Explain varicose veins

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Varicose Veins

Definition

Varicose veins are abnormally dilated, tortuous, and elongated superficial veins caused by sustained elevation of intraluminal venous pressure, which leads to progressive vessel dilation and subsequent incompetence of the venous valves. The result is retrograde blood flow (reflux) in the superficial venous system. - Robbins, Cotran & Kumar Pathologic Basis of Disease

Epidemiology

Adult prevalence of visible varicose veins: 30-50% of the population.
Up to 20% of males and one-third of females develop lower extremity varicose veins at some point.
Prevalence rises sharply with age - in the Edinburgh Vein Study, trunk varicosity prevalence went from 11.5% in people aged 18-24 to 55.7% in those aged 55-64.

Risk Factors:

Female sex (female : male ratio higher in most studies)
Increasing age
Obesity / elevated BMI
Pregnancy (compression of the inferior vena cava by the gravid uterus elevates venous pressure; can be up to 10x normal in dependent posture)
Family history (faulty venous wall development has a familial pattern)
Prolonged standing or sitting
Ethnicity (some variation in prevalence)

Anatomy and Pathophysiology

The superficial veins most commonly affected are the great saphenous vein (GSV) and the small saphenous vein (SSV):

GSV is affected in approximately 60% of cases (medial thigh and calf distribution)
SSV in approximately 20% (posterolateral calf)

Venous blood is normally returned to the heart against gravity by a combination of:

Calf muscle pump (compresses deep veins during walking)
One-way venous valves (prevent retrograde flow)
Pressure gradient toward the heart

When valves become incompetent, blood refluxes from the deep to the superficial system through perforating veins, raising pressure in the superficial system. Key sites of valve incompetence include:

The saphenofemoral junction (SFJ) - the most common, sometimes visible as a saphena varix in the groin
The saphenopopliteal junction (SPJ)
Mid-thigh perforators
Calf perforators at 5, 10, and 15 cm above the medial malleolus

Classification:

Primary varicose veins: intrinsic weakness of the venous wall itself
Secondary varicose veins: result from deep/superficial venous insufficiency (e.g., post-DVT, pelvic outflow obstruction)

Clinical Features

Symptoms

Patients typically describe:

Aching, heaviness, throbbing, burning, or bursting sensation over affected areas
Symptoms worsen with prolonged standing or sitting and toward the end of the day
Symptoms relieved by leg elevation and compression hosiery
Itching (pruritus) over the vein
Ankle swelling (edema)
Fatigue of the affected limb

Signs

On examination:

Visibly tortuous, dilated subcutaneous veins
Ankle edema
Skin changes in advanced/chronic disease (see complications below)

The Trendelenburg test (tourniquet test) is used clinically to localise the level of valve incompetence - a tourniquet is applied at different levels of the leg while it is elevated; rapid venous filling on standing indicates incompetence below that level.

Complications

Complication	Detail
Superficial thrombophlebitis	Painful inflammation/clotting in a varicose vein
Bleeding	From attenuated, thin-walled vein clusters; can be significant
Stasis dermatitis ("brawny induration")	Brown discolouration from haemolysis of extravasated red cells; chronic venous congestion
Lipodermatosclerosis	Fibrotic hardening of subcutaneous fat from chronic inflammation
Venous (stasis) ulceration	The end-stage complication; venous disease accounts for ~85% of all chronic lower limb ulcers
Hyperpigmentation	Iron-staining of skin
DVT (rare from superficial veins)	Embolism from superficial varicosities is actually very rare - unlike deep vein thrombosis

Venous leg ulcers are a major public health burden: community prevalence is 0.1-0.3% (up to 2-4% in the elderly), and dressings alone account for 1-3% of Western healthcare expenditure. - Bailey & Love's Short Practice of Surgery, 28th Ed.

Other Varicosities Worth Noting

Esophageal varices: caused by portal hypertension (liver cirrhosis). Rupture can cause life-threatening upper GI haemorrhage.
Hemorrhoids: varicose dilation of the anorectal venous plexus from prolonged pelvic vascular congestion (pregnancy, straining).

Investigations

Duplex ultrasound is the cornerstone of assessment - it provides both anatomical mapping of the venous system and physiological information about reflux. It is indispensable for planning any intervention. It can identify:

Site and extent of valvular incompetence
Presence of deep vein reflux or obstruction
Perforator incompetence

Treatment

Conservative

Compression stockings: the first-line treatment for symptom relief. Graduated compression of 20-30, 30-40, or 40-50 mmHg (knee-high to waist-high depending on the extent of disease). Provides adequate symptom control in many patients.
Lifestyle: weight loss, leg elevation, avoiding prolonged standing

Interventional (indicated when symptoms worsen despite compression, or when lipodermatosclerosis or ulceration is present)

