Varicose Veins

Definition

Epidemiology

• Adult prevalence of visible varicose veins: 30-50% (Bailey & Love) / ~15% in men and ~30% in women in the US (Harrison's)
• Prevalence increases sharply with age - the Edinburgh Vein Study showed prevalence rising from 11.5% (age 18-24) to 55.7% (age 55-64)
• Risk factors:
  • Female sex - higher prevalence in women across most studies
  • Age - progressive increase with aging
  • Pregnancy - significantly increases risk
  • Family history - strong familial susceptibility; ~50% of primary cases have a positive family history
  • Obesity and increased height - BMI and height correlate with prevalence
  • Prolonged standing - inconclusive but commonly cited
  • Ethnicity - influences prevalence
• Bailey and Love's Short Practice of Surgery 28th Ed., p. 1052

Anatomy Relevant to Varicose Veins

• Great saphenous vein (GSV) - originates on the medial foot, ascends anterior to the medial malleolus, runs along the medial calf and thigh, drains into the common femoral vein at the saphenofemoral junction (SFJ)
• Small saphenous vein (SSV) - originates on the dorsolateral foot, ascends posterior to the lateral malleolus, drains into the popliteal vein
• Perforating veins - connect superficial to deep systems; normally direct flow superficial → deep

• Medial thigh/calf → GSV incompetence
• Posterolateral calf → SSV incompetence
• Anterolateral thigh/calf → Anterior accessory GSV (AAGSV) incompetence
• Harrison's Principles of Internal Medicine 22E; Bailey and Love 28th Ed.

Classification

Primary vs. Secondary

CEAP Classification (Clinical, Etiologic, Anatomic, Pathophysiologic)

• Harrison's Principles of Internal Medicine 22E, Table 293-1; Bailey and Love 28th Ed.

Pathophysiology

1. Valve incompetence - Normally, one-way venous valves prevent reflux. When valve leaflets fail (primary degeneration or post-thrombotic damage), blood refluxes downward under gravity, raising hydrostatic pressure in the superficial system.
2. Venous wall weakness - Intrinsic structural defects in smooth muscle and connective tissue of the vein wall allow progressive dilatation.
3. Chronic venous hypertension - Sustained high pressure leads to extravasation of fluid and blood elements (including hemosiderin, fibrin cuffs) into surrounding tissue, causing the chronic skin changes of venous insufficiency.
4. Calf muscle pump failure - Normal venous return relies on the calf muscle pump; dysfunction worsens venous hypertension.

• Harrison's Principles of Internal Medicine 22E, p. 2224-2225

Clinical Features

Symptoms

• Aching, heaviness, throbbing, burning or "bursting" sensation in the affected leg
• Symptoms worsen with prolonged standing and improve with elevation or compression hosiery
• Pruritus (itching) - especially with complications
• Ankle swelling - more common with complications
• Symptoms can severely impact daily activities and quality of life, independent of the degree of incompetence

Signs

• Tortuous, dilated, bulging subcutaneous veins (clinically obvious in standing position)
• Saphena varix - a large, dilated vein at the SFJ presenting as a painless groin lump that disappears on lying down; may be confused with a femoral hernia; may show a cough impulse
• Skin changes in advanced disease: hyperpigmentation, stasis dermatitis (eczema), lipodermatosclerosis, atrophie blanche
• Venous ulcer - typically in the gaiter area (medial/lateral malleolus)

Acute Complications

• Superficial vein thrombosis (thrombophlebitis) - painful, tender, inflamed cord along a varicosity
• Bleeding - rupture of an attenuated vein cluster, can be significant

Chronic Complications

• Lipodermatosclerosis, hyperpigmentation, eczema, venous ulceration (~20% of chronic venous insufficiency patients)
• Bailey and Love's Short Practice of Surgery 28th Ed., pp. 1052-1053; Schwartz's Principles of Surgery 11th Ed.

Investigations

Duplex Ultrasound Scanning (Gold Standard)

• Presence and distribution of reflux in deep and superficial systems
• Exact extent of reflux, including affected junctions and perforators
• Presence of deep-venous obstruction
• Suitability of veins for the different treatment modalities (diameter, tortuosity, depth)

Other Investigations (rarely needed)

• CT venography / MR venography / conventional venography - reserved for suspected proximal obstruction, May-Thurner syndrome, or IVC filter occlusion
• Plethysmography - can quantify severity of reflux and calf pump function
• Bailey and Love's Short Practice of Surgery 28th Ed., pp. 1053-1054; Harrison's 22E, p. 2225

Treatment

1. Conservative (Supportive) Measures

• Leg elevation - periodic elevation reduces symptoms
• Avoid prolonged standing/sitting
• Compression hosiery - graduated compression stockings:
  • 20-30 mmHg for simple varicose veins (CEAP C2)
  • 30-40 mmHg for CVI with edema/ulcers (CEAP C3-C6)
  • British classification: Class 1 (14-17 mmHg), Class 2 (18-24 mmHg), Class 3 (25-35 mmHg)
  • Improves symptoms but does not prevent progression; compliance is poor
  • Level 1 evidence shows interventional treatment offers superior quality of life improvement
• Weight loss in overweight/obese patients
• Exercise - leg strengthening improves calf pump function

2. Endothermal Ablation (First-line Interventional Treatment)

Endovenous Laser Ablation (EVLA)

• A flexible glass fibre is inserted; laser energy (~1470 nm wavelength) generates thermal energy at the tip
• Energy delivery ~60-80 J/cm used to achieve durable closure
• Efficacy: >95% closure rate

Radiofrequency Ablation (RFA)

• ClosureFast™ device (Medtronic) is most widely used
• Electromagnetic current heats a wire coil to 120°C for 20-second cycles
• Automatic treatment cycle reduces operator-dependent error
• Efficacy: >95% closure rate
• Recent meta-analysis (Jiang et al., 2024, PMID 38316290) found both RFA and EVLA are effective with no significant difference in outcomes; choice is often personal preference

3. Foam Sclerotherapy

• Sclerosing agents include hypertonic saline, sodium tetradecyl sulfate (STS), and polidocanol
• Mechanism: destroys venous endothelium, causing inflammatory occlusion
• Used for telangiectasias, reticular veins, and larger varicose veins (higher concentrations for larger veins)
• Can be used alone or adjunctively after thermal ablation for tributaries
• After injection, elastic bandages are worn continuously for 3-5 days, then compression stockings for ≥2 weeks
• Complications: allergic reaction, local hyperpigmentation, matting, superficial thrombophlebitis, and rarely, skin necrosis or DVT
• A multicenter RCT confirmed significant symptom relief vs. placebo

4. Surgery

• Saphenofemoral/saphenopopliteal junction ligation (high tie)
• Stripping of the GSV or SSV
• Multiple avulsion phlebectomy (stab avulsion) of visible tributaries

5. NICE/Guideline Recommendations

• Bailey and Love's Short Practice of Surgery 28th Ed., pp. 1054-1057; Harrison's Principles of Internal Medicine 22E, pp. 2225-2226; Schwartz's Principles of Surgery 11th Ed.

Complications of Varicose Vein Surgery/Procedures

• Bruising and haematoma
• Wound infection
• DVT and pulmonary embolism (rare)
• Nerve injury - saphenous nerve (medial calf paraesthesia with GSV surgery), sural nerve (lateral calf/foot with SSV surgery)
• Lymphatic injury - lymphocele, lymphoedema
• Recurrence - neovascularisation at the junction is a common cause
• Skin burns - with thermal ablation if tumescent anaesthesia is inadequate
• Bailey and Love's Short Practice of Surgery 28th Ed., p. 1057

Summary Table