In the United States, 35% of adults suffer from various types of chronic venous insufficiency, ranging from cutaneous sideroblastic vasculopathy and simple varicose veins all the way to venous ulcers (which affect about 4% of Americans over 65 years of age). In contrast, several large Western studies between 1930 and 1960 found the prevalence of varicose veins in the general population to be approximately 2% by questionnaire.
Etiology
Varicose veins are only one type of chronic venous insufficiency. Age, gender, pregnancy, constipation, occupation, posture, previous lower extremity deep vein thrombosis and genetic factors are all causes of varicose veins. Some surveys have shown that the prevalence of varicose veins is three to four times higher in women than in men; in addition, the prevalence is five times higher in older people than in younger people.
It is worth noting the role of genetic factors in the development of varicose veins, a study found that if both parents have varicose veins, the risk of the disease in children is 90%; if a single parent has varicose veins, the risk of the disease in daughters is 62% and in sons is 25%; if both parents do not have the disease, the risk of the disease in children is 20%.
Clinical manifestations
The main symptoms arising from varicose veins are cosmetic appearance, ankle edema, gastrocnemius pain and even more severe cases such as skin pigmentation, seborrheic scleroderma and eczema. Ulcers are the end result of the development of simple varicose veins. Thrombotic superficial phlebitis and venous bleeding are less common.
Symptoms
Dilated veins
As the superficial venous system becomes progressively involved, the most common first symptom, in addition to mild edema, may be an aesthetically disfiguring aneurysmal dilatation of the superficial veins. Initially, the dilated veins tend to appear on the medial aspect of the lower calf. As chronic venous insufficiency progresses, the veins become more curved and numerous, and the patient may notice the upward spread of the varicose veins. Although in some women mild varicose veins develop during adolescence, their number increases rapidly during pregnancy. As the number of pregnancies increases, the number and diameter of varicose veins usually increases.
Swelling
Edema is an early symptom of venous disease. The swelling is mild and is confined to the ankle above the shoe line. The edema usually resolves with bed rest and especially with elevation of the affected limb. In the early stages of chronic venous insufficiency, the edema is limited to the vicinity of the ankle, but as the varicose veins progress, the edema can spread to the level of the mid-calf and above.
Early swelling is concave on acupressure, but as chronic edema develops and fibrous degeneration of the subcutaneous tissue occurs, the area of acupressure swelling is no longer concave. It is important to clarify that whether or not the swollen area is depressed on finger pressure depends primarily on the degree of subcutaneous fibrous degeneration, not on whether the swelling is lymphoid or venous.
Leg pain
Chronic venous insufficiency can present with several types of pain. The most common is a heavy or dull, trapped pain in the limb after prolonged standing, which the patient may describe as if it were filled with water and filled in the lower leg. The pain is usually found in the calf area, and walking may reduce the pain of chronic venous insufficiency as opposed to gastrocnemius pain with inadequate arterial blood supply. Patients may also experience pain along the dilated veins after prolonged standing, which may be the result of stagnation of venous blood within the phleboma and dilatation of the vein walls.
Lying flat, especially with the affected limb elevated, can reduce the heaviness for a short time. Pain can be exacerbated in warm, humid weather or during a woman’s menstrual period, as both of these conditions can cause significant water and sodium retention, which can exacerbate edema.
Skin changes
Initially, patients may observe skin pigmentation, commonly in the mid-calf. This is usually characterized by brown skin deposits of iron-containing haematoxylin. In case of thrombotic superficial phlebitis, hyperpigmentation may occur along the involved veins. In the mid to late stages, lipodermatosis (fibrous degeneration of the skin due to deposits of ferritin and plasma proteins) and eczematous dermatitis (stasis eczema) usually occur and lead to a dermatologic visit.
In advanced stages, skin ulcers develop, often in the boot area, which are usually painless in the absence of infection. These severe calf skin changes are mainly secondary to insufficiency of the deep venous system.
Bleeding from a ruptured superficial vein
The most common site is the medial ankle, which can bleed spontaneously or as a result of minor local trauma. Hemorrhage can often be stopped by direct local compression or by elevating the affected limb in a flat position. Because rebleeding is almost impossible to avoid, hospitalization is indicated.