Varicose Veins

Definition

Pathophysiology

1. A pressure gradient between leg veins and the thorax
2. A patent, compliant venous system with competent valves
3. The calf muscle pump - during muscle contraction, intramuscular pressure rises to 200-300 mmHg, compressing deep veins and driving blood toward the heart

• Progressive vein wall damage, thickening, dilatation, loss of compliance
• Valvular dysfunction - worsening the hypertension in a vicious cycle
• Chronic soft-tissue damage: oedema, pigmentation, lipodermatosclerosis, ulceration

Causes of venous hypertension

Aetiology & Risk Factors

• Primary (idiopathic): Intrinsic weakness of the vein wall / valve leaflets - the most common type. Upright posture in humans is thought to be a predisposing evolutionary factor.
• Secondary: DVT with post-thrombotic valve damage; obstruction by pelvic masses (fibroid, ovarian cyst, lymphadenopathy, pregnant uterus), ascites, retroperitoneal fibrosis.
• Congenital: AV fistula, venous dysplasia (Klippel-Trenaunay syndrome).
• Hormonal: Progesterone relaxes vascular smooth muscle - explains higher prevalence in women (ratio ~10:1 female:male in some series) and worsening during pregnancy.
• Occupational: Prolonged standing (traffic police, conductors, surgeons).
• Family history is a strong independent risk factor.

Clinical Features

Symptoms

• Aching, heaviness, or throbbing in the leg - worst after prolonged standing, relieved by elevation
• Ankle swelling - particularly toward end of day
• Pruritus over the varicosities
• Night cramps
• Cosmetic concern - the most common presenting complaint in uncomplicated cases

Important: symptoms do not correlate well with the size of varicosities. Patients may have severe symptoms with minimal visible veins and vice versa.

Signs

• Dilated, tortuous, visible subcutaneous veins - typically along the medial thigh and calf in GSV distribution, posterior calf in SSV distribution
• Ankle oedema (pitting)
• Skin changes of chronic venous insufficiency (see CEAP classification below)

CEAP Classification

Clinical Examination & Special Tests

Inspection (standing patient)

• Note distribution - GSV (medial aspect, from groin to ankle) vs SSV (posterior calf, popliteal fossa)
• Skin changes: pigmentation (haemosiderosis), eczema, lipodermatosclerosis, atrophie blanche, ulceration (typically over the medial malleolus)

Fig. Haemosiderosis and mild eczema - early skin changes of chronic venous disease (Bailey & Love)

Key Clinical Tests

• Elevate leg to empty veins; compress the saphenofemoral junction (SFJ) with thumb/tourniquet
• Ask patient to stand
• Positive (Type I): veins remain empty on standing while SFJ is compressed, then fill rapidly when pressure released → SFJ incompetence
• Positive (Type II): veins fill from below even with SFJ compressed → incompetent perforators below compression point

• A variant of Trendelenburg; tourniquet applied at different levels of the limb to localise the incompetent perforator
• Veins filling above the tourniquet = incompetent communicating vein above; filling below = below

• Elastic bandage applied to the limb; patient walks
• Crampy pain on walking = deep vein thrombosis or obstruction (deep venous compromise)
• Modified Perthes': tourniquet at upper thigh + patient walks; if superficial varicosities empty = deep veins are patent and perforators competent; if veins enlarge and pain occurs = deep veins obstructed

• Tap a prominent varicosity; an impulse is felt by a finger placed higher up the vein (or at the SFJ) = valves absent/incompetent between the two fingers
• Percussion wave that transmits downward implies incompetent valves in that segment

• Standing patient: mark sites of maximal bulge on skin
• Patient lies flat; elevate leg to empty veins
• Palpate along varicosities and feel for fascial defects (gaps/pits) - these mark sites of incompetent perforators

• Leg elevated then lowered; patient coughs forcefully
• Expansile impulse at the saphenous opening = SFJ incompetence

Investigations

• Duplex ultrasound - gold standard for pre-operative mapping; identifies reflux at SFJ/SPJ and perforators, confirms deep vein patency. Performed standing with a Valsalva or calf-squeeze manoeuvre.
• Hand-held Doppler - office screening tool; detects reflux signal at SFJ/SPJ
• Venography / CT venography - rarely needed; reserved for complex recurrence or suspected venous obstruction

Complications

Fig. Venous ulcer - the most severe chronic complication (Bailey & Love)

Treatment

Conservative

• Compression stockings (Class II: 23-32 mmHg): reduces venous hypertension, improves symptoms; first-line for those unfit/unwilling for intervention; must exclude significant arterial disease first (ABPI >0.8)
• Leg elevation, regular exercise to improve calf pump
• Weight loss, avoid prolonged standing

Interventional (in order of modern preference)

