Lower extremity venous disease is a common concern among dermatology patients. Leg veins are visibly present or symptomatic in greater than 50% of the adult population, with approximately 25% of the adult population suffering from varicose veins.1,2 Among individuals with varicosities, more than one quarter suffer from superficial venous insufficiency (SVI).1 There is a direct relationship between prevalence of varicosities and age as well as gender. Among those less than 25 years of age, less than 8% of women and 1% of men suffer from varicose veins, whereas more than half of women and more than one third of men aged 65 to 74 are affected.3
Studies have demonstrated that symptomatic varicose veins negatively impact quality of life.4 Symptoms classically associated with SVI include fatigue, heaviness, aching, burning, pain, pruritus, edema, and cramping. Recent evidence points toward SVI as a cause of restless legs syndrome (RLS).5 Prolonged standing, excessive warmth, menses, pregnancy, as well as oral contraceptives or other hormonal therapies often aggravate these symptoms. Patients often relate improvement in their symptoms with ambulation, compression therapy, leg elevation, and cooler ambient temperatures.
Early on, patients with SVI develop dilated, protuberant, and torturous veins, so-called varicose veins. With more advanced disease, patients may develop an eczematous or stasis dermatitis, pigmentary alteration of the skin, as well as lipodermatosclerosis, and atrophie blanche. Most severely, this condition can result in the formation of venous stasis erosions and ulcers, which are classically located over the medial malleolus. At this stage, patients may suffer from recurrent cellulitis, or, eventually, even malignant degeneration.
LEG VEIN ANATOMY AND PHYSIOLOGY
The lower extremity vascular system is comprised of both superficial and deep vessels, with interconnections throughout. The superficial venous system is one of primary collecting veins that are relatively distensible and thin-walled. The superficial vessels run within the skin and subcutaneous tissue and connect by epifascial perforating veins to the deeper vasculature within the muscular system.6,7 Chief among the superficial vessels are the great saphenous vein (GSV) and the small saphenous vein (SSV).
The GSV drains the majority of the leg, with its origin at the medial aspect of the foot. It passes anteriorly to the medial malleolus before traveling upward along the anteromedial aspect of the calf and then the medial aspect of the thigh, terminating at the saphenofemoral junction near the groin. A normal GSV measures approximately 3 to 4 mm in diameter within the thigh. The SSV drains the posterior and lateral leg, and originates at the lateral foot, before traveling along the midline of the calf. Termination is variable, although most commonly, the SSV enters into the popliteal vein at or around the knee at the saphenopopliteal junction. The GSV and SSV are encased by superficial fascia, but tributaries to these veins lie superficial to this fascia. An intersaphenous connecting ...