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Clinical Crossroads | Conferences With Patients and Doctors| Clinician's Corner

Management of Varicose Veins and Venous Insufficiency

Allen Hamdan, MD
JAMA. 2012;308(24):2612-2621. doi:10.1001/jama.2012.111352.
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Chronic venous disease, reviewed herein, is manifested by a spectrum of signs and symptoms, including cosmetic spider veins, asymptomatic varicosities, large painful varicose veins, edema, hyperpigmentation and lipodermatosclerosis of skin, and ulceration. However, there is no definitive stepwise progression from spider veins to ulcers and, in fact, severe skin complications of varicose veins, even when extensive, are not guaranteed. Treatment options range from conservative (eg, medications, compression stockings, lifestyle changes) to minimally invasive (eg, sclerotherapy or endoluminal ablation), invasive (surgical techniques), and hybrid (combination of ≥1 therapies). Ms L, a 68-year-old woman with varicose veins, is presented. She has had vein problems over the course of her life. Her varicose veins recurred after initial treatment, and she is now seeking guidance regarding her current treatment options.

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Figure 1. Common Pattern of Major Superficial and Deep Veins of the Lower Extremity
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The GSV, anterior accessory branch of the GSV, and the SSV are common sources of axial reflux (see Figure 2) in the lower extremity that can lead to the development of varicose veins and associated symptoms. These veins can be treated by ligation or stripping or by endovenous ablation.

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Figure 2. Schematic of Venous Reflux
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Types of venous reflux include axial, perforator, and local reflux. Axial reflux is reversal of the normal direction of blood flow in the major vessels of either the deep or superficial venous system of the lower extremity, in which blood flow is directed from the inguinal or popliteal region down toward the foot. Axial reflux due to valvular incompetence may occur vertically along the length of the lower extremity in the great saphenous vein and its accessory branches and in the small saphenous vein. Perforator reflux occurs in horizontal tributaries that connect deep to superficial systems, and local reflux is isolated within short clusters of varicose veins.

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Figure 3. Representative Examples of Duplex Ultrasound of the Great Saphenous Vein (GSV) at the Saphenofemoral Junction (SFJ)
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Longitudinal color ultrasound and spectral tracing from 2 patients. A, Example of normal phasic flow in the right GSV at the SFJ. B, Example of reflux in the right GSV after manual augmentation—the application of gradual, firm pressure distal to the location of interest followed by swift release to prompt an increase in venous flow velocity.

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