Venous Insufficiency |
| Pediatric
venous insufficiency (PVI) is a condition that has historically been
overlooked due to its perceived rarity and the assumption that it
primarily affects adults. However, recent studies have challenged this
view, revealing that children and adolescents can present with a wide
range of venous disorders, some of which mirror adult presentations
while others are distinct due to congenital or developmental vascular
anomalies. The lack of standardized pediatric-specific diagnostic
criteria and treatment guidelines complicates clinical management and
long-term care. A descriptive study published in 2015 by Andraska and colleagues examined 20 pediatric patients under 18 years old who underwent venous reflux studies. The most common indications for referral were limb swelling, varicose veins, and rubor or acrocyanosis. Duplex ultrasound revealed venous reflux in 90% of cases. Interestingly, one-third of the patients were ultimately diagnosed with conditions other than primary venous insufficiency, including vascular malformations, lymphedema, and complex regional pain syndrome (CRPS). This highlights the diagnostic complexity in pediatric populations, where reflux may be present but not pathologic, or may be secondary to another vascular condition. Moreover, the study found that superficial valve closure time was significantly prolonged in patients with primary chronic venous insufficiency (CVI) and Klippel-Trenaunay syndrome (KTS), distinguishing them from those with alternative diagnoses. A 2016 follow-up study from the same group reinforced these findings. Among a similar cohort, superficial reflux time was again significantly elevated in those with primary chronic venous disease (CVD) and KTS. In 44% of cases, an alternative diagnosis was made despite ultrasound evidence of reflux. The absence of typical signs like hyperpigmentation or ulceration suggests a milder, yet clinically relevant, disease course. These results emphasized the value of adjunct imaging such as magnetic resonance venography and lymphoscintigraphy in confirming or ruling out CVI, especially in patients with ambiguous symptoms. In children with KTS—a congenital vascular disorder characterized by capillary malformations, limb overgrowth, and venous abnormalities—venous insufficiency is common and often more severe. Persistent embryonic veins (PEVs), including lateral marginal veins (LMVs) and persistent sciatic veins (PSVs), contribute to chronic reflux. A 2021 clinical study evaluated the feasibility and safety of mechanochemical ablation (MOCA) in 11 pediatric patients with KTS. MOCA, which uses a combination of mechanical endothelial injury and chemical sclerotherapy, achieved 100% technical success and primary vein occlusion. Two patients experienced partial recanalization after over a year but responded well to repeat treatment. No major complications were reported. The study highlighted MOCA's value in avoiding heat-related risks associated with thermal ablation—particularly important in pediatric patients with delicate vascular structures. A 2025 retrospective review of a rural pediatric population added broader insight into the practical management of venous insufficiency. Thirty-four adolescents were included, with the majority presenting with bilateral symptoms. After evaluation, 13 patients underwent treatment including radiofrequency ablation (RFA), endovenous laser ablation (EVLA), ultrasound-guided sclerotherapy, or microphlebectomy. RFA and EVLA were associated with 100% vein occlusion and no significant complications. Patients resumed normal activity within 48 hours, and cosmetic outcomes were favorable—an important factor in treating adolescents. Notably, female patients were more likely to present with bilateral disease, while male patients were more likely to undergo treatment. The study also found no significant associations between disease severity and age, body mass index (BMI), or vein diameter. Across all studies, a consistent theme emerged: pediatric venous reflux is common, but not always clinically significant. Physiologic reflux has been observed in up to 13% of healthy adolescents, suggesting that adult diagnostic thresholds may not be appropriate for children. Nevertheless, in symptomatic patients with confirmed reflux and failure of conservative management (e.g., compression therapy), minimally invasive procedures such as RFA, EVLA, or MOCA are increasingly preferred over traditional surgical options. The differential diagnosis for pediatric lower extremity symptoms remains broad. Venous insufficiency may mimic or coexist with conditions such as lymphedema, vascular malformations, CRPS, or postural orthostatic tachycardia syndrome (POTS). A multidisciplinary evaluation, including advanced imaging and vascular expertise, is often necessary for accurate diagnosis and targeted treatment. The natural history of pediatric CVI is still not well understood. It remains unclear whether early intervention changes disease trajectory or prevents complications like venous ulcers later in life. However, the current evidence supports that early diagnosis and treatment—when indicated—can improve symptoms, functional outcomes, and quality of life. Minimally invasive techniques, with low risk and strong cosmetic outcomes, are especially suitable for this age group. In conclusion, pediatric venous insufficiency is more prevalent than previously assumed and requires careful diagnostic evaluation to differentiate true pathology from physiologic variants. Emerging treatments such as MOCA, RFA, and EVLA have shown to be safe and effective when used appropriately. Further prospective studies are needed to refine diagnostic criteria, validate treatment thresholds, and establish long-term outcomes in this unique population. References: 1- Andraska EA, Horne D, Campbell D, Eliason J, Wakefield TW, Coleman DM: Patterns of Pediatric Venous Insufficiency. J Vasc Surg Venous Lymphat Disord. 3(1):132-3, 2015 2- Andraska EA, Horne DC, Campbell DN, Eliason JL, Wakefield TW, Coleman DM: Patterns of pediatric venous disease. J Vasc Surg Venous Lymphat Disord. 4(4):422-5, 2016 3- Lambert G, Teplisky D, Cabezas M, Szhafir I, Silva M, Garriga M, Oliva A, Sierre S: Mechanochemical Endovenous Ablation of Varicose Veins in Pediatric Patients with Klippel-Trénaunay Syndrome: Feasibility, Safety, and Initial Results. J Vasc Interv Radiol. 32(1):80-86, 2021 4- Zabiba A, Dominguez Cervantes J, Thakur S, Agarwal S, Kaur K, Maatouk H, Zabiba F, Messiah S: A Retrospective Study of Outcomes in a Rural Pediatric Population Treated for Venous Insufficiency. J Pediatr Surg. 60(3):162117, 2025 |
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