1. Injection Sclerotherapy

Destroys the venous endothelium using a sclerosant agent
Agents include: hypertonic saline (11.7-23.4%), sodium tetradecyl sulfate (0.125-1%), polidocanol (0.5-1%)
Foam sclerotherapy (mixing sclerosant with air/gas) improves contact with vein walls and is effective for larger vessels
A recent multicentre RCT showed significant symptom relief and cosmetic improvement vs placebo
After injection, compression bandaging for 3-5 days prevents thrombus formation, followed by elastic stockings for 2+ weeks
Complications: allergic reaction, local hyperpigmentation, thrombophlebitis, DVT, skin necrosis

2. Endovenous Thermal Ablation (Laser / Radiofrequency)

Endovenous laser ablation (EVLA) and radiofrequency ablation (RFA) are now the preferred treatments for GSV and SSV reflux
Both are performed percutaneously under ultrasound guidance with local tumescent anaesthesia
Equally effective to surgical stripping but with faster recovery and less procedural morbidity
A recent meta-analysis (Jiang et al., 2024, PMID 38316290) compared RFA vs laser ablation, finding both highly effective with comparable outcomes

3. Nonthermal/Nonsclerosant Techniques

Mechanochemical ablation (MOCA): combines mechanical endoluminal injury with sclerosant injection
Cyanoacrylate glue (VenaSeal): catheter-delivered adhesive occludes the vein without heat or sclerosant - promising early results

4. Surgical Treatment

Saphenofemoral/saphenopopliteal junction ligation plus GSV/SSV stripping - the traditional gold standard
Now largely replaced by endovenous techniques in most centres
Surgical anatomy matters: the popliteal fossa contains the popliteal artery (deepest), popliteal vein (intermediate), and sciatic nerve/common fibular nerve (most superficial) - injury to the common fibular nerve during SSV surgery can cause foot drop

CEAP Classification (Clinical Severity)

Venous disease is systematically classified using the CEAP system:

Class	Description
C0	No visible/palpable signs
C1	Telangiectasias / reticular veins
C2	Varicose veins
C3	Edema
C4a	Pigmentation / eczema
C4b	Lipodermatosclerosis / atrophie blanche
C5	Healed venous ulcer
C6	Active venous ulcer

Recent Evidence

A 2024 systematic review and meta-analysis (Bontinis et al., PMID 39559844) examined interventions for recurrent varicose veins at the saphenofemoral junction, supporting endovenous approaches even for recurrent disease. A 2024 meta-analysis comparing RFA vs laser ablation (PMID 38316290) found both techniques similarly effective, supporting either as first-line thermal ablation options.

Sources: Robbins, Cotran & Kumar Pathologic Basis of Disease; Bailey & Love's Short Practice of Surgery, 28th Ed.; Schwartz's Principles of Surgery, 11th Ed.; Gray's Anatomy for Students

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Understanding Your Varicose Vein Treatment Options

A Guide for Patients

What Are Varicose Veins?

Varicose veins are swollen, twisted veins that you can see just under the skin - usually in the legs. They happen when the tiny valves inside your veins stop working properly. Normally, these valves keep blood flowing toward your heart. When they weaken or fail, blood pools in the vein, causing it to bulge and become visible.

You are not alone. Varicose veins affect up to 1 in 3 adults. They are more common in women, older adults, and people who spend a lot of time on their feet.

Common Symptoms

Aching, heaviness, or throbbing in your legs
Swelling around the ankles
Itching or burning over the vein
Leg fatigue that gets worse as the day goes on
Symptoms that improve when you put your feet up

Note: Symptoms often have nothing to do with how large the veins look. Small veins can cause significant discomfort.

When Should You See a Doctor?

You should make an appointment if you have:

Symptoms that affect your daily life or sleep
Skin changes around the ankle (darkening, hardening, or rash)
A sore or wound near your ankle that is slow to heal
A vein that is suddenly very painful, red, or hard (this may be a blood clot)
Sudden bleeding from a vein

Your Treatment Options

Treatment depends on the size and location of your veins, your symptoms, and your overall health. Your doctor will usually start with the most simple option first and move to procedures only if needed.

1. Compression Stockings

What it is: Special elastic stockings that gently squeeze your legs to help blood flow upward.

How it works: The gentle pressure prevents blood from pooling in the veins and eases aching and swelling.

What to expect:

Worn daily, usually from morning until bedtime
Come in different strengths (your doctor will recommend the right level)
Available in knee-high or thigh-high styles
Should be put on before getting out of bed in the morning

Pros: No procedure needed, no recovery time, relieves symptoms for many people

Cons: Must be worn consistently to work; do not permanently remove veins

2. Sclerotherapy (Injection Treatment)

What it is: A doctor injects a chemical solution directly into the varicose vein, causing it to seal shut and gradually fade away.

How it works: The solution irritates the inner lining of the vein. The vein closes, turns into scar tissue, and is absorbed by the body over several weeks.

