Varicosis (overview) I83.9

Pathologically dilated, tortuous epifascial veins, which are usually found in the course of the V. saphena magna and parva Varicosis is caused by a failure of the venous valve system with secondary degenerative wall changes of the epifascial veins of the legs.

Clinically there are spindle-, cylinder- or sack-shaped dilated, tortuous superficial (epifascial) veins, whereby several turns can form regular varicose clusters and convolutes.

From an etiopathogenetic point of view:

• primary varicosis (congenital wall degeneration)
• secondary varicosis (secondary varices - acquired): occurs mainly in the context of a postthrombotic syndrome (compensatory)

By location and calibre of the affected veins:

• Intracutaneous varices:
  • spider veins varicose veins/telegiectasia
  • Reticular Varices
• Subcutaneous/transfascial varices/varicosis
  • Regular charities
  • Site branch varices
  • Perforating varices

According to the severity of the varicosis (see also clinic):

• There are 4 clinical degrees of severity (Widmer/Partsch - see also CEAP classification):
  • Grade 1: Varicose, no significant symptoms.
  • Grade 2: Varicose veins with symptoms (dysaesthesia, itching, feeling of heaviness, tension, slight tendency to swelling), no complications
• Grade 3: Varicose veins with symptoms (like grade 2, only more pronounced) with complications
  • eczema, hyperpimentation, atrophy
  • Scars of a healed leg ulcer
  • Varicophlebitis
• Grade 4: Varices with symptoms (like grade 3) with complications (like grade 3 only more pronounced)
  • florid leg ulcer

50-80% of the Central European population suffer from varicose changes of varying degrees; 15% from varicosis requiring treatment. Increasing prevalence with age; w:m=3:1

The aetiology is not completely clear in all details. Local hemodynamic factors as well as genetic factors are of particular interest.

Haemodynamically, varicosis is based on a failure of the valve system with reflux of blood from the deep into the epifascial venous system (bidirectional blood flow), irrespective of its aetiopathogenesis. The consequence is an increase in pressure in the epifascial venous system with resulting changes.

Predisposing factors are among others: age, overweight, standing activity, hormonal factors such as pregnancy.

First manifestation in the 3rd decade of life

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

The clinic is characterized by different forms of varicose veins with different clinical significance. Truncal varicosis is the varicose degeneration of the V. saphena magna or the V. saphena parva. Furthermore, varicosis can occur in the area of insufficient perforating veins (perforating varicosis).

• V. saphena magna:
  • Complete truncal varicosis: Proximal point of insufficiency lies in the crosse (orifice of the V. saphena magna) itself. Depending on how far the valve insufficiency extends distally, 4 stages are distinguished:
    • Grade 1: Distal insufficiency point (D.I.) is located in the groin
    • Grade 2: D.I. on the thigh
    • Grade 3: D.I. on lower leg
    • Grade four D.I. on the foot.
  • Incomplete truncal varicosis: Proximal point of insufficiency is not identical with the cricket.
    Different types are distinguished depending on the point of insufficiency:
    • lateral branch typeDodd-Perforant-typdorsal
    • type.
• V. saphena parva:
  • Complete truncal varicosis: Proximal point of insufficiency lies in the airlock region of the vena saphena parva. Depending on the route of the insufficiency 3 stages are distinguished: Grade 1: Distal point of insufficiency (D.I.) lies in the lock region, grade 2: D.I. lies in the middle lower leg, grade 3: D.I. lies in the region of the lateral malleolus.

Medical history, clinical examination, Doppler sonography. Duplex sonography before surgical interventions in the groin and popliteal fossa. By means of photopletysmographic procedures, e.g. light reflection rheography and D-PPG (digital photoplethysmography), a classification into better and not better venous insufficiencies can be made; this provides information about the hemodynamic relevance of the varicose vein condition if duplex sonography is not sufficient.