• Endovenous Laser Ablation (EVLA) and Radiofrequency Ablation (RFA) - catheter placed under ultrasound guidance into the GSV/SSV; thermal energy delivered along catheter withdrawal under tumescent local anaesthesia. Causes endothelial destruction and fibrosis.
• Both techniques have comparable efficacy; a 2024 meta-analysis (PMID: 38316290) found RFA associated with lower post-procedural pain and bruising compared to EVLA, with similar occlusion rates.
• Minimally invasive; most patients treated as day-case

• Chemical sclerosant (sodium tetradecyl sulphate or polidocanol) injected as foam under ultrasound guidance; destroys endothelium causing fibrosis
• Good for incompetent perforators, recurrent disease, and smaller veins
• Can be combined with endothermal ablation for tributaries
• A 2025 network meta-analysis (PMID: 37649310) supports foam sclerotherapy as effective monotherapy for truncal varicosities

• Rotating wire mechanically damages endothelium; liquid sclerosant injected simultaneously
• No tumescent anaesthesia required; useful for needle-phobic patients
• Similar early efficacy to endothermal ablation but higher medium-term recanalisation rates

• Cyanoacrylate adhesive injected via catheter to seal the vein lumen
• Minimal pain; no tumescent anaesthesia needed
• High consumable cost; long-term data still accumulating

• Flush ligation at SFJ + stripping of GSV from groin to knee + multiple avulsion phlebectomy (stab avulsions) of tributaries
• Now largely superseded by endovenous techniques except in complex/recurrent cases or where endovenous access is not feasible
• Still requires trained vascular surgeons; performed under general or locoregional anaesthesia

• Multiple small stab incisions to remove tributary varicosities
• Used as an adjunct to truncal ablation

Recent Evidence (2024-2026)

Summary Table

Treatment of Varicose Veins

Overview: Treatment Goals

1. Relieve symptoms (aching, heaviness, swelling)
2. Prevent / treat complications (eczema, pigmentation, lipodermatosclerosis, ulceration, haemorrhage, thrombophlebitis)
3. Cosmetic improvement
4. Eliminate the source of reflux to prevent recurrence

1. Conservative (Non-Interventional) Treatment

Compression Therapy

• Compression stockings reduce venous hypertension by increasing interstitial pressure and improving calf pump efficiency
• British classification:
  • Class 1: 14-17 mmHg - mild; for telangiectasias, tired legs
  • Class 2: 18-24 mmHg - moderate; symptomatic varicose veins, post-sclerotherapy
  • Class 3: 25-35 mmHg - strong; severe CVI, lymphoedema, venous ulcers

Important caveats: Level 1 trial data show interventional treatment gives superior quality-of-life improvement over compression alone. Compliance rates are universally poor. There is no evidence that stockings prevent progression. Incorrect application can cause pressure necrosis or tourniquet effect. Compression should be used as an adjunct, not primary treatment, unless the patient refuses intervention. Always exclude significant arterial disease first (ABPI must be > 0.8).

Other Conservative Measures

• Leg elevation above heart level for at least 30 min, 3-4x/day
• Regular walking - activates calf pump
• Weight loss - reduces intra-abdominal pressure
• Avoid prolonged standing

2. Interventional Treatment

Decision Framework

Truncal reflux (GSV/SSV)?
    YES → Duplex ultrasound mapping → Endothermal ablation (first-line)
    NO  → Branch varicosities / telangiectasias → Sclerotherapy / Phlebectomy

A. Endothermal Ablation (First-Line for Truncal Reflux)

Endovenous Laser Ablation (EVLA)

• A fine glass fibre is inserted percutaneously into the GSV/SSV under ultrasound guidance, positioned 1-2 cm below the SFJ
• Laser energy (typically 1470 nm wavelength) is delivered as the fibre is withdrawn at a controlled pullback speed
• Three fibre tip designs: bare tip, divergent forward-firing, or radial/side-firing (thought to give more even energy distribution and less post-op bruising)
• Highest technical occlusion rates of any single technique
• Performed outpatient; patient mobilises immediately

Radiofrequency Ablation (RFA)

• A catheter with segmental electrode array (e.g. ClosureFAST) is introduced in the same manner
• Radiofrequency energy heats the vein wall to 120°C in 20-second treatment cycles, causing collagen contraction and fibrosis
• A 2024 meta-analysis (PMID: 38316290) found RFA and EVLA have similar occlusion rates but RFA has less post-procedural pain and bruising

B. Sclerotherapy

Agents (FDA-approved):

• Sodium tetradecyl sulphate (STS) - most commonly used
• Polidocanol - fastest growing adoption; essentially painless; very low allergic/anaphylactic rate; minimal tissue necrosis risk
• Sodium morrhuate
• Glycerine
• Hypertonic saline (23.4%) - widely used but not FDA-approved for this indication

Liquid vs Foam Sclerotherapy:

Using CO₂ as the mixing gas (instead of air) reduces the risk of neurological complications (visual disturbance, migraine, stroke) - important especially in patients with patent foramen ovale.

