Presentations of Venous Disease

INTRODUCTION

Venous disease encompasses a wide spectrum of clinical manifestations, from asymptomatic spider veins on the legs to intermittently bulging branches of the greater saphenous vein extending across the knee to dull achy pain in the posterior calf after prolonged standing. The science of treating venous disease, phlebology, has roots dating to the ancient Greeks in 400 BCE, at which time venous disease was recognized as undesirable and unsightly. Procedures involving the use of instrumentation to traumatize veins were described by Hippocrates in the fourth century BCE, and procedures such as vein stripping were routinely practiced in the years to follow.

In modern days, diagnosing and treating venous disease still presents a formidable challenge. Venous insufficiency, which is caused by valvular incompetence in the deep or superficial venous system, is the most common form of venous disease. Venous disease affects 40% to 55% of the population, with the common symptoms of leg pain, swelling, and skin changes. Superficial venous insufficiency occurs when a high-pressure leakage develops between the deep and superficial systems or within the superficial system itself, followed by sequential failure of the venous valves in superficial veins. The two major divisions of the superficial system are the great saphenous vein (GSV) and the small saphenous vein (SSV). Venous insufficiency in this system allows venous blood to escape from its normal flow path to flow in a retrograde fashion down an already-congested leg. Over time, incompetent superficial veins acquire the typical dilated and tortuous appearance of varicosities. Furthermore, insufficiency can lead to chronic morbidity in the form of ulcerative and edematous skin changes in the lower extremities.

Further “downstream,” changes involving the smaller branching vessels, such as unsightly or symptomatic venulectasias and/or telangiectasias, are major consequences of superficial venous valvular insufficiency. To optimize the treatment of varicosities and telangiectasias, pattern recognition of common clinical manifestations is highly recommended. For a regional consideration of the anatomy that gives rise to varices, it is helpful to divide the thigh and calf into four quadrants: lateral, medial, anterior, and posterior ( Figs. 2.1 and 2.2 ). A regional approach can lead to some unavoidable repetition because many veins extend through many regions or have tributaries that cross many boundaries. Clinical photographs accompanied by simplified diagrams are helpful for identifying the root causes of an unfamiliar pattern of reflux. An understanding of normal venous anatomy is essential for a thorough understanding of venous disease ( Figs. 2.3 and 2.4 ). Knowledge of the location of the major perforator veins, which connect the deep venous system to the superficial system, is also important for determining the etiology of patterns of varicosities ( Fig. 2.5 ).

A labeled diagram of the thigh shows labeled venous compartments and branches. The labeled diagram of a thigh in vertical orientation includes directional markers for anterior, posterior, medial, and lateral. A dashed arrow runs vertically down the anterior midline, labeled the great saphenous vein. To the lateral side, the lateral subdermic venous system is labeled, along with its anastomotic branch. On the posterior side, the vein of Giacomini and the posterior lateral thigh perforating vein are labeled. On the medial side, the diagram shows potential great saphenous vein branches and an intersaphenous anastomosis. — Fig. 2.1

A labeled diagram of the calf shows labeled venous compartments and vascular branches. The labeled diagram of a lower leg in vertical orientation includes directional markers for medial, lateral, anterior, and posterior. A dashed line runs along the medial aspect of the leg, labeled the great saphenous vein. The lateral side includes the label L S V S for the lateral subdermic venous system. Near the midline on the posterior side, the small saphenous vein is labeled, along with its anastomosis with the great saphenous vein. The anterior side shows the superficial anterior tributaries of the great saphenous vein. A curved arrow on the posterior side indicates the direction of venous flow upward. — Fig. 2.2

A full-length anterior view diagram of the leg shows the great saphenous vein and labeled branches. The full-length anterior view diagram of a human figure displays the great saphenous vein, which extends from the foot to the groin. The diagram includes labeled branches and connecting veins. At the foot, the dorsal venous arch connects to the great saphenous vein. Further up the leg, the anterior tributary vein, the posterior arch vein, and multiple perforator veins are labeled. In the thigh and pelvic region, labels include superficial iliac circumflex vein, superficial epigastric vein, superficial external pudendal vein, and subterminal and terminal valves. Also labeled are the accessory saphenous vein and the deep femoral vein. — Fig. 2.3

