Varicose vein

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Varicose Veins

Definition

Varicose veins are tortuous, dilated, elongated subcutaneous veins resulting from sustained venous hypertension and valvular incompetence, predominantly affecting the superficial venous system of the lower limbs. They are distinguished from telangiectasia (thread veins) and reticular veins, which are smaller and more superficial.

Clinical Photograph

Varicose veins: (a) GSV distribution marked for intervention, (b) SSV distribution with phlebitis, (c) AAGSV distribution with gaiter area skin changes

Figure: (a) Left leg GSV varicosities marked for intervention; (b) Right leg SSV distribution with recent phlebitis; (c) Anterolateral AAGSV distribution with gaiter area skin changes - Bailey & Love, p.1049

Epidemiology

Adult prevalence: 30-50% of the general population
More common in women than men
Prevalence increases with age - from 11.5% (age 18-24) to 55.7% (age 55-64) per the Edinburgh Vein Study
Risk factors: pregnancy, family history, increasing BMI and height, possibly prolonged standing
Less common in primitive/rural communities (Africa, Far East)

Pathophysiology

The primary problem lies in the vein wall rather than mechanical valve failure alone. Vein wall changes include:

Inflammatory cell infiltration and activation
Dysfunctional smooth muscle cell proliferation
Collagen deposition, decreased elastin content
Increased matrix metalloproteinases
Net result: loss of compliance → dilatation → elongation (tortuosity) → secondary valvular dysfunction

This creates retrograde flow with gravity (venous incompetence). Secondary varicosities can follow deep vein thrombosis (post-thrombotic) or occur with congenital arteriovenous fistulae.

Causes of predisposition:

Primary: valvular incompetence, vein wall weakness
Secondary: obstruction to venous return - pregnancy, pelvic tumours (fibroid, ovarian cyst, carcinoma cervix/rectum), ascites, abdominal lymphadenopathy, retroperitoneal fibrosis
Congenital: arteriovenous fistula (in younger patients)

CEAP Classification

The CEAP (Clinical-Etiology-Anatomy-Pathophysiology) system is used internationally:

Clinical categories (C):

Grade	Description
C0	No visible or palpable signs of venous disease
C1	Telangiectasia/reticular veins
C2	Varicose veins
C3	Oedema
C4a	Pigmentation/eczema
C4b	Lipodermatosclerosis/atrophie blanche
C5	Healed venous ulcer
C6	Active venous ulcer

Anatomical (A): Superficial (As), Perforator (Ap), Deep (Ad) Pathophysiological (P): Reflux (Pr), Obstruction (Po), Both (Pr,o)

Symptoms

Patients describe:

Aching, heaviness, throbbing, burning, or bursting sensation in the legs
Symptoms worsen throughout the day or with prolonged standing
Relieved by elevation and compression hosiery
Ankle swelling (especially by end of day)
Pruritus (itching), especially with complications
Night cramps
Bursting pain on walking (suggests associated deep vein thrombosis)

Note: symptoms are independent of the degree of venous incompetence - asymptomatic varicosities can coexist with severe symptoms from minimal veins on the other side. - S. Das, p.105

Clinical Signs

Inspection:

Tortuous dilated subcutaneous veins
Distribution gives clue to axis involved:
- Medial thigh/calf → GSV incompetence
- Posterolateral calf → SSV incompetence
- Anterolateral thigh/calf → AAGSV incompetence
Saphena varix: dilated vein at the SFJ appearing as a groin lump, disappears when recumbent (can mimic a femoral hernia - impulse on coughing)
Skin changes: pigmentation, eczema, lipodermatosclerosis, venous ulcer (medial malleolus)

Key clinical tests:

Test	Method	What it detects
Trendelenburg test	Tourniquet applied at SFJ after leg elevation; observe vein filling on standing	SFJ incompetence
Schwartz test (Percussion)	Tap prominent varicosity; impulse felt at saphenous opening	Continuous column of blood (incompetent valves)
Cough impulse (Morrissey)	Leg elevated, then patient coughs; expansile impulse at saphenous opening	SFJ valve incompetence
Fegan's method	Mark varicosity bulges; elevate limb; palpate for fascial gaps	Sites of incompetent perforators
Auscultation	Continuous machinery murmur	Arteriovenous fistula (secondary varicosities)

Investigation

Duplex ultrasound is now the gold standard - tourniquet tests and hand-held Doppler have been abandoned. Duplex establishes:

Presence and distribution of reflux in deep and superficial systems
Anatomy of the SFJ and SPJ
Presence of deep vein thrombosis or obstruction
Location of incompetent perforators

A 7.5-13 MHz linear array transducer is standard. Blue = antegrade flow toward heart; red = reverse (reflux).

