Short note on varicose veins with definition, epidemiology, symptoms, signs, investigation and treatment
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"varicose veins"[MeSH Terms] AND treatment
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Varicose Veins
Clinical photograph demonstrating varicose veins - Gray's Anatomy for Students
Definition
Varicose veins are dilated, bulging, tortuous superficial veins measuring at least 3 mm in diameter, typically occurring in the lower limbs. They are distinct from:
- Reticular veins: dilated intradermal veins, 1-3 mm diameter, blue-green, do not protrude from the skin surface
- Telangiectasias (spider veins): <1 mm diameter, near the skin surface, forming blue/purple/red linear or web patterns
Varicose veins are classified as:
- Primary: originate in the superficial system; result from defective valve structure and function in the saphenous veins, intrinsic wall weakness, or high intraluminal pressure
- Secondary: result from venous hypertension due to deep-venous insufficiency, deep-venous obstruction, incompetent perforating veins, or arteriovenous fistulas
(Harrison's Principles of Internal Medicine 22E, p.2223; Bailey and Love's 28th Ed.)
Epidemiology
- Adult prevalence of visible varicose veins: 30-50% (Bailey and Love's 28th Ed.)
- At least 10% of the general population is affected (Schwartz's 11th Ed.)
Risk factors:
| Factor | Detail |
|---|---|
| Gender | Higher prevalence in women in most studies |
| Age | Prevalence rises sharply with age; Edinburgh Vein Study: 11.5% (18-24 yrs) rising to 55.7% (55-64 yrs) |
| Pregnancy | Increases risk due to hormonal changes and elevated intra-abdominal pressure |
| Family history | ~50% have a family history; genetic susceptibility is well-documented |
| Obesity/BMI | Increasing BMI associated with higher prevalence |
| Prolonged standing | Inconclusive but commonly cited occupational factor |
| Ethnicity | Influences prevalence; Western populations more affected |
| Hormonal therapy | Exogenous estrogens associated with increased risk |
Symptoms
Symptoms may be absent (asymptomatic) or significant. Typical complaints include:
- Aching, heaviness, throbbing, burning, or bursting sensation over affected areas or the whole limb
- Pruritus (itching) - more frequent in the presence of complications
- Ankle swelling (edema) - mild in early disease
- Early fatigue of the affected leg
- Cosmetic concern - unsightly dilated veins
Key feature: Symptoms typically worsen throughout the day or with prolonged standing and improve with leg elevation or compression hosiery. Symptoms are independent of the degree of venous incompetence and can significantly impair health-related quality of life.
Telangiectasias and reticular veins without significant reflux rarely cause physical symptoms but patients often seek cosmetic treatment.
(Bailey and Love's 28th Ed., p.1052; Schwartz's 11th Ed.)
Signs
On examination (standing position):
- Tortuous, dilated subcutaneous veins - usually clinically obvious
- Distribution helps identify the affected system:
- Medial thigh and calf varicosities → Great Saphenous Vein (GSV) incompetence (~60% of cases)
- Posterolateral calf varicosities → Small Saphenous Vein (SSV) incompetence (~20% of cases)
- Anterolateral thigh and calf → Anterior accessory GSV (AAGSV) incompetence
- Saphena varix: large dilated vein at the saphenofemoral junction (SFJ) presenting as a lump in the groin - disappears when recumbent, may transmit a cough impulse (can mimic a groin hernia)
- Pitting edema - may extend from ankle to knee or thigh in severe disease
- Signs of chronic venous insufficiency (CVI):
- Stasis dermatitis / eczema (corona phlebectatica)
- Hyperpigmentation (hemosiderin deposition)
- Lipodermatosclerosis: induration + hemosiderin deposition + inflammation, just above the ankle
- Atrophie blanche: white scar patches with focal telangiectasias, near medial malleolus
- Phlebectasia corona: fan-shaped intradermal veins near the ankle
- Venous ulceration: shallow, irregular border, medial/lateral malleolus
Bedside clinical tests (now largely replaced by duplex ultrasound):
- Brodie-Trendelenburg test: leg elevated to empty veins, tourniquet placed on proximal thigh, patient stands - rapid filling after tourniquet release = superficial venous insufficiency (primary); filling before release = deep-venous incompetence (secondary)
- Perthes test: tourniquet on midthigh while standing, patient walks 5 min - collapse of superficial veins = patent deep system; distension = deep venous obstruction
(Bailey and Love's 28th Ed.; Harrison's 22E, p.2224)
Investigations
Duplex Ultrasound Scanning (gold standard)
Tourniquet tests and hand-held Doppler have now been abandoned. Duplex ultrasound is recommended for all patients prior to any intervention. It should be performed with the patient standing, using a 7.5-13 MHz high-frequency linear array transducer.
