Vericose vein

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"varicose veins"[MeSH Terms] AND treatment

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Varicose Veins

Clinical photograph demonstrating varicose veins of the lower limb - Gray's Anatomy for Students

Definition

Varicose veins are dilated, bulging, tortuous superficial veins measuring at least 3 mm in diameter. They must be distinguished from:

Reticular veins - dilated intradermal veins, 1-3 mm, appearing blue-green, do NOT protrude from the skin surface
Telangiectasias (spider veins) - <1 mm diameter, near skin surface, forming blue/purple/red linear or spider-web patterns
Harrison's Principles of Internal Medicine 22E, p.2223

Epidemiology

Adult prevalence: 30-50% for visible varicose veins
Gender: Higher prevalence in women (most studies)
Age: Prevalence rises sharply with age - from ~11.5% (age 18-24) to ~55.7% (age 55-64) in the Edinburgh Vein Study
Risk factors: Pregnancy, family history, increasing BMI, tall stature, advancing age, ethnicity
Bailey & Love's Short Practice of Surgery 28th Ed, p.1052

Classification

Primary vs. Secondary

Type	Cause
Primary	Intrinsic defect of saphenous vein valves, weak vein wall, high intraluminal pressure; ~50% have family history
Secondary	Venous hypertension from deep-venous insufficiency, DVT post-thrombotic syndrome, incompetent perforating veins, arteriovenous fistulas

CEAP Classification (Clinical, Etiologic, Anatomic, Pathophysiologic)

Grade	Description
C0	No visible/palpable signs
C1	Telangiectasias or reticular veins
C2	Varicose veins
C2r	Recurrent varicose veins
C3	Edema
C4a	Pigmentation or eczema
C4b	Lipodermatosclerosis or atrophie blanche
C4c	Corona phlebectatica
C5	Healed venous ulcer
C6	Active venous ulcer
C6r	Recurrent active venous ulcer

Harrison's Principles of Internal Medicine 22E, Table 293-1

Anatomy Relevant to Varicose Veins

The great saphenous vein (GSV) - the longest vein in the body - runs from the medial foot, anterior to the medial malleolus, along the medial calf and thigh, draining into the common femoral vein. The small saphenous vein (SSV) runs from the dorsolateral foot, posterior to the lateral malleolus, along the posterolateral calf, draining into the popliteal vein.

GSV incompetence: ~60% of cases - medial thigh and calf varicosities
SSV incompetence: ~20% of cases - posterolateral calf varicosities
Anterolateral thigh/calf: suggests non-saphenous or tributary source

Symptoms

Aching, heaviness, throbbing, burning, "bursting" sensation
Pruritus (itching)
Ankle swelling
Symptoms worsen with prolonged standing/sitting and throughout the day
Symptoms relieved by leg elevation or compression hosiery
Symptoms are independent of the degree of reflux or visible size of varices
Significant quality-of-life deficit documented in studies
Bailey & Love's 28th Ed, p.1052; Schwartz's Principles of Surgery 11th Ed

Complications

Complication	Notes
Superficial thrombophlebitis	Painful, cord-like inflammation
Bleeding	From attenuated vein clusters; can be dramatic
Chronic venous insufficiency	Venous hypertension, extravasation of fluid/blood
Lipodermatosclerosis	Fibrotic, woody induration of subcutaneous tissue
Hyperpigmentation	Hemosiderin deposition
Venous eczema	Stasis dermatitis
Venous ulceration	Typically above medial malleolus (gaiter area)

Clinical Examination & Special Tests

Brodie-Trendelenburg Test - Distinguishes primary (superficial insufficiency) from secondary (deep venous insufficiency) varicose veins:

Elevate leg supine, empty veins
Apply tourniquet to proximal thigh, ask patient to stand
Rapid filling within 30s = deep venous insufficiency + incompetent perforators (secondary)
Filling only after tourniquet removal = primary superficial incompetence

Perthes Test - Assesses deep venous obstruction:

Tourniquet on mid-thigh while standing
Patient walks 5 minutes
Collapse of superficial veins = patent deep system
Further distension = deep venous obstruction

Harrison's 22E, p.2224

Investigations

Duplex Ultrasound (gold standard):

Combines B-mode imaging + spectral Doppler
Detects venous obstruction AND venous reflux in superficial + deep veins
Reflux: reversal of flow >0.5 sec during Valsalva or distal compression/release
Patient stands facing examiner, leg externally rotated
Groin scan: identifies "Mickey Mouse" sign - GSV medial to common femoral artery at saphenofemoral junction (SFJ)
"Saphenous eye" view - transverse cross-section of GSV in fascial compartment

MR/CT/Conventional Venography - reserved for suspected IVC/iliofemoral pathology (post-DVT, May-Thurner syndrome, extrinsic tumour compression)

Treatment

Conservative Measures

Leg elevation, avoid prolonged standing
Graduated elastic compression stockings (20-30, 30-40, or 40-50 mmHg)
Trial of compression hosiery to confirm venous origin of symptoms

Interventional Indications

Symptoms unrelieved despite compression
Lipodermatosclerosis
Venous ulcer

1. Sclerotherapy

Liquid sclerotherapy: for telangiectasias and small varicosities
Foam sclerotherapy: for larger veins; a multicenter RCT showed significant symptom relief vs placebo
Sclerosants: hypertonic saline (11.7-23.4%), sodium tetradecyl sulfate (0.125-1%), polidocanol (0.5-1.0%)
Mechanism: destroys venous endothelium
Compression bandages applied for 3-5 days post-injection, then elastic stockings for ≥2 weeks
Complications: local hyperpigmentation, allergic reaction, superficial thrombophlebitis, DVT, skin necrosis

2. Endovenous Laser Ablation (EVLA)

Laser fibre inserted into vein, wavelength typically 1470 nm
Thermal energy generated ablates the vein wall
Tumescent perivenous anaesthesia is administered first
Better for very large veins (>15 mm diameter)
Less expensive consumables

3. Radiofrequency Ablation (RFA)

Catheter-based (e.g., ClosureFast™); automated treatment cycle
Simpler to use, single-button press; shorter learning curve
Marginally less post-procedural pain and bruising than EVLA
Both EVLA and RFA: equally effective, faster recovery than open surgical stripping

4. Phlebectomy (Ambulatory/Hook Phlebectomy)

Surgical avulsion of varicosities through small stab incisions
Can be performed concomitantly with endothermal ablation or as a staged procedure
Done under tumescent anaesthesia

5. Surgical Stripping (Historical Gold Standard)

High tie and stripping of GSV/SSV
Now largely replaced by endovenous techniques due to equivalent efficacy but slower recovery

6. Nonthermal, Nonsclerosant Techniques (Newer)

Mechanical endovenous ablation (MOCA) combining catheter injury + sclerosant
Cyanoacrylate glue - proprietary adhesive formulations showing promising early results
Schwartz's Principles of Surgery 11th Ed, p. (block 11); Bailey & Love 28th Ed; Harrison's 22E, p.2224-2225

Recent Evidence

A 2024 meta-analysis (PMID: 38316290) comparing endovenous radiofrequency ablation vs laser ablation found both techniques to have equivalent efficacy for lower extremity varicose veins, supporting current practice of choosing between them based on operator experience and vein characteristics.

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