Treatment

Conservative

Compression hosiery (first-line for symptom relief)
Leg elevation, weight loss, exercise
Useful as trial to confirm symptoms are venous before intervention

Interventional (current evidence)

1. Endovenous Thermal Ablation

Endovenous Laser Ablation (EVLA): Laser fibre inserted under ultrasound guidance; perivenous tumescent anaesthesia used; energy delivered as fibre is withdrawn. Highest technical efficacy.
Radiofrequency Ablation (RFA): Uses radiofrequency energy via catheter. Comparable efficacy to EVLA with possibly less post-procedural pain.
- A 2024 meta-analysis (Jiang et al., J Vasc Surg Venous Lymphat Disord, PMID 38316290) found RFA and EVLA have comparable clinical outcomes; RFA may have slight advantage in post-operative comfort.

2. Foam Sclerotherapy

Sclerosant (e.g., sodium tetradecyl sulphate or polidocanol) mixed with air/gas to create foam
Ultrasound-guided for truncal veins
Can be used alongside thermal ablation for tributaries

3. Ambulatory Phlebectomy (Stab Avulsion)

Micro-incisions (2-3 mm) to remove varicosities
Often combined with truncal ablation in same sitting

4. Open Surgery (Trendelenburg + Stripping)

Flush ligation of SFJ + stripping of GSV
Now less commonly performed; reserved for recurrent disease, complex anatomy, or where endovenous techniques are unavailable

For recurrent varicose veins from the SFJ/GSV, a 2024 systematic review (Bontinis et al., Int Angiol, PMID 39559844) found endovenous techniques are effective for recurrence.

Complications

Type	Examples
Chronic	Pigmentation, eczema, lipodermatosclerosis, atrophie blanche, venous ulcer
Acute	Superficial vein thrombosis (thrombophlebitis), haemorrhage (from rupture)
Post-operative	DVT, nerve injury (saphenous/sural nerve), wound haematoma, recurrence

Differential Diagnosis of Varicose Veins (causes of dilated leg veins)

Primary (idiopathic) varicose veins
Secondary to DVT (post-thrombotic syndrome)
Secondary to pelvic obstruction (pregnancy, tumour)
Congenital AV fistula (Klippel-Trenaunay syndrome - port wine stain + limb hypertrophy + varicosities)
May-Thurner syndrome (iliac vein compression)

Sources:

Bailey and Love's Short Practice of Surgery, 28th Edition, pp. 1047-1060
S. Das: A Manual on Clinical Surgery, 13th Edition, pp. 105-109
Pfenninger and Fowler's Procedures for Primary Care, 3rd Edition

Venoux system of lower limb

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Venous System of the Lower Limb

The venous system of the lower limb is divided into three interconnected compartments: the deep venous system, the superficial venous system, and the perforating (communicating) veins that link them. Blood flows from superficial → deep → central circulation.

1. Overview

The venous system contains approximately 60% of total blood volume at a mean pressure of 5-10 mmHg. Return of blood from the lower limb to the right atrium depends on:

Venous valves (preventing reflux)
Calf muscle pump (augmenting flow during exercise)
Respiratory/thoracic pressure changes

2. Deep Venous System

Figure: Anatomy of the deep veins of the lower limb - Bailey & Love, p.1047

The deep veins lie beneath the deep fascia and accompany the arterial tree:

Leg (Crural Veins)

Three pairs of venae comitantes (paired veins running alongside each artery):

Anterior tibial veins (paired) - accompany anterior tibial artery
Posterior tibial veins (paired) - accompany posterior tibial artery
Peroneal (fibular) veins (paired) - accompany peroneal artery

These six veins intercommunicate freely and converge in the popliteal fossa.

They also receive the muscular veins of the calf:

Soleal veins - drain the soleus muscle (form a sinus/plexus - a common site for DVT initiation)
Gastrocnemius veins - drain both heads of gastrocnemius

Popliteal Fossa

All six crural veins + soleal + gastrocnemius veins join to form the popliteal vein.

Thigh

The popliteal vein passes through the adductor hiatus → enters the subsartorial canal as the femoral vein (previously called "superficial femoral vein" - a misnomer, it is a deep vein).

In the femoral triangle, it receives the profunda femoris (deep femoral) vein before passing behind the inguinal ligament to become the external iliac vein.

Pelvis and Abdomen

External iliac vein + Internal iliac vein → Common iliac vein
Left common iliac vein passes behind the right common iliac artery (clinically important - site of May-Thurner compression syndrome)
Right and left common iliac veins join on the right side of the aorta → Inferior vena cava → Right atrium

3. Superficial Venous System

The superficial veins lie in the subcutaneous fat, superficial to the deep fascia (fascia lata) but deep to the saphenous fascia - within what is called the saphenous envelope. There are two main axes.

