What is venous varicosity?

Venous Varicosity: Definition and Clinical Significance

A venous varicosity is a dilated, twisted, and elongated vein that occurs when valves become incompetent, causing blood to pool and the vein wall to weaken and dilate to at least 3 mm in diameter when measured with the patient standing upright. 1

Pathophysiology

Venous varicosities develop through a combination of:

• Valvular dysfunction: Incompetent valves fail to prevent backward blood flow, causing reflux
• Vein wall weakness: Loss of elasticity in the vein wall leads to failure of valve leaflets to fit together properly
• Increased venous pressure: Causes progressive dilation and tortuosity of veins
• Genetic predisposition: Recent research has identified 30 genetic loci associated with varicose vein development 2, 3
• Inflammatory processes: Leukocyte infiltration and activation lead to further vein wall damage 4
• Matrix metalloproteinase (MMP) activation: Causes degradation of extracellular matrix proteins, affecting the structural integrity of the vein wall 4

Clinical Presentation

Varicose veins exist on a spectrum of chronic venous disorders:

• Telangiectasias (spider veins): <1 mm in diameter
• Reticular veins: 1-3 mm in diameter
• Varicose veins: ≥3 mm in diameter
• Chronic venous insufficiency: May include edema, hyperpigmentation, and venous ulcers 1

Common Symptoms

• Localized symptoms: Pain, burning, itching, tingling at the site
• Generalized symptoms: Aching, heaviness, cramping, throbbing, restlessness, swelling
• Timing: Symptoms typically worsen at the end of the day, especially after prolonged standing
• Relief: Symptoms usually improve with leg elevation 1

Some patients may be asymptomatic, with varicosities presenting as a cosmetic concern only.

Risk Factors

• Family history of venous disease
• Female sex (more common in women)
• Older age
• Increased intra-abdominal pressure from:
  • Obesity
  • Pregnancy
  • Chronic constipation
  • Abdominal tumors
• Prolonged standing
• Prior deep venous thrombosis
• Height (taller individuals have higher risk) 3
• Multiple pregnancies 5

Potential Complications

Although most varicose veins cause only discomfort or cosmetic concerns, potential complications include:

• Skin pigmentation changes
• Venous eczema
• Infection
• Superficial thrombophlebitis
• Venous ulceration
• Lipodermatosclerosis (chronic inflammation, fibrosis, and contraction of skin/subcutaneous tissues)
• Rarely, significant external hemorrhage from vein perforation 1

Diagnostic Approach

The CEAP (Clinical, Etiologic, Anatomic, Pathophysiologic) classification system is commonly used to characterize venous disease:

• Clinical classification (C0-C6):

  • C0: No visible or palpable signs of venous disease
  • C1: Telangiectasias or reticular veins
  • C2: Varicose veins
  • C3: Edema
  • C4: Skin changes (pigmentation, eczema)
  • C5: Healed venous ulcer
  • C6: Active venous ulcer 1

• Diagnostic imaging: When venous disease is severe or interventional therapy is being considered, venous duplex ultrasonography is the modality of choice to document reflux and assess vein diameter 1

Treatment Options

Conservative Management

• Compression therapy (20-30 mmHg gradient compression stockings)
• Lifestyle modifications:
  • Leg elevation
  • Regular exercise
  • Weight management
  • Avoiding prolonged standing
• Medical therapy: Horse chestnut seed extract may ease symptoms, though long-term safety data are limited 1

Interventional Treatment

For symptomatic varicose veins with documented valvular reflux, interventional treatment options include:

• Endovenous thermal ablation (radiofrequency or laser): Preferred first-line treatment for saphenous vein incompetence with vein diameter >4.5mm due to higher occlusion rates (91-100% at 1 year) 6
• Sclerotherapy: More appropriate for smaller veins (≤3mm in diameter) 6
• Surgery: Traditional stripping and ligation, now largely replaced by less invasive options 1

Current guidelines suggest that referral for interventional treatment should not be delayed for a trial of external compression when valvular reflux is documented 1.

Clinical Pearls and Pitfalls

• Don't delay appropriate referral: Evidence suggests that interventional treatment should be offered if valvular reflux is documented, without requiring a prolonged trial of compression therapy first 1
• Consider underlying causes: Varicose veins may be a manifestation of deeper venous disease, especially when accompanied by significant symptoms or complications
• Special locations: Vulvar varicosities may require specialized evaluation, particularly if associated with pelvic congestion syndrome 7
• Post-procedure care: Compression therapy and walking for 15-20 minutes immediately after interventional treatment are recommended to reduce complications and promote successful vein closure 6

By understanding the pathophysiology and clinical implications of venous varicosities, clinicians can better identify patients who would benefit from intervention to improve morbidity, mortality, and quality of life.