JOURNAL OF VASCULAR SURGERY

Volume 53, Number 16S

Fig 2. Posterior superficial and perforating veins of the leg. (Used with permission of Mayo Foundation for Medical Education and Research.)

nect the posterior accessory GSV of the calf (the posterior arch vein in the old nomenclature) with the posterior tibial veins and form the lower, middle, and upper groups. They are located just behind the medial malleolus (lower), at 7 to 9 cm (middle) and at 10 to 12 cm (upper) from the lower edge of the malleolus. The distance between these perforators and the medial edge of the tibia is 2 to 4 cm.66 (Fig 1). Paratibial perforators connect the main GSV trunk with the posterior tibial veins. In the distal thigh, perforators of the femoral canal usually connect directly the GSV to the femoral vein.

Venous valves

Bicuspid venous valves are important structures assisting unidirectional flow in the normal venous system. The GSV usually has at least 6 valves (range, 4-25), with a constant valve present within 2 to 3 cm of the SFJ in 85% of cases,67 and the SSV has a median of 7 to 10 valves (range, 4-13).68 There are valves in the deep veins of the lower limb, but the common femoral or external iliac vein has only one valve in about 63% of cases.68 In 37%, there is no valve in the common femoral or external iliac veins. The internal iliac vein has a valve in 10%; its tributaries have valves in 9%.69

Gloviczki et al 9S

DIAGNOSTIC EVALUATION

Clinical examination

Patients with varicose veins may present with no symptoms at all; the varices are then of cosmetic concern only, with an underlying psychologic impact. Psychologic concerns related to the cosmetic appearance of varicose veins will, however, reduce a patient’s QOL in many cases.

Symptoms related to varicose veins or more advanced CVD include tingling, aching, burning, pain, muscle cramps, swelling, sensations of throbbing or heaviness, itching skin, restless legs, leg tiredness, and fatigue.70 Although not pathognomonic, these symptoms suggest CVD, particularly if they are exacerbated by heat or dependency noted during the course of the day and relieved by resting or elevating the legs or by wearing elastic stockings or bandages.51 Pain during and after exercise that is relieved with rest and leg elevation (venous claudication) can also be caused by venous outflow obstruction caused by previous DVT or by narrowing or obstruction of the common iliac veins (May-Thurner syndrome).69-71 Diffuse pain is more frequently associated with axial venous reflux, whereas poor venous circulation in bulging varicose veins usually causes local pain.

History. A thorough medical history is essential in the patient’s evaluation and may establish the diagnosis of primary, secondary, or congenital varicosities. Questions to patients who present with varicose veins should address previous DVT or thrombophlebitis, established thrombophilia, medication history (particularly birth control pills), smoking, pregnancies, and a family history of varicosity or thrombotic disorders. Premenopausal women with varicose veins should also be questioned for symptoms of pelvic congestion syndrome (pelvic pain, aching, or heaviness; dyspareunia). Advanced age is the most important risk factor for varicose veins and for CVI. A positive family history, female sex, and multiparity are also risk factors for varicose veins, and a positive family history and obesity are risk factors for CVI.57

Physical examination. Clinical evaluation should focus on signs of venous disease, and examination in the standing patient in a warm room, with good light, should establish the size, location, and distribution of varicose veins. Inspection and palpation are essential parts of the examination, and auscultation (bruit) is particularly helpful in those with vascular malformation and arteriovenous fistula.71 Varicose dilations or venous aneurysms, palpable cord in the vein, tenderness, a thrill, bruit, or pulsatility should be recorded. In addition, the presence of spider veins or telangiectasia, limb swelling that is usually partially pitting or nonpitting, induration, pigmentation, lipodermatosclerosis, atrophie blanche, eczema, dermatitis, skin discoloration, increased skin temperature, and healed or active ulcers should be documented.

Ankle mobility should also be examined, because patients with advanced venous disease frequently have decreased mobility in the ankle joints. Sensory and motor functions of the limb and foot are assessed to help differen-