology · Vascular Medicine
The facts most likely to be tested
Press 1–5 to rate · ↑↓ to navigate
Varicose veins result from venous valvular incompetence leading to venous reflux and venous hypertension.
The most common clinical presentation is dull, aching leg pain that worsens with prolonged standing and improves with leg elevation.
Physical examination reveals dilated, tortuous, palpable veins typically involving the great saphenous vein distribution.
The preferred diagnostic test for confirming venous reflux is venous duplex ultrasonography.
Chronic venous insufficiency may progress to stasis dermatitis, characterized by hyperpigmentation and hemosiderin deposition in the medial malleolus area.
Leg elevation and compression stockings relieve symptoms, but for intervention candidates with symptomatic axial saphenous reflux, SVS/AVF/AVLS (2023) recommends superficial venous intervention over long-term compression and suggests against a mandatory 3-month compression trial.
Definitive treatment for symptomatic saphenous reflux involves endovenous thermal ablation or sclerotherapy to eliminate the incompetent venous segment.
Vignette unlocked
A 54-year-old female presents to the clinic complaining of a heavy, aching sensation in her lower extremities that worsens throughout the day. She works as a cashier and stands for 8 hours daily. Physical examination reveals dilated, tortuous, bluish vessels along the medial aspect of her left calf. There is mild brownish discoloration and induration of the skin near the medial malleolus. Venous duplex ultrasonography demonstrates retrograde flow in the great saphenous vein lasting 2 seconds. Distal pulses are normal, she is otherwise healthy and fully ambulatory, and she wishes to proceed with definitive treatment.
What is the most appropriate next step in management?
Endovenous thermal ablation of the great saphenous vein
The patient has symptomatic varicose veins with skin changes of chronic venous insufficiency and duplex-confirmed axial reflux in the great saphenous vein (reflux >0.5 seconds). For patients like her who are candidates for intervention, the 2023 SVS/AVF/AVLS guideline recommends superficial venous intervention, typically endovenous thermal ablation, over long-term compression stockings and suggests against requiring a 3-month compression trial first. Compression and leg elevation remain options for symptom relief or for patients who prefer or require a conservative approach, although some insurers still require a trial.
Full handout
High yield triage
Etiology / Epidemiology
Caused by venous valvular incompetence and venous hypertension. Common in females, pregnancy, and those with prolonged standing.
Clinical Manifestations
Dilated, tortuous superficial veins. Corona phlebectatica and hemosiderin deposition are classic signs of chronic venous insufficiency.
Diagnosis
Duplex ultrasound is the test of choice to confirm reflux >0.5 seconds.
Treatment
Endovenous thermal ablation is preferred for symptomatic saphenous reflux in intervention candidates; compression stockings and leg elevation are used for symptom relief or when a conservative approach is chosen. Avoid compression in severe peripheral arterial disease.
Prognosis
Risk of stasis dermatitis and venous ulcers. Monitor for superficial thrombophlebitis.
Full handout
Epidemiology & Etiology
Prevalence increases with age, female gender, and family history. Prolonged standing and obesity increase hydrostatic pressure, leading to valvular failure. Pregnancy is a major risk factor due to hormonal changes and mechanical compression of the vena cava.
Pertinent Anatomy
Involves the great saphenous vein and its tributaries. Valvular incompetence allows retrograde flow, causing venous pooling in the lower extremities.
Pathophysiology
Venous hypertension results from valvular incompetence or obstruction. Chronic high pressure leads to capillary leakage of fibrinogen and red blood cells into the dermis. This triggers an inflammatory cascade resulting in lipodermatosclerosis and skin ulceration.
Clinical Manifestations
Patients present with dull, aching pain or heaviness that worsens throughout the day. Look for dilated, tortuous veins and corona phlebectatica (ankle telangiectasias). Red flags include sudden swelling, warmth, or tenderness suggesting superficial thrombophlebitis or DVT.
Diagnosis
Duplex ultrasound is the diagnostic test of choice. It identifies reflux >0.5 seconds in the superficial (saphenous) veins and >1.0 second in the deep veins. Ankle-brachial index (ABI) should be performed to rule out peripheral arterial disease before initiating compression therapy.
Treatment
For symptomatic patients with saphenous axial reflux who are candidates for intervention, endovenous thermal ablation (or sclerotherapy/nonthermal options) is preferred over long-term compression, and SVS/AVF/AVLS (2023) suggests against a mandatory 3-month compression trial before intervention (although some insurers still require one). Leg elevation and compression stockings remain appropriate for symptom relief, for patients who prefer conservative care, or when comorbidities or limited mobility make intervention less suitable. Contraindications for compression include an ABI <0.5, as this indicates severe arterial insufficiency.
Prognosis
Most patients remain stable with conservative care. Complications include stasis dermatitis, venous stasis ulcers, and hemorrhage. Long-term monitoring is recommended for patients with signs of chronic venous insufficiency.
Differential Diagnosis
DVT: unilateral swelling and warmth
Peripheral Arterial Disease: diminished pulses and claudication
Lymphedema: non-pitting edema and Stemmer sign
Cellulitis: fever and spreading erythema
Baker's Cyst: posterior knee mass