3A. Great Saphenous Vein (GSV)

GSV axis - superficial veins anterior view

Figure: Great saphenous vein axis with AAGSV and tributaries - Bailey & Love, p.1047

Feature	Detail
Origin	Medial side of the dorsal venous arch of the foot
Ankle	Passes anterior to the medial malleolus
Leg	Ascends medially with the saphenous nerve; medial to tibia
Knee	Loops posteriorly around the medial condyle of femur
Thigh	Continues in the medial thigh
Termination	Pierces the cribriform fascia at the saphenous opening (~2.5 cm below and lateral to the pubic tubercle) → drains into the common femoral vein at the saphenofemoral junction (SFJ)
Clinical significance	Longest vein in the body; most frequently affected by incompetence

Tributaries at the SFJ (the "bouquet"):

Superficial external pudendal vein
Superficial circumflex iliac vein
Superficial epigastric vein
Anterior femoral cutaneous vein
Posteromedial thigh tributary
Anterolateral thigh tributary

Anterior Accessory of the Great Saphenous Vein (AAGSV):

One of the most common tributaries
Originates around the lateral border of the knee (sometimes from the lateral end of the dorsal venous arch)
Courses anterolateral to the GSV
Drains into the GSV at or near the SFJ
Commonly mistaken for the GSV on duplex scan ("duplex GSV" - a true duplicated GSV is rare)

3B. Small Saphenous Vein (SSV)

Figure: Small saphenous vein, saphenopopliteal junction, and Giacomini vein - Bailey & Love, p.1047

Feature	Detail
Origin	Lateral side of the dorsal venous arch
Ankle	Posterior to the lateral malleolus (with the sural nerve)
Leg	Ascends in the posterior midline of the calf; sits in the groove between the two heads of gastrocnemius
Termination	Pierces the fascia of the popliteal fossa → drains into the popliteal vein at the saphenopopliteal junction (SPJ) - highly variable, may be as low as mid-calf
Extension	May continue cranially as the Giacomini vein - communicates with the GSV system, sometimes joining the GSV at/near the SFJ

3C. Veins of the Foot

Superficial veins - anterior and posterior views

Figure: Superficial (epifascial) veins of the right lower limb - THIEME Atlas

Structure	Location	Drains into
Dorsal venous arch	Over metatarsal heads	Medial end → GSV; lateral end → SSV
Medial marginal vein	Medial border of foot	GSV
Lateral marginal vein	Lateral border of foot	SSV
Dorsal venous network	Dorsum of foot	Dorsal arch, then GSV/SSV
Plantar venous arch	Plantar surface	Posterior tibial veins (deep) via plantar digital/metatarsal veins
Plantar venous network	Plantar surface	Plantar arch → posterior tibial veins
Posterior venous arch of foot	Dorsum, connects arches	Empties into SSV/GSV

The dorsal and plantar arches are connected by intercapitular veins.

Because the sole bears significant weight and pressure, most venous drainage of the foot is via the dorsal venous arch rather than the plantar surface.

4. Perforating (Communicating) Veins

Perforating veins are valved vessels that pierce the deep fascia, connecting superficial to deep veins. Valves normally allow flow only from superficial → deep. When valves become incompetent, reversal of flow causes superficial hypertension and varicosities.

Figure: Deep and superficial veins with perforators, plantar and dorsal venous networks - Color Atlas of Human Anatomy

The three clinically important groups of perforators (THIEME Atlas, p.551):

Group	Location	Clinical relevance
Dodd group	Medial thigh, middle third	Incompetence → medial thigh varicosities
Boyd group	Medial leg, just below knee	Common site of incompetence
Cockett group	Medial distal leg (ankle region)	Most important clinically; incompetence causes gaiter area pigmentation, lipodermatosclerosis, venous ulcers

The Cockett perforators are located at approximately 7.5, 12.5, and 18.5 cm above the medial malleolus.

5. Venous Physiology - Calf Muscle Pump

At rest (standing), superficial venous pressure in the foot is ~80-90 mmHg (hydrostatic). During walking:

Calf muscle contraction compresses the deep veins
Valves direct flow upward (antegrade)
Superficial pressure falls to ~25 mmHg
On stopping exercise, pressure rises slowly back to resting level (refilling time)

In venous incompetence (valve failure), pressure does not fall adequately during exercise, producing venous hypertension - the root cause of all complications (oedema, skin changes, ulceration).

6. Summary: Flow Pathway

Foot veins (dorsal venous arch / plantar network)
         ↓
Great saphenous vein        Small saphenous vein
(medial)                    (posterior)
         ↓                          ↓
Saphenofemoral junction     Saphenopopliteal junction
(common femoral vein)       (popliteal vein)
         ↓
     Femoral vein
         ↓
  + Profunda femoris vein
         ↓
  External iliac vein
         ↓
  Common iliac vein
         ↓
  Inferior vena cava
         ↓
   Right atrium

All along this pathway: perforating veins connect superficial → deep systems at the leg and thigh.

Sources:

Bailey and Love's Short Practice of Surgery, 28th Edition, pp. 1046-1049
Gray's Anatomy for Students, p. 671
THIEME Atlas of Anatomy: General Anatomy and Musculoskeletal System, p. 551
Color Atlas of Human Anatomy, Vol. 2 (Internal Organs), pp. 144-146

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