• Transient local discomfort (common)
• Hyperpigmentation (reduced by microthrombectomy of clotted blood in treated veins)
• Skin/fat necrosis if extravasation occurs (more common without US guidance)
• Allergic reaction / anaphylaxis
• Neurological events: visual disturbance, migraine, stroke (rare; risk higher with PFO)

C. Mechanochemical Ablation (MOCA - ClariVein)

• A rotating catheter tip is introduced into the vein
• The spinning wire mechanically abrades the endothelium
• Liquid sclerosant is simultaneously infused via the catheter during pullback
• No tumescent anaesthesia required - less painful procedurally; good choice for needle-phobic patients
• Similar early occlusion rates to endothermal ablation, but higher medium-/long-term recanalisation rates
• Limitation: maximum catheter length limits treatment of very long segments; maximum safe sclerosant dose limits treatment of large/dilated veins

D. Cyanoacrylate Glue (VenaSeal)

• A catheter is advanced into the GSV to 5 cm below the SFJ
• Cyanoacrylate (medical superglue) is injected in 0.1 mL aliquots as the catheter is withdrawn; the vein is compressed after each injection to seal the lumen
• No tumescent anaesthesia required - minimal intraprocedural pain
• Early efficacy comparable to thermal techniques
• Adverse effects: foreign body/hypersensitivity reactions to the adhesive have been reported (PMID: 37054883 - systematic review of glue reactions); long-term data still accumulating
• Highest consumable cost of any technique

E. Ambulatory Phlebectomy (Stab Avulsion)

• Used for tributary varicosities (branch veins, not the truncal axial vein)
• Multiple 1-2 mm stab incisions (no sutures required) along the course of marked varicosities under tumescent local anaesthesia
• A phlebectomy hook or mosquito clamp grasps and extracts the vein segment
• Can be combined with any truncal ablation method
• Evidence shows fewer recurrences than sclerotherapy for tributaries, but risks include blisters, telangiectatic matting, scar formation, bruising
• CPT codes: 37765 (10-20 stab incisions), 37766 (>20 stab incisions)

F. Open Surgery (Trendelenburg + Stripping)

Trendelenburg Operation (Saphenofemoral Ligation)

• Flush ligation and division of the GSV at the saphenofemoral junction (SFJ) through a groin incision
• All tributaries at the SFJ (5-6 tributaries: superficial circumflex iliac, superficial epigastric, superficial external pudendal, anterolateral/posteromedial thigh veins) must be ligated flush with the femoral vein to prevent neovascularisation and recurrence

Stripping

• A flexible stripper wire is passed down the GSV lumen from the groin incision to a small ankle or knee incision and the vein is stripped out (invagination stripping method minimises nerve injury)
• Stripping should be limited to the above-knee GSV - stripping below the knee significantly increases risk of saphenous nerve injury
• For SSV: sapheno-popliteal junction ligation through a popliteal fossa incision; sural nerve at risk during SSV stripping

Multiple Stab Avulsions

• Dilated tributaries are removed through stab incisions at the time of stripping

When is surgery still used?

• Very large, tortuous veins unsuitable for catheter insertion
• Failed endovenous techniques or complex recurrence
• Concomitant surgery requiring general anaesthesia anyway
• Anatomical variations precluding endovenous access

G. Treatment of Specific Situations

H. CHIVA (Conservative and Hemodynamic treatment for Insufficiency in an Outpatient setting)

• Selective removal of only incompetent branches, preserving the saphenous trunk
• Requires meticulous pre-op duplex mapping and highly experienced operator
• Reported lower recurrence rates in selected series compared to stripping
• SVS/AVF Guidelines suggest this approach only for those with experience (Grade 2B/C)

3. Treatment of Complications

4. Post-Treatment Compression

Summary: Hierarchy of Treatments

1st line (truncal reflux):  Endothermal ablation (EVLA or RFA) - outpatient, LA
2nd line (truncal):         Ultrasound-guided foam sclerotherapy (UGFS)
3rd line (truncal):         Open surgery (ligation + stripping) - if above not feasible

Tributaries:                Phlebectomy or liquid/foam sclerotherapy
Telangiectasias:            Liquid sclerotherapy or laser/IPL
No TLA wanted:              MOCA or cyanoacrylate glue
Conservative only:          Compression Class 2 + lifestyle

• Bailey and Love's Short Practice of Surgery, 28th Ed.
• Schwartz's Principles of Surgery, 11th Ed.
• Mulholland & Greenfield's Surgery, 7th Ed.
• 2023 SVS/AVF/AVLS Guidelines - Gloviczki et al., J Vasc Surg Venous Lymphat Disord, 2024 (PMID: 37652254)
• RFA vs EVLA meta-analysis - Jiang et al., 2024 (PMID: 38316290)
• Sclerosant network meta-analysis - Chen et al., 2025 (PMID: 37649310)

