Varice I83.9

Author: Prof. Dr. med. Peter Altmeyer

Last updated on: 29.10.2020

Synonym(s)

Varicose vein

Definition
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Abnormal, congenital or acquired, short or long, spindle-, cylinder- or sack-shaped dilated epifascial vein sections with a tendency to tortuosity, whereby several turns can form regular varicose clusters and convolutes. S.a. Varicosis.

Classification
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Depending on the location, level and calibre of the affected veins, a distinction is made:
- Trunk varices: vena saphena magna and parva (complete and incomplete)
- Side branch varices (e.g. arcade and arch veins)
- Perforating varices
- Pudendal Varices
- Reticular varices: Intracutaneous reticular veins
- Spider veins varices
- Teleangiectasia.
Staging of the truncal varicosis of the saphenous vein (according to Hach):
- Stage I: Insufficiency of the crusts in the groin.
- Stage II: Insufficiency starting from the crust to a hand's breadth above the knee joint.
- Stage III: Insufficiency starting from the crust to below the knee.
- Stage IV: Insufficiency from the crust to the medial ankle.
The staging of saphenous varicosis of the saphenous vein trunk is also classified according to Hach:
- Stage I: Insufficiency of the krosse in the hollow of the knee.
- Stage II: Insufficiency starting from the crusty leg to a hand's breadth above the knee joint.
- Stage III: Insufficiency from the crust to the middle of the lower leg.
- Stage IV: Insufficiency from the crutch to the lateral ankle.

Venous classification according to Weiss
Type		Diameter (mm)	Colour	Localization
Type I	Teleangiectasia	0,1-1	red	intradermal
Type Ia	Matting	< 0,2	light red, two-dimensional
type II	Veneto Asia	1-2	purple
type III	Reticular Varices	2-4	blue
type IV	Site branch varices	3-8	blue-green	subcutaneous
Type V	Regular charities	> 8	blue-green	subcutaneous

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Occurrence/Epidemiology
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Varicose veins are one of the most common clinical pictures in the Central European population. About 70% of the German population show pathological changes of the peripheral venous system, with women being affected significantly more often than men. A total of approx. 12 million patients are affected by varicosis, with approx. 20% suffering from trunk varicosis, 50% from branch varicosis, two thirds from reticular and one third from spider veins. In total, 5% of the cases are in need of treatment.

Etiopathogenesis
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Not clarified in all details. In most cases there are congenital, degenerative changes in the vein wall, especially in the tunica media and the collagenous fibrous skeleton. Predisposing factors include age, standing activity, overweight, chronic constipation, regular alcohol consumption, pregnancy and multiple births, lack of exercise.

Localization
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Located mainly in the area of the legs, in the course of the vena saphena magna and parva.

Clinical features
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Feeling of heaviness in the leg (improvement through walking or running), tired legs, pain in the area of the varicose veins (especially when standing), premenstrual pain in the area of the varicose veins (also over reticular varicose veins and spider veins), ankle swelling and evening ankle edema, increase in symptoms when warm, improvement through elevated leg positioning, nightly foot and calf cramps.

Diagnosis
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Apparative diagnostics with ultrasound Doppler/colour duplex sonography devices and CW Doppler duplex sonography devices. Phlebography only in problem cases. Photoplethysmography is suitable for assessing the course of the disease.

Differential diagnosis
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Generally typical and therefore unmistakable clinical picture.

Fatty tissue hernias (hernias of the fascia of the foot lifts in the lateral area of the lower legs)
Pieced nodules (heel edges and lateral foot edges)
Hemangioma, cavernous
Angiokeratoma
Lymphangioma.

Complication(s)
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Chronic venous insufficiency; rupture of varices; thrombophlebitis. Isomorphic stimulus for e.g. psoriasis vulgaris, lichen planus, eczema, nummular, dermatoliposclerosis, hyperpigmentation, ulcus cruris.

Therapy
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Depending on vein involvement and severity (truncal veins, lateral branches), compression therapy, sclerotherapy, foam sclerotherapy or surgery ( crossectomy, Babcock stripping of the saphenous vein, cryostripping), endoluminal laser therapy or radio wave therapy (VNUS closure) are indicated.

General therapy
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As general measures, weight normalisation and regular physical activity are recommended. Furthermore, if the activity is predominantly sitting or standing, a sufficiently frequent interruption of this posture should be ensured. Hydrotherapeutic measures often lead to an improvement of the symptoms. In many cases a medical compression stocking is indispensable. Diuretics can be used to start treatment of pronounced oedema.

External therapy
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S.u. Compression therapy and compression bandage, phlebological. Consistent compression therapy is used as an alternative or supplement to sclerotherapy and surgery, as an accompanying measure immediately after sclerotherapy and surgery, and as an auxiliary therapy for varicosis such as phlebitis and varicose vein rupture. Short-stretch bandages, permanent compression bandages or the medical compression stocking are used. The legs can be elevated and, if necessary, lymph drainage and intermittent compression therapy (see AIK below) can be performed.

Operative therapie
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The procedures consist of miscectomy (removal of the truncal veins at the junction with the deep vein system), truncal vein resection, exhairesis of lateral branches and perforator dissection. Contraindications are acute deep leg and pelvic vein thromboses, hemodynamically relevant collateral functions of veins, sufficient venous segments for bypass material, severe general diseases, bed-riddenness, disorders of hemostasis and lymphedema. Recurrence rates after venous surgery are up to 40%.

Progression/forecast
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Primary varicosis and secondary varicosis and development of chronic venous insufficiency may occur.

Literature
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Bradbury A et al (1999) What are the symptoms of varicose veins? Edinburgh vein study cross sectional population survey. BMJ 318: 353-356
Breuninger H et al (2001) Cryostripping of the long saphenous vein with a percutaneously guided probe. Dermatol Surgery 27: 545-548
de Araujo T (2003) Managing the patient with venous ulcers. Ann Intern Med 138: 326-834
London NJ et al (2000) ABC of arterial and venous disease. Varicosis veins. BMJ 320: 1391-1394
Margolis DJ et al (2002) Hormones replacement therapy and prevention of pressure ulcers and venous leg ulcers. Lancet 359: 675-677
Schöpf E, Friedel S (1985) Newer aspects of diagnosis and therapy of primary varicosis. Dermatologist 36: 379-380
Stansby G (2000) Women, pregnancy, and varicose veins. Lancet 355: 1117-1118
Weiss RA, Weiss MA (1993) Painful teleangiectasis: diagnosis and treatment. in: Bergan JJ, Goldman MP (eds) Varicose veins and teleangiectasias: diagnosis and treatment. Quality Medical (St. Louis), pp 389-406