22.19: Varicose Veins I: Introduction

Varicose veins, or varicosities, are abnormally dilated and twisted superficial veins caused by venous valve incompetence. This condition commonly affects the lower extremities, especially the saphenous veins, due to the higher pressure from prolonged standing and walking. However, varicosities can also occur in other areas, such as the esophagus, vulva, spermatic cords, and anorectal region.

Etiology and types

1. Primary varicose veins, often idiopathic, are more common in women due to inherent weaknesses in the vein walls.
2. Secondary varicose veins result from direct injury, a history of venous thromboembolism (VTE), or excessive vein distention. Secondary varicosities can appear as esophageal varices (due to portal hypertension), varicoceles in the spermatic cords, and hemorrhoids in the anorectal area.
3. Congenital varicose veins arise from chromosomal defects and genetic mutations leading to abnormal venous system development. These defects can include deletions, duplications, or mutations in specific genes, such as FOXC2, which are crucial for the formation and function of venous valves. Such abnormalities can cause malformations in the vein walls and valves, resulting in improper blood flow, venous insufficiency, and vein enlargement from birth. Additionally, congenital conditions like Klippel-Trenaunay syndrome and Parkes-Weber syndrome, often associated with chromosomal abnormalities, can present with congenital varicose veins as part of their clinical features.
4. Reticular veins are smaller varicose veins that appear flat, less tortuous, and blue-green.
5. Telangiectasias, referred to as spider veins, are small visible vessels (generally less than 1 mm in diameter) that appear bluish-black, purple, or red.

Risk factors

The risk factors that contribute to the development of varicose veins include:

• Family history of the condition
• The structural weakness of veins
• Female gender
• Tobacco use
• Advancing age
• Obesity
• Multiparity
• History of VTE
• Venous obstruction due to extrinsic pressure (such as tumors)
• Thrombophilia increases the tendency to form blood clots, can cause recurrent VTE, damage veins, and valves, and lead to chronic venous insufficiency and varicose veins.
• Phlebitis: Phlebitis inflames veins, damaging walls and valves, resulting in vein dilation and poor blood return, leading to varicose veins.
• Previous leg injury
• Occupations requiring prolonged standing or sitting

Pathophysiology

In primary varicose veins, weakened vein walls cause the valve ring to enlarge, preventing the leaflets from fitting together properly and resulting in valve incompetence. Incompetent vein valves allow blood to flow backward, especially when standing, which increases venous pressure and causes further venous distention.

Clinical manifestations

Common symptoms include a heavy, achy feeling or pain after prolonged standing or sitting, which can be relieved by walking or elevating the limb. Additional symptoms may include heavy, achy feelings, itchy or burning sensations, tingling, throbbing, or cramp-like sensations in the legs, swelling, restless or tired legs, fatigue, and nocturnal leg cramps.