5.1.2 Varicose Veins and Chronic Venous Insufficiency

BD74.1

Varicosis, varicosity, chronic venous disease, chronic peripheral venous insufficiency.

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.

Ectatic changes in the superficial veins due to insufficient valves.

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. 

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.

Venous system of the lower legs:

Truncular
- Epifascial varices

Cutaneous varices with cosmetic relevance
- Reticular varices 
- Spider veins

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.

Imaging techniques: Duplex sonography, doppler sonography, photoplethysmography, hyperspectral imaging, infrared thermography.

Usually not necessary, except in situations like capillary convolutes mimicking Kaposi's sarcoma.

Chronic over years.

Ulcer, stasis dermatitis and/or contact dermatitis, superficial thrombosis, bleeding, deep vein insufficiency.

Clinical findings. Palpation of the insufficient visible veins, imaging techniques.

Congenital vessel malformation.

Dermatitis of different causes.

Lower leg eczema: Allergic contact dermatitis, asteatotic, nummular dermatitis, skin mycosis, psoriasis. 

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.

In young men with CVI, think of Klinefelter’s syndrome.