Varicose veins and venous insufficiency manifest in a variety of symptoms ranging from cosmetic issues to severe ulcers. Approximately 23-85% of adults have varicose veins depending on definition. Risk increases with age, family history, prolonged standing, obesity, smoking and other factors. Symptoms include dilated veins, leg edema, skin changes and ulceration. Diagnosis involves duplex ultrasound and other tests. Treatment depends on severity but may include compression stockings, bandages, lifestyle changes and interventions.

1. Varicose Veins and Venous Insufficiency
Adrija Hajra
PGY2
Internal Medicine

2.  Venous insufficiency of the lower extremities manifests itself in various clinical spectrums, ranging from
asymptomatic but cosmetic problems to severe symptoms, such as venous ulcer.
 Approximately 23% of adults in the United States have varicose veins. This figure rises to 80% for men and 85%
for women if reticular veins and spider telangiectasias are included.
 According to the National Institute of Health, venous disease increases with age. Older people are at a much
higher risk of developing varicose veins. Some numbers show that varicose veins affect one out of two people
over the age of 50.

3. Risk factors — The risk factors for developing venous insufficiency include
 Advancing age
 Family history of venous disease
 Ligamentous laxity (eg, hernia),
 Prolonged standing,
 Increased body mass index,
 Smoking,
 Lower extremity trauma,
 Prior venous thrombosis (ie, post-thrombotic),
 Some hereditary conditions (eg, Klippel-Trenaunay syndrome),
 High estrogen states (pregnancy)
venous wall degeneration (ie, venous aneurysm), arteriovenous (AV) shunt (eg, traumatic AV fistula, AV
malformation), and non-thrombotic iliac vein obstruction (eg, May-Thurner syndrome)

7. Category Primary abnormality Consequences
Anatomical Valvular incompetence
Retrograde transmission of pressure and
volume into the superficial venous
system, increased venous hypertension
producing further valvular incompetence
Histological
Elongation and dilation of capillary beds,
increased capillary surface area,
increased basement membrane type IV
collagen, formation of pericapillary fibrin
cuff, fragmentation and obliteration of
cutaneous microlymphatics
Increased interstitial accumulation of
vascular water, red blood cells, fibrin,
tissue hypoxia, and formation of a
subcutaneous panniculitis
(lipodermatosclerosis)
Physiological
Loss of reflexive constriction of
precapillary arterioles, erythrocyte and
leukocyte aggregation
Increased capillary hydrostatic pressure,
reduced oxygen transport, slowed
arteriolar circulation, enlarged capillary
spaces, leukocyte aggregation and
activation, and formation of a
subcutaneous panniculitis
(lipodermatosclerosis)

8. Clinical signs:
 Dilated veins (eg, telangiectasia, varicose veins),
 Leg edema
 Skin changes (lipodermatosclerosis; a fibrosing
dermatitis of the subcutaneous tissue)
 Skin ulceration

10. Characteristic Arterial ulcer Venous ulcer Neuropathic ulcer
Location
Over toe joints, malleoli
(over the bony
prominence), anterior
shin, base of heel,
pressure points
Medial and lateral
malleolar area above
bony prominence,
posterior calf, may be
large, circumferential
Plantar surface of foot
over metatarsal heads,
heel, pressure points
Appearance
Irregular margins, base
dry and often pale or
necrotic (brown/black
fibrous tissue)
Irregular margins, pink or
red base that may be
covered with yellow
fibrinous tissue, exudate
common (may be heavy);
ulcers can be large,
sometimes
circumferential
Punched out ulcer, usually
superficial but sometimes
deep, red base
Ulcer within callus Rare No
Calloused border, ulcer
can be underlying a callus
Foot temperature Warm or cool Warm Warm

11. Characteristic Arterial ulcer Venous ulcer Neuropathic ulcer
Arterial pulses Absent Present Present or absent
Sensation Variable Present
Absent tactile, pain,
temperature and vibratory
sensations
Foot deformities No No Often
Skin changes
Shiny, taut, loss of hair
Dependent rubor of leg and
foot that becomes pale with
leg elevation
Erythema, brown-blue
hyperpigmentation can be
spotty or diffuse: "stasis"
changes; atrophie blanche
(white sclerotic areas),
edema; dry skin; varicose
veins common; if
lipodermatosclerosis is
present, skin may be bound
down; bilateral lower
extremities often affected
Waxy or shiny, loss of hair,
may be taut; dry skin; may
have non-pitting edema,
especially on dorsal foot
Reflexes Present Present Absent

12. Diagnosis:
Duplex ultrasonography
Venography
Air plethysmography/Photoplethysmography
Ankle-brachial index

13. Duplex ultrasonography is indicated in the following clinical situations:
●If a clinical diagnosis of venous insufficiency or obstruction cannot be established but symptoms are strongly
suggestive.
●In patients with signs of chronic venous disease but whose symptoms are questionably related to the venous
disease.
●In atypical cases, such as an unusually early age of onset (<40 years) of symptoms or following trauma.
●In cases of ulceration. (Patients with ulceration due to superficial venous reflux may benefit from venous
ablation procedures.)
●In patients with clinically suspected venous disease who do not respond to standard conservative measures.