Treatment of Varicose Veins

A. Conservative Treatment

1. Compression Stockings

• Must exclude arterial disease first (ABPI > 0.8 required)
• Does not prevent progression; inferior to intervention for QoL
• Used as adjunct or when patient refuses intervention

2. Lifestyle Measures

• Leg elevation (above heart level, 3–4×/day)
• Regular walking (activates calf pump)
• Weight loss (reduces intra-abdominal pressure)
• Avoid prolonged standing

B. Interventional Treatment

1. Endothermal Ablation ← First-Line for Truncal Reflux (GSV/SSV)

2024 meta-analysis (PMID: 38316290): Both have equivalent occlusion; RFA has less pain and bruising. SVS/AVF/AVLS 2023 Guidelines (PMID: 37652254): Endothermal ablation recommended over open surgery (Grade 1B) and over foam sclerotherapy (Grade 1B).

2. Sclerotherapy

• Polidocanol - most widely used; virtually painless; lowest allergy/necrosis risk
• Sodium tetradecyl sulphate (STS)
• Sodium morrhuate
• Hypertonic saline 23.4%

• Hyperpigmentation (reduced by microthrombectomy of clot)
• Skin/fat necrosis (if extravasation)
• Thrombophlebitis
• Allergic reaction / anaphylaxis
• Rare: stroke, visual disturbance, migraine (higher risk with PFO; use CO₂ foam to reduce this)

SVS/AVF Guidelines Grade 1B: Liquid or foam sclerotherapy recommended for telangiectasias, reticular veins, and varicose veins.

3. Mechanochemical Ablation (MOCA - ClariVein)

• Rotating wire tip mechanically abrades endothelium + liquid sclerosant injected simultaneously
• No tumescent anaesthesia required → less painful, needle-phobic patients benefit
• Comparable early efficacy to endothermal, but higher medium/long-term recanalisation
• Limited by catheter length and maximum safe sclerosant dose

4. Cyanoacrylate Glue (VenaSeal)

• Superglue injected in 0.1 mL aliquots via catheter; vein compressed to seal lumen
• No tumescent anaesthesia required; minimal intraprocedural pain
• High early occlusion rates
• Risk: foreign body / hypersensitivity reactions to adhesive
• Highest consumable cost; long-term data still limited

5. Ambulatory Phlebectomy (Stab Avulsion)

• For tributary/branch varicosities (not the truncal axial vein)
• Multiple 1–2 mm stab incisions under tumescent local anaesthesia; vein extracted with hook or mosquito clamp
• No sutures needed; day-case procedure
• Fewer recurrences than sclerotherapy for tributaries
• Risks: bruising, blistering, telangiectatic matting, scarring

6. Open Surgery (Trendelenburg + Stripping)

1. Flush SFJ ligation (Trendelenburg) - all tributaries at SFJ ligated flush with femoral vein (prevents neovascularisation/recurrence)
2. Stripping of above-knee GSV with flexible stripper (invagination technique minimises saphenous nerve injury; below-knee stripping avoided - high nerve injury risk)
3. Multiple stab avulsions of dilated tributaries

• Veins too large/tortuous for catheter access
• Failed endovenous techniques / complex recurrence
• Anatomical variations precluding endovenous access
• Patient preference or resource constraints

C. Treatment by Vein Type / Clinical Situation

D. Treatment of Complications

E. Quick Reference: Treatment Ladder

TRUNCAL REFLUX (GSV/SSV)
│
├─ 1st line → Endothermal Ablation (EVLA or RFA)
├─ 2nd line → Ultrasound-guided Foam Sclerotherapy
├─ 3rd line → Open Surgery (Ligation + Stripping)
└─ No TLA wanted → MOCA or Cyanoacrylate Glue

TRIBUTARIES / BRANCHES
├─ Phlebectomy (stab avulsion)
└─ Foam / Liquid Sclerotherapy

TELANGIECTASIAS / RETICULAR VEINS
└─ Liquid Sclerotherapy or Laser/IPL

CONSERVATIVE ONLY (unfit / patient choice)
└─ Class 2 Compression + Lifestyle

• Bailey and Love's Short Practice of Surgery, 28th Ed.
• Mulholland & Greenfield's Surgery, 7th Ed.
• Schwartz's Principles of Surgery, 11th Ed.
• 2023 SVS/AVF/AVLS Guidelines - Gloviczki et al., PMID: 37652254
• RFA vs EVLA meta-analysis - Jiang et al., 2024, PMID: 38316290
• Sclerosant network meta-analysis - Chen et al., 2025, PMID: 37649310