Peripheral Venous Disease: Varicose Veins and Chronic Venous Insufficiency

Abstract

Chronic venous disease and varicose veins affect 15–25 % of the general population and represent significant expense to the healthcare system, costing up to a billion dollars a year in the United States. Venous insufficiency from obstruction, reflux, and/or calf pump failure leads to the formation of varicosities as well as edema, pain, skin pigmentation, and, in severe cases, ulceration. A diagnosis of venous reflux is established by venous valvular failure with retrograde flow and valve closure times >500 ms in the superficial or perforating veins or >1,000 ms in the deep veins by duplex ultrasound. Patients with symptomatic varicosities from chronic venous insufficiency may be treated with eradication of the refluxing vein, most commonly the great saphenous, with or without concomitant phlebectomy. Newer endovenous therapies such as endovenous laser ablation and radiofrequency ablation have supplanted traditional high ligation and stripping as the standard of care, with excellent safety profile and good mid-term efficacy. Sclerotherapy and especially the newer technique of transilluminated powered phlebectomy offer advantages over traditional stab phlebectomy for the eradication and removal of the branch varicosities. Compression remains the mainstay of therapy for patients who are not candidates for surgery and to augment healing of venous ulcers. Perforator reflux and pelvic varicosities represent challenging clinical scenarios in the management of chronic venous insufficiency.