Varicose Veins

Dilated, tortuous, elongated superficial veins in the lower extremity, from incompetence of valves in the superficial veins, or in the communicating/perforating veins between the deep and superficial systems. Varicose veins are the C2 category of the CEAP (clinical-etiology-anatomy-pathophysiology) classification used to grade chronic venous disorders, which runs from C0 (no visible/palpable venous disease) through C1 (telangiectasia/reticular veins), C2 (varicose veins), C3 (oedema), C4a/C4b (pigmentation/eczema, lipodermatosclerosis), to C5/C6 (healed/active venous ulcer).

Epidemiology and demographics: affects females 5:1. Varicose veins are reported in up to 30% of the general population, with rates rising with age. The Framingham Study found a two-year incidence of varicose veins of 39.4 to 51.9 per 1000, highest in women in their 40s.

History

Risk factors: female sex, family history, pregnancy, multiparity, age, occupation (prolonged standing), low-fibre diet. Body weight, constipation, and a personal history of venous thrombosis are also recognised risk factors. Ask about the cosmetic impact and how it affects the patient.

Symptoms are uncommon but can include swelling, fatigue, heaviness in the limb, aching discomfort, and itching. Cramps, mild tenderness, skin discoloration and exercise intolerance are also reported. Severe cases can progress to lower-limb venous hypertension syndrome — pain worse after standing, night cramps, skin irritation/pigmentation, ankle swelling, and loss of skin features (e.g. hair).

Complications to ask about: superficial thrombophlebitis, skin eczema, skin ulceration, bleeding, calcification, Marjolin ulcer (SCC). Patients with varicose veins are also at higher risk of deep vein thrombosis (DVT) than matched controls without varicose veins, and DVT requires prolonged anticoagulation with its own morbidity — the differential for a swollen, discoloured leg with varicosities should always include DVT, lymphoedema, cellulitis, and stasis dermatitis. Unlike the deep system, clots confined to superficial veins rarely embolise, so pulmonary embolism from varicose veins alone is rare.

Examination

General inspection for visible varicose veins, most prominent from the thigh to the ankle with discoloration usually most marked around the ankle and calf. Special tests: venous groin cough impulse (saphenous vein incompetence), Trendelenburg test (saphenous vein competence), short saphenous vein incompetence test, and incompetent perforating vein test — these are best learned from video demonstration rather than written description. In the Trendelenburg test, the leg is elevated until the superficial veins collapse and the saphenofemoral junction is manually occluded before the patient stands. If distal varicosity remains empty once the occlusion is released, the point of entry is most likely at the saphenofemoral junction, and that patient can benefit from ligation of the saphenous vein at this junction.

Investigations

Venous duplex ultrasound accurately localises sites of incompetence and assesses the functionally important deep venous system, and should also assess for coexisting DVT. Contrast venography is now rarely performed in clinical practice.

Management

Prevention: maintain ideal weight, high-fibre diet, rest, and supportive stockings if at risk.

Conservative treatment: keep off legs as required, supportive stockings/tights, avoid scratching itchy skin over the veins. Graduated compression stockings are the mainstay non-procedural option, ranging from 20 to 30 mmHg for mild varicose veins up to 30 to 40 mmHg for varicose veins with severe oedema or skin changes. Compression therapy is deemed safe when the ankle-brachial pressure index (ABPI) is above 0.8, and reduced compression is advised when the ABPI is between 0.5 and 0.8. Compression should generally be avoided when the ABPI is below 0.5, with vascular specialist referral for arterial assessment. Patient compliance with compression stockings is poorly studied, with non-concordance rates of up to 80% reported in real-world practice, so this should be actively discussed with the patient rather than assumed.

Injection sclerotherapy uses a chemical irritant such as polidocanol to obliterate small, non-axial varicose veins under 6 mm diameter. For aesthetic reasons, sclerotherapy might be indicated in symptomatic and even asymptomatic varicose veins. Spider and reticular veins are treated with a higher sclerosant concentration, with injections repeated one to two weeks apart.

Interventions (per NICE guidance) need referral to a vascular surgeon:

1. Offer endothermal ablation (laser or radiofrequency) first.
2. If unsuitable, offer ultrasound-guided foam sclerotherapy.
3. If unsuitable, offer surgery (traditional high ligation and stripping of the great/small saphenous vein, or ambulatory phlebectomy for tributary veins).

A 2021 Cochrane review of 24 trials with 5,135 participants compared these procedures for great saphenous vein incompetence. Heat-based endovenous treatment with a laser may be more successful than traditional surgery, and heat-based radio wave endovenous treatment may be better than both laser endovenous treatment and surgery at preventing varicose veins from recurring in the longer term. The review’s authors were not able to reach firm conclusions about which of the treatments compared is superior. Unwanted effects were generally low for all treatments, and people in the studies said they had improved well-being regardless of the treatment they received. There is no cure for varicose veins, and even after surgical removal recurrences are common — part of why prevention and conservative management remain first-line before referral.