A 43 Year Old Woman With Varicose Veins

A 43-year-old woman presents to her physician’s office with complaints of heaviness and fatigue in her legs.  She does not experience the symptoms in the morning but they become more noticeable as the day progresses and with prolonged standing. When she stands for many hours, she develops swelling in both of her legs. The symptoms are concentrated over her medial calf where she has
prominent tortuous veins. She first noted the veins approximately 15 years ago when she was pregnant. Initially, they did not cause her any discomfort but have progressively enlarged now and over the past 10 years have become increasingly painful. She recalls that her mother had similar veins in her legs.

This patient was diagnosed with varicose veins or Venous insufficiency.

Case Discussion
Varicose veins: Also known as Venous insufficiency is a condition that is caused by improperly functioning valves in the venous system and is most commonly seen in the legs causing abnormally thick, enlarged and twisted, engorged veins. This may lead to skin changes and even ulceration in advanced cases.


Etiology: It is most frequently a result of valvular dysfunction.

• Valvular dysfunction may be primary or secondary (result of trauma, deep venous thrombosis [DVT], or May-Thurner syndrome).
• It may affect deep system (i.e., femoral veins), superficial system (i.e., saphenous vein), or both.
•The superficial system is involved in 88% of cases either alone or in conjunction with the deep system.
• Dysfunction leads to loss of compartmentalization of veins, leading to distention and increased pressure

Risk Factors : include:
• Family history.
• Deep venous thrombosis.
• Female gender.
• Estrogen increase (hormone replacement, pregnancy, oral contraceptive pills).
• Age.
• Obesity.
• Prolonged standing.

Clinical features In the early course of the disease varicose veins do not cause any pain. The enlarged and twisted veins can only be a cosmetic concern for females. When the disease progresses the signs and symptoms may include;

• Achy and heavy feeling in the legs
• Throbbing sensation in the legs 
• Muscle cramping and burning of the legs
• Pain and worsening of the symptoms after standing for prolonged time.
• Itching around one or more of the swelled veins
• Skin ulcers may begin to appear which needs immediate medical attention. 

Differential Diagnosis:

• Arterial ulcers—Tend to be at toes, shin, and pressure points (heels or sides of feet).

• Diabetic ulcers—Occur at ambulatory pressure points, mostly at first metatarsal head.

• Malignancy (basal cell or squamous cell carcinoma).

• Chronic infectious diseases (osteomyelitis, leprosy).

• Vasculitides—Irregular border, black necrosis, erythema, or bluish or purplish discoloration of adjacent tissue.

Management: 

1. Varicose veins are diagnosed by physical examination and clinical presentation. 

2. Ultrasound doppler may be done to see the functioning of the vein valves and any evidence of blood clot.

3. Treatment involves self care that includes exercise, losing weight, elevating the legs and avoid long standing. 

4. Wearing compression stockings is often the first approach before going on to other treatments. Compression stockings are worn all day and work by gradually squeezing the legs that help the veins and leg muscle to efficiently pump the blood back to the heart. 

5. Sclerotherapy is a procedure that involves injecting small and medium sized varicose veins with a solution that scars and closes those veins. The process is effective if done correctly but sometimes is needed to be done repeatedly . 

6. Laser surgery is anew technique that close off smaller varicose veins and spider veins.

7. Several other surgical methods are also available for varicose vein treatment and depends upon the condition of the patient and the need for surgery.