A posterior view diagram of the leg shows the small saphenous vein and its labeled branches. The posterior view diagram of a human leg displays the small saphenous vein running from the dorsal venous arch of the foot upward along the back of the leg. Labeled structures include the posterior medial thigh vein, the posterior lateral thigh vein, and the posterior accessory vein. The posterior arch vein and the anterior lateral tributary vein are labeled near the lower leg. The vein of Giacomini connects to the small saphenous vein and extends upward toward the thigh. The saphenopopliteal junction is marked at the upper portion of the calf. — Fig. 2.4

A full leg diagram shows labeled clinically important perforating veins. The full-length diagram features the lower limb, displaying the superficial and deep veins, along with five labeled perforating veins. At the upper thigh, the saphenofemoral junction is marked. Moving downward, the mid-thigh perforators, the perforator of the adductor canal, and the perforator of the calf are labeled along the medial side of the leg. Near the ankle, the posterior tibial perforators are labeled. The diagram outlines the vertical venous axis and highlights specific perforating veins that connect superficial veins to deep veins. Each labeled perforator is positioned to indicate anatomical relevance along the length of the limb. — Fig. 2.5

TREATMENT APPROACH

It is best to approach the clinical examination of venous disease by visualizing the lower extremities while the patient is in the standing position from superior to inferior, starting from the upper thigh to the calf and concluding with the ankle. Above and below the knee, a division of four compartments can be made in the anterior and posterior planes. When considering the thigh, the presence of reflux in the GSV can manifest in the appearance of varicosities in the medial thigh compartment ( Box 2.1 ).

Box 2.1

Thigh Quadrants

Medial thigh
Incompetent saphenofemoral junction	Hidden reflux at saphenofemoral junction (only palpable on standing)
Superficial axial branch veins (medial tributaries) of GSV	Resistant telangiectatic matting (just above knee) due to GSV reflux
Distal saccular saphenous vein dilation (just above knee)
Pudendal vein	Mid-thigh perforators
Posterior thigh
Superficial gluteal	S-shaped reticular vein of the posterior thigh
Posterior thigh perforators emptying into LSVS	S-shaped reticular vein of the posterior thigh
Vein of Giacomini
Lateral thigh
Lateral subdermic venous system (Albanese)—most common cosmetic pattern	Anterolateral tributary of the GSV
Branch varicosity of small saphenous vein
Anterior thigh
Anterolateral tributary of GSV
Inguinal fold reticulars	Incompetent saphenofemoral junction
Superficial axial branch veins (lateral tributaries) of GSV	Small anterior branches of the LSVS
Patellar

GSV , Great saphenous vein; LSVS , lateral subdermic venous system.

Pudendal veins are 3- to 4 mm blue reticular varicosities that can be seen extending from the external genitalia. These indicate reflux in the pudendal tributary of the GSV, and when they become engorged, as may happen during sexual activity or menses, pain can occur. Treatment of these varicosities by sclerotherapy is easily accomplished in the absence of saphenofemoral junction incompetence.

Because the GSV typically lies deep and is surrounded by fascial layers, it may be difficult to clinically appreciate the prominence that accompanies reflux in this anatomic compartment. In the case of saphenofemoral junction reflux, duplex ultrasound (DUS) is usually necessary to confirm the reflux. Prolonged standing may facilitate visualization of the GSV ( Fig. 2.6 ). As the GSV courses distally, superficial tributaries can become varicose as they accept reflux from above and below. In the most distal aspect of the thigh medially, just above the knee, the GSV can emerge from the fascial layers and may become apparent as an enlarged bulbous segment ( Fig. 2.7 ). Clinical manifestations of a refluxing GSV can vary based on the degree of reflux and branch involvement ( Fig. 2.8 ).