14. Classification and Scoring System

15. CEAP classification for chronic venous disorders
Clinical classification
C0 No visible or palpable signs of venous disease
C1 Telangiectasias, reticular veins
C2 Varicose veins
C2r Recurrent varicose veins
C3 Edema
C4 Changes in skin and subcutaneous tissue secondary to chronic venous disease
C4a Pigmentation or eczema
C4b Lipodermatosclerosis or atrophie blanche
C4c Corona phlebectatica
C5 Healed
C6 Active venous ulcer
C6r Recurrent active venous ulcer
S With symptoms attributable to venous disease
A Absence of symptoms attributable to venous disease

16. Etiology classification
Ep Primary
Es Secondary
Esi Secondary (intravenous)
Ese Secondary (extravenous)
Ec Congenital
En No cause identified
Anatomy classification
As Superficial veins (Tel, Ret, GSVa, GSVb, SSV, AASV, NSV)
Ad Deep veins (IVC, CIV, IIV, EIV, PELV, CFV, DFV, FV, POPV, TIBV, PRV, ATV, PTV, MUSV, GAV, SOV)
Ap Perforator veins (TPV, CPV)
An No venous anatomic location identified

17. Pathophysiology classification
Pr Reflux
Po Obstruction
Pr,o Reflux and obstruction
Pn No venous pathophysiology identifiable

18. Pain or discomfort of presumed venous origin
None (0 points)
Occasional, not restricting activity (1 point)
Daily, with partial interference of activity (2 points)
Daily, limiting most activities (3 points)
Varicose veins
None (0 points)
Few, scattered branch varicositis or clusters, or corona phebectatic (1 point)
Multiple varicosities confined to calf or thigh (2 points)
Multiple varicosities involving calf and thigh (3 points)
Venous edema
None (0 points)
Foot and or ankle only (1 point)
Above ankle but below knee (2 points)
Above knee (3 points)

19. Pigmentation
None or focal (0 points)
Perimalleolar area only (1 point)
Diffuse but limited to lower one-third of calf (2 points)
Wide distribution above lower one-third of calf (3 points)
Inflammation: Erythema related to cellulitis, dermatitis, or venous eczema
None (0 points)
Perimalleolar area only (1 point)
Diffuse but limited to lower one-third of calf (2 points)
Wide distribution above lower one-third of calf (3 points)
Induration
None (0 points)
Perimalleolar area only (1 point)
Diffuse but limited to lower one-third of calf (2 points)
Wide distribution above lower one-third of calf (3 points)

20. Number of active ulcers
None (0 points)
1 (1 point)
2 (2 points)
≥3 (3 points)
Duration of active ulcers
N/A (0 points)
<3 months (1 point)
>3 months <1 year (2 points)
>1 year (3 points)
Size of active ulcers
N/A (0 points)
<2 cm diameter (1 point)
2 to 6 cm diameter (2 points)
>6 cm diameter (3 points)
Compression therapy
None (0 points)
Intermittent stocking use (1 point)
Stocking use most days (2 points)
Continuous stocking use (3 points)

21. How to approach

22.  Avoid prolonged standing/sitting, elevation of the leg, walking/flexion
exercise
 Evaluate for pulse/ABI
Venous ulcer present
Refer for arterial vascular
evaluation
Does ulcer appear infected Prescribe graduated
compression stockings
 Antibiotic
 Debridement
 Light dressing
Compression therapy
Skin changes limiting adherence
Referral for ? possible interventionCompression therapy
Referral for possible intervention
Emollient
Topical steroid

23.  Compression stockings
 Compression bandage
 Multilayer compression bandage
 Intermittent pneumatic compression
Skin necrosis
Fungal infection
Contact dermatitis

24. Class Pressure Level of support Indication CEAP
OTC <15 mmHg Minimal
Asymptomatic
individuals as needed
for comfort
0,1
I 15-20 mmHg Mild
Minor varicosities;
tired, aching legs;
minor ankle, leg, or
foot swelling
1,2,3
II 20-30 mmHg Moderate
Moderate to severe
varicosities, moderate
swelling, phlebitis,
following vein ablation
3,4
III 30-40 mmHg Firm
Severe varicosities,
severe swelling,
management of active
ulceration, following
DVT, post-surgery
4,5,6
IV >40 mmHg Extra firm Lymphedema NA
Prescription of Compression stockings

25. Intervention

29. References:
Up to date
Piazza G. Varicose veins. Circulation. 2014 Aug 12;130(7):582-7.
Youn YJ, Lee J. Chronic venous insufficiency and varicose veins of the lower extremities. The Korean journal
of internal medicine. 2019 Mar;34(2):269.
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