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Varicose Veins - Complete Clinical Guide

What Are Varicose Veins?

Varicose veins are dilated, tortuous, elongated subcutaneous veins, most commonly affecting the lower limbs. They result from valvular incompetence, which causes retrograde blood flow (reflux), leading to elevated venous pressure that progressively dilates the vein wall and renders distal valves incompetent in a cascading fashion.

Adult prevalence: 30-50% of the population
More common in women, elderly, and those with obesity, pregnancy, tall stature, or family history
The Great Saphenous Vein (GSV) is affected in ~60% of cases, and the Small Saphenous Vein (SSV) in ~20%

(Bailey and Love's Short Practice of Surgery, 28th Ed.)

Classification

Type	Description
Primary	Intrinsic venous wall weakness, valvular defect without underlying deep vein disease
Secondary	Caused by deep vein thrombosis (DVT), obstruction, or deep venous insufficiency
Uncomplicated	Asymptomatic or symptomatic only, no skin changes
Complicated	Skin changes, lipodermatosclerosis, ulceration, thrombophlebitis, or bleeding

Symptoms

Patients typically describe:

Aching, heaviness, throbbing, burning or bursting over affected areas
Symptoms worsen throughout the day and with prolonged standing or sitting
Symptoms relieved by leg elevation or compression hosiery
Itching, ankle swelling, early fatigue of the leg
More severe: hyperpigmentation, lipodermatosclerosis, venous ulceration, superficial thrombophlebitis, bleeding from attenuated vein clusters

(Schwartz's Principles of Surgery, 11th Ed.; Bailey and Love, 28th Ed.)

Clinical Signs

Here is what varicose veins look like on examination - the tortuous dilated veins are pre-marked for intervention:

Recurrent varicose veins secondary to an incompetent thigh perforator

Varicose veins of the thigh and calf, marked for surgical planning - Bailey and Love's Surgery, 28th Ed.

Clinical examination findings:

Visible tortuous, dilated subcutaneous veins
Medial thigh/calf varices: suggest GSV incompetence at the saphenofemoral junction (SFJ)
Posterolateral calf varices: suggest SSV incompetence at the saphenopopliteal junction (SPJ)
Anterolateral thigh/calf varices: may indicate anterior accessory GSV (AAGSV) incompetence
Saphena varix: a painless lump at the groin (dilated SFJ), disappears when recumbent, and has a cough impulse - can be mistaken for an inguinal hernia

Diagnosis

Clinical Assessment

The history and physical examination remain the starting point. A trial of compression hosiery can help confirm symptoms are venous in origin if they improve.

Investigation: Duplex Ultrasound (Gold Standard)

"Tourniquet tests and the use of hand-held Doppler have now been abandoned. There is good evidence to support the policy of duplex ultrasound scanning for all patients with varicose veins prior to any intervention."

Bailey and Love's Short Practice of Surgery, 28th Ed.

Why duplex ultrasound?

Combines B-mode imaging with colour/spectral Doppler
Transducer: 7.5-13 MHz linear array
Patient is examined standing (to open the valves and demonstrate reflux)

What the scan establishes:

Presence of reflux in the deep and superficial venous systems
Exact distribution of reflux - which junctions (SFJ, SPJ) and perforators are incompetent
Presence of deep vein obstruction (e.g., from prior DVT)
Suitability of incompetent veins for different treatments (diameter, tortuosity, varix)
Presence of thrombus in superficial veins
Possible pelvic source of reflux

Diagnostic thresholds for reflux:

Superficial/crural veins: retrograde flow lasting ≥ 0.5 seconds
Proximal deep veins: retrograde flow lasting ≥ 1.0 second
Reflux is elicited by Valsalva, calf squeeze release, or pneumatic cuff deflation

Other Investigations (selected cases)

Investigation	Indication
CT/MR venography	Suspected pelvic vein reflux or obstruction, May-Thurner syndrome
Venous plethysmography	Functional assessment of venous return (rarely needed)
ABPI (Ankle-Brachial Pressure Index)	Before prescribing compression, to exclude arterial disease (must be >0.8)
Coagulation screen / thrombophilia testing	Recurrent thrombophlebitis or DVT

Treatment

Treatment is indicated when:

Symptoms worsen or are unrelieved by compression therapy
Complications develop: lipodermatosclerosis, venous ulcer, recurrent thrombophlebitis, bleeding

1. Conservative Management

Compression stockings: 20-30 mmHg or 30-40 mmHg, knee-high to waist-high; should cover symptomatic varices. Provides adequate symptom relief in many patients.
Lifestyle measures: weight loss, regular walking, avoid prolonged standing, leg elevation when resting
Venotonics: (e.g., micronised purified flavonoid fraction, horse chestnut seed extract) - limited evidence, used as adjunct in some countries

2. Endovenous Thermal Ablation (First-line interventional)

Modern first-line treatments - performed under local tumescent anaesthesia as a day-case procedure.

