Venous Insufficiency and Varicosities: Diagnosis and Treatment

Diagnosis

A thorough history and physical examination are usually sufficient for diagnosis. Additional testing is generally reserved for severe cases or when intervention is planned.

Doppler venous ultrasound gives information about the anatomy and flow patterns of the venous system. It accurately maps the veins of the leg and identifies the location and severity of valvular incompetence. In addition, it evaluates for deep venous thrombosis, which is fairly common in these patients. Ankle–brachial index (ankle–to–brachial blood pressure ratio) is calculated in conjunction with Doppler ultrasound to assess the presence of concurrent arterial disease, which is common in patients with venous disease.

Venography is an invasive method for evaluating the venous system. It is rarely used due to the safety and accuracy of Doppler ultrasound. However, venography is useful in some patients, particularly those who will undergo vascular surgery.

Treatment

Bed rest, leg elevation, and compression stockings or bandages are the initial therapy in most patients. Compression stockings act by decreasing venous pressure and reflux. They should be able to exert 20 to 30 mmHg at the ankle with a decreasing pressure gradient toward the knee (note that compression stockings are different from the “antiembolism” stockings used in hospitals for DVT prevention, which exert less than 10 mmHg).

Intermittent pneumatic compression pumps can be used for several hours daily and may be more effective than compression stockings or bandages.

Several drug therapies have been used. Diuretics may be used in patients with severe edema. Aspirin and oral antibiotics may be used to accelerate the healing of venous ulcers.

Venous ablation by injection sclerotherapy is useful in many patients with varicose veins for whom conservative therapies have failed.

Several surgical options are available and have high success rates. These include venous ligation with or without stripping, endovenous catheter ablation, and valvular reconstruction.