The venous drainage system of the lower extremity consists of three sets of veins: the deep veins, the superficial veins, and the perforating veins. All veins contain delicate one-way valves that normally open to allow blood to flow unimpeded toward the heart (Fig. 1) and prevent blood from flowing in a retrograde fashion after the valves close (Fig. 2). If the valves are damaged, they become incompetent and permit the reversal of venous blood flow into the dependent limb, which results in a pressure increase and distention of the affected vessel. With an increased venous pressure, often called venous hypertension, in the greater and/or lesser saphenous veins, smaller veins under the skin may also dilate and present as varicosities. Venous valve destruction can also occur in the deep and perforating veins, but this results in a different and more serious symptom complex, which is beyond the scope of this chapter.

Successful treatment of patients with symptomatic chronic venous insufficiency (CVI) requires a detailed analysis of the anatomic and physiologic correlates of venous dysfunction. Using this information the physician may determine whether correction of the source of CVI is possible and if so which procedures may be useful to do so. With the proliferation of minimally invasive procedures in the last decade, conventional surgical correction of venous insufficiency is performed less frequently. However, these procedures remain useful in some instances as the primary procedure of choice. Regardless of whether a surgical, endovenous, injection-based, or other procedure is performed, the goal is the same: correction of abnormal venous reflux or obstruction resulting in CVI. Patients with CVI require treatment for limb swelling, skin changes, and ulceration, as well as the pain and disability associated with these objective signs. Although cosmetic considerations should not be ignored, the primary concern in CEAP classes 3 to 6 is to effectively obliterate abnormal reflux and minimize recurrence for long-term symptom resolution.

Various reports cite the incidence of varicose veins in the general population as ranging from 7% to 25%. The variability in these reports is attributable to whether spider veins (Fig. 3) are included in the definition for varicosities. Spider veins are estimated to occur in approximately 25% of the population (15% in males and 25% in females), and are manifested by dilated red streaks under the skin, often associated with a deeper blue reticular vein in that region. This condition is generally considered cosmetic, and sclerotherapy treatment is often curative.

Larger varicosities, as shown in Figure 4, are more often associated with insufficiency of the greater or lesser saphenous vein and present as subcutaneous bulges in the thigh or calf region. Symptoms of mild pain, heaviness, or even swelling after prolonged standing are often associated with this condition and there are multiple treatment options available for this condition.

Because of the broad spectrum of venous disease of the superficial veins of the lower extremity, an objective classification has been developed so that clinicians are better able to categorize the severity of the illness and more effectively evaluate the results of various treatment options. The most commonly used is the CEAP classification, which includes clinical, etiologic, anatomic, and pathologic signs. The clinical portion of the schemata is the most important to the practicing physician and is described in Table 1.