Technique	Mechanism	Notes
Endovenous Laser Ablation (EVLA/EVLT)	Laser energy heats and destroys vein wall	Equally effective to surgery; faster recovery
Radiofrequency Ablation (RFA)	Radiofrequency heat causes vein wall fibrosis	Slightly less post-procedure bruising vs. laser

Procedure: GSV or SSV punctured under ultrasound guidance with a 21-gauge needle, sheath placed over a guidewire, laser fibre or RFA catheter advanced to just below the SFJ, tumescent anaesthetic infiltrated around the vein, then the catheter is withdrawn while delivering energy.

A 2024 meta-analysis (PMID: 38316290) comparing RFA vs. laser ablation found comparable efficacy for varicose vein treatment, with some differences in post-procedural pain and recurrence.

Risks: DVT, ecchymosis, saphenous nerve injury (particularly with SSV treatment)

3. Sclerotherapy

Destroys the venous endothelium by injection of a sclerosant agent.

Agent	Concentration (telangiectasias)	Concentration (larger varices)
Hypertonic saline	11.7-18.7%	23.4%
Sodium tetradecyl sulfate (Sotradecol)	0.125-0.25%	0.5-1%
Polidocanol	0.25-0.5%	0.75-1.0%

After injection: elastic bandages worn continuously for 3-5 days, then compression stockings for a minimum of 2 weeks.

Foam sclerotherapy (sclerosant mixed with air/CO2 to create foam) is used for larger veins and under ultrasound guidance (UGFS - Ultrasound-Guided Foam Sclerotherapy) - suitable when thermal ablation is not appropriate.

Complications: allergic reaction, local hyperpigmentation, thrombophlebitis, DVT, skin necrosis.

4. Mechanochemical Ablation (MOCA)

Newer non-thermal technique combining mechanical endoluminal injury (rotating wire catheter) with simultaneous sclerosant injection (e.g., ClariVein device). Avoids tumescent anaesthesia and risk of nerve thermal injury.

5. Cyanoacrylate Adhesive Closure

Non-thermal, non-sclerosant technique: medical-grade glue (cyanoacrylate) is injected to seal the vein lumen. Good early results reported; no tumescent anaesthesia required.

6. Surgical Treatment

Reserved for patients unsuitable for endovenous techniques, recurrent disease, or very large diameter GSV (>2 cm).

High tie and stripping (Trendelenburg + Babcock): Ligation at the SFJ (groin) + stripping of GSV to just below the knee via a medial groin incision and a distal incision. Lower recurrence rate than SFJ ligation alone.
Stab avulsions (phlebectomy): 2-mm incisions made directly over branch varicosities; the vein is dissected and avulsed through the small incision. Minimal scarring, effective for large tributaries.
CHIVA (Conservative and Hemodynamic treatment of Insufficiency in Outpatients): Haemodynamics-based approach; a 2026 meta-analysis (PMID: 41707860) found comparable efficacy to conventional stripping/ablation techniques.

Complications of Varicose Veins

Complication	Details
Superficial thrombophlebitis	Painful, hard, inflamed cord along the vein; treat with NSAIDs and compression
Bleeding	Acute rupture of a varix (especially at the ankle), can be life-threatening if not controlled by elevation + compression
Venous eczema	Itchy, eczematous skin over the varices
Hyperpigmentation	Haemosiderin deposition from red cell extravasation
Lipodermatosclerosis	Fibrosis and induration of the skin and subcutaneous tissue - precedes ulceration
Venous leg ulcer	End-stage; venous disease accounts for ~85% of all chronic lower limb ulcers

Summary: Investigation & Treatment Pathway

Clinical presentation (symptoms + signs)
          ↓
ABPI to exclude arterial disease
          ↓
Duplex ultrasound (MANDATORY before any intervention)
          ↓
    ┌─────────────────────┐
    │  Incompetent GSV/SSV │
    └─────────────────────┘
          ↓
    Mild symptoms → Compression stockings + lifestyle
          ↓
    Worsening/complications → Interventional:
    • Endovenous thermal ablation (EVLA or RFA) - 1st line
    • Foam sclerotherapy (UGFS) - if unsuitable for thermal
    • MOCA / Cyanoacrylate - non-thermal alternatives
    • Surgery (stripping + stab avulsion) - large veins / recurrence

Sources:

Bailey and Love's Short Practice of Surgery, 28th Ed. (Chapter 62)
Schwartz's Principles of Surgery, 11th Ed. (Chapter 24)
Pfenninger and Fowler's Procedures for Primary Care, 3rd Ed. (Chapter 92)
PMID 38316290 - RFA vs. Laser Ablation meta-analysis (2024)
PMID 41707860 - CHIVA vs. conventional techniques meta-analysis (2026)

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