Two types:

Liquid sclerotherapy - used for smaller veins and spider veins
Foam sclerotherapy - the solution is mixed with air to create a foam, which works better for larger veins

What to expect:

Done in a clinic, no anaesthesia needed
Takes about 30-45 minutes
You wear compression bandages for 3-5 days after, then compression stockings for at least 2 weeks
You can walk right away and return to normal activities quickly
Multiple sessions may be needed

Pros: Quick, no incisions, effective for a wide range of vein sizes

Possible side effects: Temporary bruising or brown skin marks, mild swelling, a small risk of blood clots, rarely skin irritation

3. Endovenous Laser Ablation (EVLA)

What it is: A thin laser fibre is inserted into the vein through a tiny needle puncture. The laser heats the vein from the inside, causing it to close.

How it works: Heat from the laser damages the vein wall. The vein seals shut and is slowly reabsorbed by the body.

What to expect:

Done under local anaesthetic (you are awake, the area is numbed)
Guided by an ultrasound scanner so the doctor can see exactly where to work
Takes about 45-60 minutes
You walk out of the clinic the same day
Wear compression stockings for 1-2 weeks after
Mild bruising and soreness for a few days

Pros: Highly effective, no hospital stay, quick recovery - most people return to normal activities within a day or two

Possible side effects: Bruising, tightness along the vein, a small chance of numbness, rarely a blood clot

4. Radiofrequency Ablation (RFA)

What it is: Very similar to laser treatment, but uses radiofrequency (heat) energy instead of laser energy to close the vein.

How it works: A thin catheter (tube) is guided into the vein. It delivers controlled heat in short bursts, sealing the vein shut as it is slowly withdrawn.

What to expect:

Done under local anaesthetic in a clinic
Guided by ultrasound
Takes about 45-60 minutes
Same-day discharge
Compression stockings worn for 1-2 weeks

Pros: Clinical studies show it is equally as effective as laser treatment, often with slightly less post-procedure discomfort

Possible side effects: Same as laser (bruising, tightness, rare blood clot)

5. Newer Techniques

Cyanoacrylate glue (e.g., VenaSeal): A medical adhesive is injected into the vein to seal it shut. No heat is used, so no tumescent anaesthetic injections are required. A good option for people who find the anaesthetic injections uncomfortable.

Mechanochemical ablation (MOCA / ClariVein): A rotating wire and sclerosant are used together. No heat and no tumescent anaesthetic needed.

Both are newer options and may not be available at every centre. Ask your doctor if they are right for you.

6. Surgery

What it is: The traditional surgical approach involves tying off the main vein at the groin (ligation) and removing it with a long wire (stripping).

When it is used: Surgery is now mainly reserved for complex or recurrent cases where endovenous techniques are not suitable.

What to expect:

Done under general or spinal anaesthetic
Short hospital stay (often same-day or overnight)
Recovery takes 1-2 weeks; most people return to work within 2 weeks

Pros: Well-established with long track record

Cons: Longer recovery than endovenous treatments; small risk of bruising, scarring, or nerve injury

Comparing Your Options at a Glance

Treatment	In-clinic?	Anaesthetic	Recovery	Best For
Compression stockings	No	None	Immediate	Mild symptoms, ongoing management
Sclerotherapy	Yes	None	1-2 days	Spider veins, small-medium varicose veins
Laser ablation (EVLA)	Yes	Local	1-3 days	Main trunk veins (GSV/SSV)
Radiofrequency (RFA)	Yes	Local	1-3 days	Main trunk veins (GSV/SSV)
Glue / MOCA	Yes	Minimal / none	1-2 days	Main trunk veins, needle-averse patients
Surgery	Hospital	General/spinal	1-2 weeks	Complex/recurrent cases

Questions to Ask Your Doctor

Before deciding on a treatment, it helps to ask:

Which treatment do you recommend for my type of varicose veins - and why?
Will I need more than one session or procedure?
What are the chances of the veins coming back?
How long will recovery take, and when can I go back to work?
Are there any risks I should know about given my health history?
Will my insurance or health plan cover this treatment?

Looking After Your Legs - Self-Care Tips

Regardless of which treatment you choose, these habits help protect your leg veins:

Stay active. Walking is one of the best things for your veins.
Put your feet up when resting - try to raise them above heart level for 15-30 minutes a day.
Avoid standing or sitting for long periods. If you must, take short walks or flex your feet regularly.
Maintain a healthy weight. Extra weight increases pressure in leg veins.
Wear compression stockings if your doctor recommends them.
Avoid tight clothing around the waist or thighs that restricts blood flow.

A Note on Realistic Expectations

Most treatments are very effective at relieving symptoms and improving the look of your legs. However, varicose veins can come back over time - this is not a sign the treatment failed. It reflects the underlying tendency of your vein walls to weaken. Follow-up appointments and ongoing compression use help manage this long-term.

This handout is for general information only. It does not replace advice from your doctor or vascular specialist. Always discuss your individual situation with your healthcare team before making any treatment decision.

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