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Varicose Veins: Why Legs Are More Susceptible & What Causes Them

Varicose veins are dilated, tortuous superficial veins (>3 mm diameter) resulting from chronic venous insufficiency (CVI). The legs are predisposed due to unique hemodynamic and structural challenges.

Pathophysiology: Why the Legs?

  1. Hydrostatic pressure gradient: Standing → column of blood from heart to foot ≈ 100 mmHg. Veins must return blood against gravity.
  2. Valvular incompetence: Primary (genetic connective tissue weakness) or secondary (post-thrombotic, trauma, hormonal) valve failure → reflux → venous hypertension → venous dilation → further valve separation (vicious cycle).
  3. Calf muscle pump failure: Immobility, neuropathy, arthritis → loss of "peripheral heart" → stasis.

Risk Factors

CategoryFactors
GeneticFamily history (FOXC2, other variants), connective tissue disorders (Ehlers-Danlos)
HormonalPregnancy (↑progesterone, ↑volume, uterine compression), OCP/HRT, menopause
LifestyleProlonged standing/sitting, obesity (↑intra-abdominal pressure), sedentary, heavy lifting
AgeProgressive loss of elastin, collagen, valve function
MedicalPrior DVT (post-thrombotic syndrome), pelvic tumors, AV fistula

Clinical Classification (CEAP)

  • C0: No visible signs
  • C1: Telangiectasias / reticular veins
  • C2: Varicose veins
  • C3: Edema
  • C4: Skin changes (pigmentation, eczema, lipodermatosclerosis, atrophie blanche)
  • C5: Healed venous ulcer
  • C6: Active venous ulcer

Conservative Management

  • Graduated compression stockings (20–30 mmHg knee-high; 30–40 mmHg for C3–C6).
  • Leg elevation > heart level 3–4×/day × 30 min.
  • Exercise (walking, calf raises, swimming).
  • Weight loss, avoid prolonged static posture.
  • Skin care (emollients, avoid trauma).

Interventional Options

  • Endothermal ablation (RFA, laser) — first-line for truncal reflux.
  • Mechanochemical ablation (MOCA), cyanoacrylate glue (VenaSeal).
  • Sclerotherapy (foam) for tributaries.
  • Phlebectomy / stripping (reserve).

Early intervention prevents progression to skin changes and ulceration. Duplex ultrasound maps reflux anatomy for treatment planning.

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