Primary lower extremity varicose veins, also known as primary varicose veins, refer to a condition involving only the saphenous veins, characterized by elongation, tortuosity, and dilation of superficial veins. It is commonly observed in individuals who engage in prolonged standing, high-intensity physical activity, or prolonged sitting.
Etiology and Pathophysiology
The primary causes of superficial varicose veins include weakness of the venous wall, valvular insufficiency, and elevated intraluminal pressure of the superficial veins. Weakness of the venous wall and valvular defects are often associated with genetic factors. Acquired factors, such as prolonged standing, heavy manual labor, pregnancy, chronic coughing, and habitual constipation, impose excessive pressure on the valves, leading to progressive relaxation and incomplete closure. Since veins located further from the heart bear higher venous pressure, varicose veins are more pronounced in the lower leg compared to the thigh.
Clinical Manifestations and Diagnosis
Primary lower extremity varicose veins are most commonly seen in the great saphenous vein, with isolated involvement of the small saphenous vein being less frequent. The condition is more common in the left leg, although both legs may be affected sequentially. The primary clinical manifestations include dilated and tortuous superficial veins in the lower limbs, as well as sensations of heaviness and fatigue in the legs. Mild swelling of the ankles may occur, along with trophic skin changes in the "stocking" area, such as skin hyperpigmentation, dermatitis, eczema, subcutaneous lipodermatosclerosis, or the formation of ulcers.
Diagnosis is usually straightforward based on characteristic clinical manifestations. When necessary, auxiliary tests such as ultrasound, plethysmography, lower limb venous pressure measurements, and venography can be used to confirm the nature of the disease with greater accuracy.
The diagnosis of primary lower extremity varicose veins requires ruling out the following conditions:
- Primary deep venous valve insufficiency in the lower limbs: Symptoms are relatively severe, and ultrasound or venography may reveal characteristic signs of deep venous valve incompetence.
- Post-thrombotic syndrome after deep venous thrombosis: There may be a history of deep vein thrombosis, with superficial venous dilation accompanied by marked limb swelling. If a differential diagnosis remains difficult, ultrasound or venography should be performed.
- Arteriovenous fistulas: This condition is characterized by increased skin temperature of the affected limb, the occasional presence of a palpable thrill, or vascular murmurs. Superficial venous pressure is significantly elevated, and venous blood oxygenation is higher.
Treatment
Non-Surgical Therapy
This approach involves the use of medical-grade compression stockings or elastic bandages to keep varicose veins in a collapsed state. Patients are advised to avoid prolonged standing or sitting and to periodically elevate the affected limb. Non-surgical therapy is aimed at symptom relief and is suitable for:
- Patients with mild symptoms who do not wish to undergo surgery
- Pregnant individuals, as symptoms may resolve postpartum
- Patients who are unable to tolerate surgery
Sclerotherapy and Compression Therapy
Injection of sclerosing agents into evacuated varicose veins induces an inflammatory reaction, leading to vein occlusion. This approach may serve as an adjunct to surgery, particularly for treating residual varicose veins. Following injection, localized compression with gauze rolls and the application of compression stockings or elastic bandages from the ankle to the injection site is required, with immediate resumption of active movement. Care must be taken to avoid leakage of the sclerosing agent, which may cause tissue inflammation, necrosis, or deep vein thrombosis.
Surgical Therapy
Surgical options are applicable to patients with a definitive diagnosis and no contraindications. These procedures include high ligation of the great saphenous vein and stripping of the main trunk along with varicose tributaries. If venous incompetence in communicating veins is confirmed, ligation of communicating veins can be performed. In recent years, minimally invasive treatments such as endovenous laser ablation and radiofrequency ablation have provided additional options for managing varicose veins.
Complications and Their Management
Superficial Thrombophlebitis
Thrombosed varicose veins may lead to thrombophlebitis with perivenous inflammation, often leaving local induration and skin adhesions. Treatment involves anticoagulation therapy and local heat application. Antibiotics are used in cases of concurrent infection. After inflammation subsides, surgical intervention should be performed.
Ulcer Formation
Skin damage and breakdown in the ankle area or "stocking" region can result in chronic, non-healing ulcers, often prone to recurrence after healing. Management includes moist wound dressings and limb elevation to improve venous return. Most shallow ulcers can heal, after which surgical treatment is recommended. For larger or deeper ulcers, after preparation with wound care, surgical intervention, including debridement and skin grafting, can facilitate healing and shorten recovery time.
Bleeding from Ruptured Varicose Veins
Bleeding typically occurs in the "stocking" area or around the ankles. It may manifest as subcutaneous bruising or external bleeding from skin breakdown. Due to high venous pressure, the bleeding rate can be significant. Management involves elevating the affected limb and applying local compression bandaging to achieve hemostasis. If necessary, suturing can be performed to stop the bleeding, followed by surgical correction.