A 76-year-old Caucasian male comes to see you in the office. He complains that he has visible and palpable tortuous swelling on both of his lower legs. It is associated with mild leg heaviness and cramping, especially in the evening. His symptoms are worse with prolonged standing, and improve with leg elevation. He has a past medical history of hypertension, hyperlipidemia, benign prostatic hyperplasia, and degenerative joint disease of both knees. On examination of his lower legs, you notice a few scattered palpable veins consistent with a diagnosis of varicose veins. There is no edema, chronic skin hyperpigmentation, or leg ulcers. Peripheral pulses are full and equal on both sides. Which of the following is the most appropriate next step in the management of this patient?

Question

A 76-year-old Caucasian male comes to see you in the office.  He complains that he has visible and palpable tortuous swelling on both of his lower legs.  It is associated with mild leg heaviness and cramping, especially in the evening.  His symptoms are worse with prolonged standing, and improve with leg elevation.  He has a past medical history of hypertension, hyperlipidemia, benign prostatic hyperplasia, and degenerative joint disease of both knees.  On examination of his lower legs, you notice a few scattered palpable veins consistent with a diagnosis of varicose veins.  There is no edema, chronic skin hyperpigmentation, or leg ulcers.  Peripheral pulses are full and equal on both sides.  Which of the following is the most appropriate next step in the management of this patient?

Quizplus · Accepted Answer

Explanation: Varicose veins refer to visible, palpable, and tortuous superficial veins of the legs, usually on the calf or medial thigh. Most of the patients with varicose veins are asymptomatic. Some patients may complain of leg cramping, heaviness, fatigue, and swelling. The symptoms are generally worse in the evening with prolonged standing, and improve with leg elevation. Treatment of varicose veins is aimed at alleviating symptoms, although some patients may seek a physician's attention due to cosmetic reasons. Various treatment options for varicose veins include leg elevation, compression stockings, sclerotherapy, and surgical ligation. Most patients with symptomatic varicose veins should initially be treated with conservative measures such as leg elevation and compression stockings. Compression stockings, along with leg elevation and weight reduction, decreases the venous pressures in the lower extremities by direct compression, and improves the patient's symptoms. Compression stockings should not be used in patients with an underlying arterial insufficiency. (Choices B and C) Injection sclerotherapy with or without anesthetics is used in patients with symptomatic, small, varicose veins who have failed at least three to six months of conservative treatment. It involves the injection of a sclerosing agent into the affected vein. It causes endothelial damage and sclerosis of the involved vein, thus preventing further vein filling. (Choice D) Surgical ligation and stripping is used in patients with large symptomatic varicose veins with ulcers, bleeding, or recurrent thrombophlebitis of the veins. (Choice E) External laser treatment is used to treat particular veins and/or telangiectasias. It is not used for the treatment of varicose veins. Educational Objective: Most patients with symptomatic lower extremity varicose veins should be treated initially with conservative measures such as leg elevation, weight reduction, and compression stockings.

A 76-Year-Old Caucasian Male Comes to See You in the Office