Varicose Veins

Varicose veins are tortuous dilated segments of vein associated with valvular incompetence.

They arise from incompetent valves, which permit blood flow from the deep venous system to the superficial venous system (at the sapheno-femoral junction and sapheno-popliteal junction). This results in venous hypertension and dilatation of the superficial venous system.

98% of varicose veins are primary idiopathic varicose veins. Secondary causes may include deep venous thrombosis, pelvic masses (e.g. pregnancy, uterine fibroids, and ovarian masses), or arteriovenous malformations.

The Edinburgh Vein Study showed an age-adjusted prevalence rate for varicose veins of 39.7% in men and 32.2% in women with around 40% of women affected during/after pregnancy. Furthermore, the Framingham Study (1988) found that the incidence of varicose veins increases every year by 1.9% in men and 2.6% in women.

Fig 1 - Varicose veins develop from valvular incompetence, resulting in dilation of the superficial venous system.

Fig 1 – Varicose veins develop from valvular incompetence, resulting in dilation of the superficial venous system.


Risk Factors

There are four major risk factors for the development of varicose veins:

  • Prolonged standing
  • Obesity
  • Pregnancy
  • Family history

Clinical Features

Patients will typically present initially with cosmetic issues, for example unsightly visible veins (in the UK this does not qualify for treatment).

Worsening varicose veins may then cause pain, aching, swelling (often worse on standing or at the end of the day), or itching. Subsequent complications may include skin changes, ulceration, thrombophlebitis or bleeding.

On examination, varicose veins can show as:

  • Oedema
  • Varicose eczema or thrombophlebitis
  • Ulcers (typically found over the medial malleolus)
  • Haemosiderin skin staining
  • Lipodermatosclerosis (tapering of legs above ankles, an “inverted champagne bottle” appearance)
  • Atrophie blanche

A saphena varix is a dilatation of the saphenous vein at the saphenofemoral junction in the groin. As it displays a cough impulse, it is commonly mistaken for a femoral hernia; suspicion should be raised in any suspected femoral hernia if the patient has concurrent varicosities present in the rest of the limb. These can be best identified via duplex ultrasound and management is via high saphenous ligation.

Fig 2 - Skin changes associated with venous insufficiency. A - hyperpigmentation of the limbs. B - pitting oedema and lipodermatosclerosis.

Fig 2 – Skin changes associated with venous insufficiency. A – hyperpigmentation of the limbs. B – pitting oedema and lipodermatosclerosis.

Classification

A standardised reporting method for the clinical manifestations of varicose veins has been described by the CEAP Classification

CEAP classification Clinical classification
C0 No visible or palpable signs of venous disease
C1 Telangiectasia or reticular veins
C2 Varicose veins
C3 Oedema
C4a Pigmentation or eczema
C4b Lipodermatosclerosis or athrophie blanche
C5 Healed venous ulcer
C6 Active venous ulcer


Differential Diagnosis

The main differentials to consider for any varicose disease are cellulitis, DVT, and ischaemic ulcers


Investigations

Gold standard for varicose vein investigations is via duplex ultrasound (best done by a trained technician), assessing valve incompetence at the long/short saphenous veins and any perforators. Deep venous incompetence, occlusion (deep venous thrombosis) and stenosis must also be actively looked for.

Note – if a patient has a DVT, you cannot treat their superficial incompetence, as the venous blood will have no route back. Consequently, any patient with deep venous incompetence is typically offered non-surgical management.


Management

Non-Invasive Treatments

Patient education is very important, such as avoiding prolonged standing, weight loss, and increase exercise (promotes calf muscle action). NICE guidance only recommends the use of compression stockings if interventional treatment is not appropriate. This is because compression stockings are good at preventing complications of varicose veins but need to be worn for the rest of the patients life.

Venous ulceration generally requires four-layer bandaging (graduated compression aiming to move blood from distally to proximally), unless there is arterial insufficiency (based on ABPI measurements, typically less than 0.7) which often excludes compression as a treatment option. Compression is done once or twice per week, and is expensive due to the price of bandages and time required to apply them over potentially a lifetime.

Surgical Treatment

In the UK, patients with varicose veins should be referred to a vascular service if they meet the following NICE criteria:

  • Symptomatic primary or symptomatic recurrent varicose veins.
  • Lower‑limb skin changes, such as pigmentation or eczema, thought to be caused by chronic venous insufficiency.
  • Superficial vein thrombosis (characterised by the appearance of hard, painful veins) and suspected venous incompetence.
  • A venous leg ulcer (a break in the skin below the knee that has not healed within 2 weeks).

Treatment options available include:

  • Vein ligation, stripping, and avulsion – making an incision in the groin (or popliteal fossa) and identifying the responsible, refluxing vein, before tying it off and stripping it away. The surgeon must be aware of surrounding arterial and nervous structures, such as the saphenous and sural nerves.
  • Foam sclerotherapy – injecting a sclerosing (irritating) agent directly into the varicosed veins, causing an inflammatory response that closes off the vein. This is done under ultrasound guidance to ensure the foam does not enter the deep venous system and only requires a local anaesthetic.
  • Thermal ablation – which involves heating the vein from inside (via radiofrequency or laser catheters), causing irreversible damage to the vein which closes it off. This is done under ultrasound guidance and may be performed under local or general anaesthetic. This is often performed with multiple avulsions of visible varicose veins.
Fig 3 - Foam sclerotherapy, performed under ultrasound guidance.

Fig 3 – Foam sclerotherapy, performed under ultrasound guidance.


Complications

Untreated varicose veins will worsen over time. Many patients who have treated varicose veins require re-intervention surgery. Whilst the complications will be specific for each procedure, typical complications seen post-operatively are:

  • Haemorrhage
  • Thrombophlebitis (important for foam or ablation treatments)
  • DVT (important for any endovenous treatments)
  • Recurrence
  • Nerve damage – Saphenous/Sural
  • Visual symptoms and stroke have been reported after foam sclerotherapy.

Further Reading

Management of varicose veins and venous insufficiency
Hamdan A, JAMA

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