C H A P T E R

Anatomy, Physiology &

188 Classification of Varicose Veins

Ravul Jindal, Bhanupriya Wadhawan, Piyush Chaudhary

Varicose veins are dilated, tortuous, elongated superficial also functions as a reservoir to hold extra blood. You
veins that are usually seen in the legs. It can occur in could say that the venous system is almost magical in its
any age group but most common in mid- twenties. It is function when you are told that the entire cardiac output
a progressive disease. It is more common in females than volume of 5–10 L/min is received into periphery venous
males. system for eventual delivery back to the heart and lungs.

ANATOMY PATHOANATOMY
All veins in the body are either part of the superficial The veins have one-way valves to prevent them from
venous system or the deep venous system. The principal backward flow. The correct functioning of the venous
superficial veins of the lower extremity are the small system depends on a complex series of valves. It has
saphenous vein (SSV), which usually runs from ankle to been known that varicose veins in the legs are caused by
knee and the great saphenous vein (GSV), which usually weakening of the veins and valves in the great saphenous
runs from ankle to groin1 (Figure 1). veins and/or small saphenous veins. When the valves
in these malfunction, blood begins to collect in the legs
Superficial collecting veins deliver their blood into the
resulting in the buildup of pressure. The veins become
great and small saphenous veins, which deliver most of
enlarged and knotted and are visible near the surface of
their blood into the deep system. Superficial veins are also
the skin as a varicose vein (Figure 3a and b).
connected to a variable number of perforating veins (PV)
that pass through openings in the deep fascia to join deep Major valves which dysfunctions in the caution of
veins of the calf or thigh either directly or through smaller varicose vein are saphenofemoral junction (SFJ) and
plexus of smaller veins2,3 (Figure 2). saphenopopliteal junction (SPJ).
All venous blood is eventually received by the deep The termination point of the GSV into the common
venous system on its way back to the right atrium of the femoral vein, located proximally at the groin,  is called
heart. The principal deep venous trunk of the leg is called the Saphenofemoral junction. The terminal valve of the
the popliteal vein from below the knee until it passes GSV is located within the junction itself. In most cases, at
upward into the distal thigh, where it is called the femoral least one additional sub terminal valve is present within
vein (FV) for the remainder of its course in the thigh. This the first few centimeters of the GSV. Most patients have
is the largest and longest deep vein of the lower extremity.
Unlike arteries with thick walls, most veins are very thin
and easily distendable, so the peripheral venous system

Femoral Vein

Long Saphenous
Popliteal Vein
Vein

Short Saphenous
Vein

Tributaries
of LSV

Fig. 1: Showing superficial and deep venous system Fig. 2: Showing perforating veins
 868 VF=femoral vein
GSV=Great saphenous vein
SSV=Supra-saphenic valve
TV=Terminal valve
PTV=Pre-terminal valve
VENOUS DISORDERS

Fig. 3a: Showing normal veins and diseased veins

A
Deep veins
Iliac vein
Venous insuficiency
Superficial veins
Common Great saphenous vein
femoral vein
Normal vein Normal vein Varicose vein
Popliteal vein Open valve Closed valve Damaged/nonfunctional valve

Incompetent valve
Fig. 4: Showing terminal and preterminal valve
Vein wall thinned

to mimic true SFJ incompetence. Reflux can also pass

and bulging
Abnormal blood flow
backward down leg
Damaged nonfunctional valve

directly into any of the other veins that join the GSV at
Normal valve opens Normal valve closes
to allow blood flow to prevent reverse cannot close properly and
toward heart of blood flow blood flow is impaired

that level, or it may pass a few centimeters along the GSV

B
Normal blood flow
back to heart

Deep vein
Superficial vein and then abandon the GSV for another branch vessel.
Perforating vein

Fascia layer Incompetence of the perforating veins leads to

hydrodynamic pressure. The calf pump mechanism helps
Incompetent perforating
Deep vein valve causing abnormal
Superficial veins blood flow

to empty the deep venous system, but if perforating vein

Perforating veins

Normal perforating
valve and normal valves fail, then the pressure generated in the deep venous
blood flow
system by the calf pump mechanism are transmitted into
Fig. 3b: Showing normal veins and diseased veins the superficial system via the incompetent perforating
veins.
a single sub terminal valve that can be readily identified
Once venous hypertension is present, the venous
approximately 1 cm distal to the junctional valve.
dysfunction continues to worsen through a vicious
PATHOPHYSIOLOGY circle. Pooled blood and venous hypertension leads to
The pathophysiology behind their formation is venous dilatation, which then causes greater valvular
complicated and involves the concept of ambulatory insufficiency. Over time, with more local dilatation, other
venous hypertension. adjacent valves sequentially fail, and after a series of
valves has failed, the entire superficial venous system is
In healthy veins, the flow of venous blood is through the incompetent. This can then cause subsequent perforator
superficial system into the deep system and up the leg and deep venous valvular dysfunction.
and toward the heart. One-way venous valves are found
in both systems and the perforating veins. Incompetence The clinical findings of varicose veins, reticular veins,
in any of these valves can lead to a disruption in the and telangiectasias are due to the hypertension in the
unidirectional flow of blood toward the heart and result superficial venous system that spreads to collateral veins
in ambulatory venous hypertension (AVH). 6 and tributary veins, causing dilated tortuous structures.
Treatment modalities are geared towards correcting the
Incompetence in the superficial venous system alone superficial venous hypertension.
usually results from failure at valves located at the SFJ
and SPJ. The gravitational weight of the column of blood In contrast to the superficial veins, the deep veins do not
along the length of the vein creates hydrostatic pressure, become excessively distended. They can withstand the
which is worse at the more distal aspect of the length of increased pressure because of their construction and the
vein. confining fascia.

Reflux at or near the SFJ does not always come through THE CLASSIFICATION OF VENOUS DISEASE
the terminal valve of the GSV, nor does it always involve Venous disease of the legs can be classified according to
the entire trunk of the GSV. Reflux can enter the GSV the severity, cause, site and specific abnormality using
below the sub terminal valve or even immediately below the CEAP classification. The elements of the CEAP
the junction, passing through a failed sub terminal valve classification are:
 869
• Clinical severity a. Pigmentation or Eczema
• Etiology or cause b. Lipodermatosclerosis or athrophie blanche
• Anatomy
• Pathophysiology
For the initial assessment of a patient, the clinical severity
is the most important and can be made by simple
observation and does not need special tests. There are
C4
seven grades of increasing clinical severity 3,4,5:

Grade Description

CHAPTER 188
C0 No evidence of venous disease.

Skin pigmentation in the gaiter area

(lipodermatosclerosis)

C1

C5

Superficial spider veins (reticular veins) only 

A healed venous ulcer

C2

C6

Simple varicose veins only

An open venous ulcer
The majority of patients referred to the vascular surgical
clinic have grade 2 diseases (simple varicose veins). 
Patients with C3-6 disease are demonstrating increase
severity of chronic venous insufficiency, and all have
a functional abnormality of the venous system.  These
C3 patients are most at risk of chronic ulceration and require
specialized tests such as venous duplex and ambulatory
venous pressure measurement to diagnose and
characterize the underlying venous abnormality. If we
correct the venous abnormality in the disease process
then the risk of complications associated with the venous
disease are much lower.
Ankle edema of venous origin
(not foot edema)
 870 REFERENCES clinical practice guidelines of the Society for Vascular
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VENOUS DISORDERS

and a systematic aspect to different vascular territories.

JD, Vasquez MA, Wakefield TW; The care of patients with
Med Hypotheses 2016; 91:73-6.
varicose  veins  and associated chronic  venous  diseases: