11 Varicose Veins and Venous Ulcers*

Chronic venous disease is the most common vascular condition to affect the lower limb. It covers a wide range of conditions which can be broadly categorised as varicose veins, chronic venous insufficiency and venous ulcers. Venous disease is associated with a large burden of ill-health and it consumes a substantial amount of NHS resources. In the UK each year roughly half a million people consult their general practitioners about varicose veins and associated symptoms. Varicose veins are one of the most common conditions seen in surgical clinics, they make up a significant part of the elective surgery workload and they are responsible for a large proportion of patients on surgical waiting lists in NHS hospitals. Venous ulcer care is a major component of community nursing services. Venous disease has been a Cinderella area of health care, in terms of both research and treatment, though this situation is changing. Moreover, this situation has raised important questions about what conditions the NHS should treat. Whilst there is lay recognition that a varicose vein is a tortuous twisted vein, a standard definition has not yet been agreed. In addition, the exact pathophysiology surrounding the development of varicose veins remains controversial. Most varicose veins are primary (i.e. arising de novo), and whilst there are some recognised predisposing factors, structural abnormalities and abnormal haemodynamic effects whichmay influence their development, there is no agreement on which of these is the main cause of veins becoming varicose. Venous ulcers are located at the severe end of the spectrum of chronic venous disorders of the leg. A chronic venous ulcer can be defined as an area of discontinuity of epidermis, persisting for 4 weeks ormore and occurring as a result of venous hypertension (increased pressure) and calf muscle pump insufficiency. Venous hypertension is the undisputed initiating factor in venous ulcer development but a detailed understanding of the aetiology of venous ulcers is lacking, not least information on the natural history of varicose veins in relation to venous ulcers. There appears to be a high degree of acceptance of symptoms of venous disorders of the leg among affected persons, but for around a third of people they do present a significant problem. Symptoms reported by patients presenting with varicose veins include aching pain, tiredness/feelings of heaviness, throbbing, itching and swelling in the lower limbs. Not all varicose veins are associated with symptoms. Cosmetic dissatisfaction with the appearance of varicose veins is probably universal, although the impact it