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A 44-year-old man presents with a 5-year history of progressive right lower extremity pain, discomfort, swelling and prominent calf veins (Figure 63-1). His symptoms occur daily, and are worse with standing, particularly during his job as a nurse working 12-hour shifts in the emergency department. Overnight his symptoms improve. He has no other known past medical history, including that of venous thromboembolism. He is interested in an intervention to improve his quality of life. Physical examination is notable only for large medial calf varicose veins and mild pitting edema around the ankle.


This patient has classic varicose veins. Varicosities are blue, subcutaneous, tortuous veins over 3 mm in diameter.


  • Patients have symptoms that range from asymptomatic to severe pain or discomfort. Patients may also present with lower extremity swelling, a distal calf rash, or a leg ulcer.1

  • Pain or discomfort is the most common symptom of chronic venous disease. The symptoms are usually described as achiness, cramping, fatigue, heaviness, itching, or throbbing. The pain and discomfort are often located at varicosity sites, at the medial extremity (for great saphenous vein reflux—Figure 63-2) or posterolateral calf (for small saphenous vein reflux).

  • Pain, discomfort, and/or swelling are usually worse with dependence (eg, standing) and improve with extremity elevation or compression.

  • Swelling and skin changes tend to start around the ankle, but can gradually progress proximally over years (Figure 63-3).

  • Leg ulcers tend to occur around the ankle or medial or lateral foot (Figure 63-4).

  • Physical findings are described using the CEAP (Clinical-Etiology-Anatomy-Pathophysiology) class (Table 63-1). Higher CEAP classes indicate more advanced venous disease.2

  • Spider veins (Figures 63-5 and 63-6) are often, but not always, asymptomatic.

  • Unlike varicose veins (Figure 63-7), reticular veins (Figure 63-8) typically do not protrude from the skin surface.


Large protuberant varicose vein along the anteromedial thigh and medial calf. This represents a tributary of an underlying incompetent great saphenous vein.


Hyperpigmentation along the anteromedial calf with surrounding spider and small varicose veins.


Severe venous stasis with a combination of hyperpigmentation, lipodermatosclerosis, eczematous crusting, and small stasis ulceration.

TABLE 63-1.CEAP Classes

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