Varicosis, varicosity, chronic venous disease, chronic peripheral venous insufficiency.
5.1.2 Varicose Veins and Chronic Venous Insufficiency
Synonyms
Epidemiology
17% of adults and 37% of those over the age of 70 have chronic venous insufficiency (CVI).
Varicose veins: 37% in females, 19% in males.
CVI: 20% in females and 17% in males.
Definition
Ectatic changes in the superficial veins due to insufficient valves.
Aetiology & Pathogenesis
Primary varicosities (95%): Familial predisposition, prolonged (occupational) standing, multiple pregnancies, obesity and smoking all lead to dilatation of the veins and incompetence of the venous valves with reflux and increased venous stasis.
Secondary varicosities (5%): Postinflammatory or post-thrombotic changes.
Signs & Symptoms
Stages of chronic venous insufficiency (by Widmer):
- Stage I: corona phlebectatica paraplantaris (prominent dilated vessels along sides of foot)
- Stage II: atrophie blanche, deposition of haemosiderin, hyperpigmentation, dermatoliposclerosis, stasis dermatitis, eczema, indurated edema
- Stage III: ulcer (active or healed)
Further clinical symptoms: pain, itching, leg heaviness.
Symptoms are in more detail described in the CEAP classification.
Localisation
Venous system of the lower legs:
Truncular
- Epifascial varices
Cutaneous varices with cosmetic relevance
- Reticular varices
- Spider veins
Classification
International standard classification for chronic venous disease (CEAP, clinical etiology anatomy pathophysiology).
Grading of truncal vein incompetence of the greater and lesser saphenous vein according to Hach Widmer’s classification of varicose veins.
Laboratory & other workups
Imaging techniques: Duplex sonography, doppler sonography, photoplethysmography, hyperspectral imaging, infrared thermography.
Dermatopathology
Usually not necessary, except in situations like capillary convolutes mimicking Kaposi's sarcoma.
Course
Chronic over years.
Complications
Ulcer, stasis dermatitis and/or contact dermatitis, superficial thrombosis, bleeding, deep vein insufficiency.
Diagnosis
Clinical findings. Palpation of the insufficient visible veins, imaging techniques.
Differential diagnosis
Congenital vessel malformation.
Dermatitis of different causes.
Lower leg eczema: Allergic contact dermatitis, asteatotic, nummular dermatitis, skin mycosis, psoriasis.
Prevention & Therapy
Leg training programme with activation of the foot, lower leg and upper leg muscle system. Movement at working place. In the evening resting legs by moving up.
Compression therapy: 90% of venous ulcers heal with adequate compression therapy.
Note: If arterial disease is also present, compression may be contraindicated.
Truncal varicosities: Surgery.
Accessory varicosities: Surgery or sclerotherapy.
Spider veins: Sclerotherapy or laser destruction.
Special
In young men with CVI, think of Klinefelter’s syndrome.
Differential Diagnosis
Podcasts
Tests
- Which of this conditions belong to the differential diagnostic considerations for venous leg ulcers?
- Statement 1 Varicosities lead to edema
- Which clinical features fit with chronic venous insufficiency?
- Which of the following are features of chronic venous insufficiency?
- Many factors can lead to chronic venous insufficiency. Which answer is false?
- What is the most common cause of leg ulcers?
- Which factors play a role in the development of leg ulcers?
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