Duplex scanning establishes:
- Presence of reflux in deep and superficial venous systems
- Exact distribution and extent of reflux in the superficial system (affected junctions, perforators)
- Presence of obstruction in the deep venous system
- Suitability of incompetent veins for various treatment options (based on diameter, tortuosity, presence of saphena varix)
- Presence of thrombus within superficial veins
- Indication of a pelvic source of reflux
Reflux definitions on duplex:
- Superficial/crural vein reflux: retrograde flow lasting ≥0.5 seconds
- Proximal deep vein reflux: retrograde flow lasting ≥1 second
The "Mickey Mouse sign" on transverse view shows the GSV and CFV lying medial to the common femoral artery.
Other investigations (occasionally required):
- MR venography (non-invasive) - for pelvic or iliac vein assessment
- Contrast venography / IVUS - invasive, reserved for complex cases
- Varicography is now historical
(Bailey and Love's 28th Ed., p.1053-1054)
Treatment / Management
1. Conservative Management
Compression hosiery - the cornerstone of conservative treatment:
- Graduated external compression (20-30, 30-40, or 40-50 mmHg)
- Stockings range from knee-high to waist-high
- Provides sufficient symptomatic relief in many patients
- First-line trial before interventional management
Other conservative measures: weight loss, leg elevation, regular exercise, avoiding prolonged standing.
2. Sclerotherapy
- Destroys the venous endothelium to obliterate the vein
- Sclerosants used:
- Hypertonic saline (11.7-23.4%)
- Sodium tetradecyl sulfate (STS) (0.125-1%)
- Polidocanol (0.5-1.0%)
- Foam sclerotherapy: ultrasound-guided foam injection - randomized trials show significant symptom relief and improved cosmetic appearance
- Elastic bandaging after injection worn for 3-5 days (to appose inflamed walls), then compression stockings for ≥2 weeks
- Complications: allergic reaction, hyperpigmentation, thrombophlebitis, DVT, skin necrosis
3. Endovenous Thermal Ablation
Catheter-based minimally invasive techniques, performed under tumescent local anaesthesia under ultrasound guidance. Both have similar outcomes and have largely replaced open surgery.
a) Endovenous Laser Ablation (EVLA):
- A laser fibre is introduced via catheter; energy delivery of ~60-80 J/cm causes thermal occlusion
- Compression applied post-procedure
b) Radiofrequency Ablation (RFA):
- Electromagnetic current heats the vein wall to 120°C in 20-second treatment cycles
- Most popular device: ClosureFast™ (Medtronic)
- Multiple RCTs show EVLA and RFA have comparable efficacy and safety; recent meta-analysis (Jiang et al., 2024) confirmed this
4. Non-Thermal, Non-Sclerosant Ablation (Newer Techniques)
- Mechanochemical ablation (MOCA): combines catheter-based mechanical endoluminal injury with liquid sclerosant - no tumescent anaesthesia required
- Cyanoacrylate adhesive (VenaSeal): proprietary glue injected under ultrasound guidance - promising early results, avoids heat and sclerosants
5. Surgical Treatment
- High ligation and stripping (Trendelenburg operation): ligation of the SFJ or SPJ + stripping of the GSV or SSV - now less commonly performed, reserved for cases not amenable to endovenous techniques
- Phlebectomy (avulsions): removal of tributary varicosities through small stab incisions; often performed alongside thermal ablation as a combined procedure
Indications for intervention (beyond conservative therapy):
- Symptoms not relieved by compression
- Lipodermatosclerosis
- Venous ulceration
- Bleeding from varicosities
- Superficial vein thrombosis (thrombophlebitis)
(Bailey and Love's 28th Ed., p.1054-1055; Schwartz's Principles of Surgery 11th Ed.; Harrison's 22E)
Complications
| Acute | Chronic |
|---|---|
| Superficial vein thrombosis (thrombophlebitis) | Lipodermatosclerosis |
| Haemorrhage (spontaneous or traumatic) | Venous eczema/stasis dermatitis |
| Venous ulceration | |
| Hyperpigmentation | |
| Atrophie blanche |
Recent evidence note: A 2024 meta-analysis (PMID 38316290) comparing endovenous RFA vs. EVLA confirmed comparable efficacy, safety, and quality-of-life outcomes - supporting either technique as first-line interventional treatment for GSV/SSV reflux over open surgery.
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