30. Primary varicosity of the extremities; superficial thrombophlebitis

Primary varicosity of the extremities and superficial thrombophlebitis

Varicose veins are dilated, tortuous superficial veins caused by venous reflux and valve incompetence. Primary varicosities arise from intrinsic venous wall/valve dysfunction; secondary varicosities may follow DVT or deep venous obstruction.
The great saphenous vein runs medially and joins the common femoral vein at the saphenofemoral junction. The small saphenous vein usually joins the popliteal vein. Perforators connect superficial and deep systems.

Valve failure produces reflux and raised ambulatory venous pressure. Vein wall remodelling and dilation worsen valve coaptation, creating a cycle of reflux.
Risk factors include family history, age, pregnancy, obesity, prolonged standing and previous DVT. Symptoms may be worse after standing and improve with elevation.

Varicose veins appear as dilated tortuous superficial veins, commonly along the medial leg or posterior calf.
Symptoms include aching, heaviness, itching, cramps, ankle swelling and cosmetic concern. Complications include eczema, pigmentation, lipodermatosclerosis, ulceration, bleeding and superficial thrombophlebitis.
Superficial thrombophlebitis presents with a tender, erythematous, warm, palpable cord along a superficial vein. Assess proximity to the saphenofemoral or saphenopopliteal junction and risk of concurrent DVT.

Duplex ultrasound confirms reflux, maps superficial anatomy, assesses deep venous patency and excludes DVT when thrombosis is suspected.
Clinical examination should include standing inspection, distribution of varicosities, skin changes, oedema, pulses and assessment for alternative causes of leg symptoms.
Use CEAP classification and a validated symptom score where helpful. Atypical unilateral swelling or sudden onset requires evaluation for DVT or proximal obstruction.

Conservative care includes exercise, weight management, leg elevation and compression for symptom control when appropriate; compression does not eliminate reflux.
Intervention is offered for symptomatic truncal reflux, bleeding, skin changes or ulceration. Endovenous laser or radiofrequency ablation is commonly first-line when anatomy is suitable; foam sclerotherapy or surgery are alternatives.
Superficial thrombophlebitis: use duplex to assess extent and exclude DVT. Short, low-risk segments may be managed with NSAIDs, compression and mobilisation. Extensive disease, proximity to deep junctions or high-risk features may require anticoagulation according to guideline-based duration and dose.
Treat associated DVT if identified. Antibiotics are not indicated unless there is true infection. Urgent assessment is needed for rapidly spreading erythema, fever, major swelling or pulmonary symptoms.
Complications include DVT, pulmonary embolism, skin changes, ulceration, bleeding, recurrence and post-procedure nerve injury or thrombosis.