Chronic venous insufficiency and varicose veins of the lower extremities

Abstract

Chronic venous insufficiency (CVI) of the lower extremities manifests itself in various clinical spectrums, ranging from asymptomatic but cosmetic problems to severe symptoms, such as venous ulcer. CVI is a relatively common medical problem but is often overlooked by healthcare providers because of an underappreciation of the magnitude and impact of the problem, as well as incomplete recognition of the various presenting manifestations of primary and secondary venous disorders. The prevalence of CVI in South Korea is expected to increase, given the possible underdiagnoses of CVI, the increase in obesity and an aging population. This article reviews the pathophysiology of CVI of the lower extremities and highlights the role of duplex ultrasound in its diagnosis and radiofrequency ablation, and iliac vein stenting in its management.

Keywords: Diagnosis; Review; Therapeutics; Venous insufficiency.

Figure 1.

Venous system of the lower limb. (A) Great saphenous vein and its tributaries. (B) Small saphenous vein and its variations. (C) Perforating veins. SEV, superficial epigastric vein; SCI, superficial circumflex iliac vein; CFV, common femoral vein; EPV, external pudendal vein; SFJ, saphenofemoral junction; AASV, anterior accessory of the great saphenous vein; PASV, posterior accessory of the great saphenous vein; GSV, great saphenous vein; CE, cranial extension of the small saphenous vein; PV, popliteal vein; SPJ, saphenopopliteal junction; FV, femoral vein.

Figure 2.

Sonographic landmark of superficial femoral veins. (A) The ‘Egyptian eye’: a transverse ultrasound image of the great saphenous vein in the thigh with/without compression showing the fascial components that constitute the saphenous compartment. (B) Transverse view of the common femoral vein (CFV) and artery in the right groin: ‘Mickey mouse’ view. GSV, great saphenous vein; CFA, common femoral artery; SFJ, saphenofemoral junction.

Figure 3.

Sonographic evaluation of compressibility. (A) Compressible popliteal vein without echogenic thrombus within the normal vein. (B) Uncompressible enlarged popliteal vein with echogenic thrombus in acute deep vein thrombosis. (C) Partially compressible popliteal vein with partially recanalized echogenic thrombus within the lumen in chronic deep vein thrombosis. A, artery; V, vein.

Figure 4.

Doppler ultrasound of the femoral veins. (A) Spontaneous blood flow with respiratory changes and normal response to an augmentation maneuver. (B) Nearly constant high velocity flow without significant respiratory changes indicate a proximal stenosis or occlusion. CFV, common femoral vein.

Figure 5.

Doppler ultrasound of the iliac veins in a patient with right left iliac vein non-thrombotic stenosis. (A) Normal spontaneous blood flow with respiratory changes at the right external iliac vein (EIV). (B) Increased iliac vein velocity at the left EIV.

Figure 6.

Venous reflux after manual augmentation. (A) Non-pathologic brisk reflux after the augmentation maneuver (reflux time < 1.0 second in the femoral vein). (B) Pathologic reflux after the augmentation maneuver (reflux time > 0.5 second in the great saphenous vein). CFV, common femoral vein; GSV, great saphenous vein.

Figure 7.

Venography and corresponding intravascular ultrasound (IVUS) of the narrowest lesion. (A) Left common iliac vein (LCIV) shows luminal haziness (black asterisk), pre-stenotic dilatation, and collateral flows on the venography obtained at digital subtraction angiography. (B) IVUS at this lesion reveals that LCIV is compressed by a calcified extrinsic mass that originated from the bulged L5-S1 disc with calcification. LCIA, left common iliac artery.