• Chronic venous insufficiency
• Varicose vein ruptures with varicose bleeding
• oedema of varying severity
• Varicosis as a predisposing factor for deep vein thrombosis (DVT) and pulmonary embolism (Note: in forms of thrombosis are summarized as "venous thromboembolism - VTE": there are no reliable larger studies on this topic: however, the current data suggest a connection between varicosis and VTE (quote from Lavall H).
• A superficial thrombophlebitis of the truncal veins is a relevant risk factor for deep vein thrombosis (DVT). In this context, DVT can definitely be ruled out.
• chronic trophic skin changes

• Depending on vein involvement and severity (truncal veins, lateral branches, see Table 1) sclerotherapy or surgery (crossectomy, stripping) and compression therapy (see Table 2).
• Truncal varicosis: Truncal varicosis of the saphenous vein (see table 3), especially in the presence of orifice insufficiencies, should rather be treated surgically. The combination of saphenous vein exhairesis up to knee level and postoperative sclerotherapy of the remaining varices on the lower leg is successful.
  Extraluminal valvuloplasty is used as a new surgical treatment for a krossen insufficiency (see below) of the saphenous vein with uncomplicated trunk varicosis. In this procedure, a Dacron ring is placed around the sluice valve plane of the saphenous vein, thereby reducing the vessel diameter to 4-5 cm and achieving sufficient valve closure. The Krossen sclerotherapy is therefore no longer a current therapy method and in any case belongs only in very experienced hands.
  The truncal varicosis of the saphenous vein (see table) should also be approached surgically, but in mild cases it can be sclerosed with not maximum dilatation. It is important to precisely prevent the junction of the saphenous vein in the femoral vein and the saphenous vein in the popliteal vein. Alternatively, newer endovascular procedures such as endoluminal laser therapy, radio wave therapy and foam sclerotherapy are available.
• Side branch varicosis/insufficiency of the perforating vv.: Sclerotherapy is sufficient for insufficiency of smaller calibre perforating veins. Surgical treatment is available for larger, localized venous convolutions and extensive insufficiency of the perforating veins (perforantes dissection).
• Reticular varicose veins/Teleangiectasia: Classic indication for sclerotherapy. For larger telangiectasias (> 0.4 mm diameter) as well as for reticular varices a combination of sclerotherapy and pulsed dye laser therapy has proven to be effective.
• Compression therapy: application of compression stockings or compression bandages, see below Compression stocking, medical, see below compression bandage, phlebological.

• Remember! Compression bandage: improvement of the condition and reduction of oedema (short-term use).

  Remember! Compression stocking: Slight improvement of the condition or maintenance of the condition (long-term use).

Classification of the veins (by floor and calibre)

Therapy decision

Classification of primary truncal varicosis of the saphenous vein

Drug support

1. Agu O et al (2002) Endothelin receptors in the aetiology and pathophysiology of varicose veins. Eur J Vasc Endovasc Surgery 23: 165-171

2. Birgitte Maessen-Visch M et al (2014) Duplex investigations in children: Are clinical signs in children with venous disorders relevant? Phlebology pii: 0268355514556143

3. Flessenkämper IH et al (2014) Two-Year Results of a Prospective Randomised Controlled Multicenter Trial to Compare Open Operative Therapy vs. Endoluminal Venous Laser Therapy with and without High Ligation for the Therapy of Varicose Greater Saphenous Veins. Central Bl Chir PubMed PMID: 24810891.

4. Kluess HG et al (2004) Guideline for the Diagnosis and Therapy of Varicose Veins. Phlebology 33: 211-221
5. Lavall H (2010) Varices and deep benign thrombosis: T Noppeney, H Nüllen Diagnosis and therapy of varicosis. Springer Medicine Publishing House Heidelberg S 176-179
6. Lorenz MB et al (2014) Sclerotherapy of varicose veins in dermatology. J Dtsch Dermatol Ges 12:391-393
7. Pannier-Fischer F et al (2003) Epidemiology of chronic venous diseases. Dermatologist 54: 1037-1044
8. Pfisterer L et al (2014) Pathogenesis of varicose veins - lessons from biomechanics. Vasa 43:88-99
9. Siedentopf F et al (2014) Chronic pelvic pain in women. Pain 28:300-304
10. Dust sand J et al (1994) Late damage to peripheral nerves by extravasation of polidocanol - an electron microscopic study. Phlebol 23: 112-119
11. Ströbel P (2010) Etiology of varicosis. In: T Noppeney, H Nüllen Diagnosis and therapy of varicosis. Springer Medicine Publishing House Heidelberg S 34 -36