Snapshot A 77-year-old woman presents to her primary care physician for varicose veins. She reports that she has had these for a few months now and hopes to improve their appearance. She also states that her legs often feel restless and heavy and that she often has nocturnal cramping of her calves. She has a past medical history of obesity, hypertension, and previous deep venous thromboses after periods of long travel. On physical exam, her bilateral lower legs are edematous with brown hyperpigmentation around the ankles. There are no ulcers. She is scheduled for a duplex ultrasound. Introduction Clinical definition disorder of incompetent venous valves causing venous insufficiency Associated conditions varicose veins Epidemiology Demographics elderly population Risk factors deep venous thrombosis venous hypertension obesity family history Etiology Primary venous disease intrinsic venous wall dysfunction Secondary venous disease venous wall dysfunction (e.g., due to deep venous thrombosis) congenital abnormality Pathogenesis incompetent venous valves cause reflux of blood over time, this results in venous hypertension prolong venous hypertension → inflammation, more valve loss, and more valve reflux Presentation Symptoms lower leg swelling with pain or ache restlessness feeling of heaviness itch burning or tingling nocturnal leg cramping lower leg symptoms relieved by elevation Physical exam stasis dermatitis brown or dark purple hyperpigmentation hemosiderin deposited in the skin erythema venous ulcers varicose veins secondary to venous insufficiency serpentine cord-like lesion lower extremity edema Imaging Duplex ultrasound indication for all patients findings venous reflux may find thrombosis Differential Congestive heart failure distinguishing factor other symptoms of heart failure, including dyspnea on exertion, orthopnea, and paroxysmal nocturnal dyspnea Pressure ulcers distinguishing factor typically on pressure points and associated with failure to reposition frequently Lymphedema distinguishing factors edema with skin thickening peau d’orange or fibrotic-appearing skin no venous reflux on Doppler ultrasound DIAGNOSIS Making the diagnosis based on clinical presentation and imaging Treatment Conservative elevation of lower extremities indication for all patients compression therapy indications for all patients symptomatic relief Non-operative endovenous laser or radiofrequency ablation indication saphenous vein incompetence Operative surgical correction indication only if endovenous ablation is contraindicated Complications Dermatitis Prognosis Likely to recur even after treatment