Estimates of the prevalence of venous disease are varied. Although it is difficult to estimate the overall prevalence of venous disease worldwide, a large U.S. survey, the Framingham study, reported that 27% of the American adult population had some form of venous disease in their legs.⁴ There is evidence that geographic location and race can influence susceptibility to superficial venous disease. People living in North American and Western European countries seem to be at a greater risk for venous disease as compared with those who live in South America, India, the Far East, or Africa.¹ Venous disease is less prevalent in African Americans, Hispanics, and Asians.⁵ It has been suggested that the low prevalence of varicose veins in Africans (1%–2%) may be associated with the higher number of venous valves in their lower extremities as compared with Caucasians.⁶

To date, most studies have investigated factors that influence susceptibility to superficial venous disease. The data suggest that female sex,⁷ increased age,⁸ pregnancy,⁹ and oral contraceptive use¹⁰ are risk factors for varicose veins. There are also reports that chronic venous disease is higher in those whose job involves prolonged standing and those working under conditions of high temperature and humidity.^11,12 Although some studies have suggested that obesity is associated with varicose veins, a number of studies have not confirmed this finding.^1,13 There is no evidence that there is a strong genetic component to these disorders.¹⁴

The clinical presentation of patients with venous disease of the lower extremities can be variable. Visible venous disease can manifest as telangiectasias or varicose veins, whereas functional disease involves reflux or obstruction of the veins. Leg swelling has been shown to be the most specific predictor of visible and functional leg vein disease.¹⁵ Ankle edema is usually the first manifestation of chronic venous insufficiency (CVI) and can lead to venous stasis. Stasis dermatitis and pigmentary changes, resulting from extravasation of erythrocytes and hemosiderin deposition, are common sequelae of long-standing venous stasis. Recurrent or chronic cellulitis, ulceration, scarring, and malignant degeneration are more serious complications of leg vein disease.¹⁶

Many patients with visible venous disease have minimal to no symptoms, whereas others may report localized pain, burning, itching, or more generalized leg fatigue, aching, and swelling. Symptomatic varicose veins occur in approximately 15% of men and 25% of women;¹ women are more likely to report symptoms than men.^15,17,18

In the leg there are two systems of veins: the deep and the superficial. The deep venous system consists of veins that lie within the muscular system. The superficial venous
system has two main veins: the greater saphenous vein (also known as the long saphenous vein) and the lesser saphenous vein (also referred to as the short saphenous vein). The greater saphenous vein (GSV) originates at the medial side of the foot and runs superiorly along the medial aspect of the leg to empty into the femoral vein at the saphenofemoral junction. The lesser saphenous vein starts at the lateral aspect of the foot and runs along the back of the calf and typically joins the popliteal vein at the saphenopopliteal junction. The deep and superficial veins are connected via perforator veins. Veins in the same fascial plane are often interconnected by a complex of communicating veins.

Venous valves are a significant part of the venous system, maintaining the blood’s upward flow. Valves are present between the superficial and deep systems at the saphenofemoral and saphenopopliteal junctions. More valves are located below the knee than above. Elevated venous pressure is most often the result of venous insufficiency with reflux through incompetent valves in the deep or superficial veins. Telangiectasias, venulectasias, reticular veins, and varicose veins represent the undesirable pathways by which venous blood refluxes back into the congested extremity (Fig. 29-1). Although most large varices arise from tributaries of incompetent truncal vessels, failed perforating veins or connecting veins can also give rise to independent varices in the greater saphenous distribution without involving the saphenous system itself.

History and physical examination are important in the evaluation of patients with venous disease. Risk factors such as prior pregnancies, use of oral contraceptives, and history of superficial thrombophlebitis or deep venous thrombosis should be noted. A careful physical examination should be done to determine the nature, extent, and location of varicose veins. Photographs of the affected areas are helpful for tracking disease progression and response to treatment. Laboratory workup to evaluate hypercoagulability or bleeding risks may be appropriate if indicated by the patient’s history.

Extensive diagnostic imaging is often unnecessary before treating spider veins and venulectasias, however, for largely dilated (>4 mm) vessels or for more severe cases, imaging modalities are available and should be used to evaluate and determine the extent of the venous disease. Duplex ultrasound has become the most widely used mode of investigation for both arterial and venous disease. This noninvasive and inexpensive technique enables the physician to evaluate competence of the deep and superficial venous valves as well as the competence of the saphenofemoral and saphenopopliteal junctions. Photoplethysmography can be used to measure venous refilling time and distinguish between deep and superficial venous insufficiency.

Graded compression stockings are often prescribed for patients with varicose veins as a method of relieving symptoms. They may be prescribed either as a definitive treatment or temporarily after varicose vein treatment.¹⁹ Compression stockings are designed to provide a pressure gradient that is greatest at the ankle and decreases proximally, mimicking the normal hydrostatic pressures of the lower extremity.²⁰ Therapy with compression stockings has been shown to improve venolymphatic drainage substantially in both healthy patients and those suffering from CVI.²¹ Most clinicians advocate the use of compression stockings after sclerotherapy; however, there are variations in the suggested duration of use, ranging from 48 hours to several weeks.

For treatment of leg veins less than 4 mm in diameter, sclerotherapy has been considered to be the gold standard.²² Sclerotherapy involves the direct injection of a sclerosing agent into a visible vein or telangiectasia. The solutions are designed to either irritate, dehydrate, change the surface tension of, or completely destroy the venous endothelial cells, thereby creating a thrombus. Ultimately, the vein is permanently occluded as the thrombus is replaced by fibrosis. There are three types of sclerosant agents: osmotic agents, detergents, and chemical irritants. The most commonly used sclerosants in the United States are hypertonic saline, sodium tetradecyl sulfate, and polidocanol.