Varicose vein

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Varicose Veins

Definition

Varicose veins are abnormally dilated, tortuous, elongated superficial veins of the lower limb resulting from valvular incompetence and venous hypertension. The term comes from the Latin varix (twisted vein). They occur almost exclusively in humans, likely related to the upright posture.

Anatomy and Venous System

The superficial venous system of the lower limb consists of:

Great saphenous vein (GSV) - the longest vein in the body, runs medially from the foot to the saphenofemoral junction (SFJ) in the groin
Small saphenous vein (SSV) - runs posterolaterally from the foot to the saphenopopliteal junction behind the knee
Anterior accessory great saphenous vein (AAGSV)
Perforating (communicating) veins - connect the superficial to deep systems; normally allow blood to flow from superficial to deep

Epidemiology

Affects ~30% of the adult population
Women are affected more commonly (ratio ~10:1 in some series)
Middle-aged individuals are the usual sufferers, though any age group can be affected
Less common in primitive civilizations (Africa, Far East)

Aetiology / Pathophysiology

The fundamental defect is valvular incompetence, allowing retrograde (downward) flow with gravity (reflux). It is no longer thought to be caused solely by primary mechanical valve failure.

Vein wall changes include:

Inflammatory cell infiltration and activation
Dysfunctional smooth muscle cell proliferation
Collagen deposition and decreased elastin content
Increased matrix metalloproteinases
Loss of compliance, dilatation, and elongation causing tortuosity
Secondary valvular dysfunction

Predisposing factors:

Prolonged standing (conductors, police, tram drivers)
Pregnancy - hormonal (progesterone) and mechanical uterine compression
Obesity
Positive family history (strong genetic component)
Previous deep vein thrombosis (DVT) - post-thrombotic veins
Pelvic tumours (fibroid, ovarian cyst, colorectal cancer) causing venous obstruction
Congenital arteriovenous fistula (in younger patients)
May-Thurner syndrome (iliac vein compression)

Classification:

Primary varicose veins - intrinsic valve/wall defect
Secondary varicose veins - due to an identifiable cause (post-thrombotic, pelvic obstruction, AV fistula)

Varicose veins: (a) GSV distribution with skin changes, (b) SSV distribution with phlebitis, (c) AAGSV distribution

Figure: (a) Left leg GSV distribution varicose veins marked for intervention; (b) SSV distribution with recent phlebitis; (c) Isolated AAGSV distribution with gaiter area skin changes - Bailey and Love, p.1049

CEAP Classification

The standard clinical classification for chronic venous disease:

Class	Features
C0	No visible or palpable signs
C1	Telangiectasias / reticular veins
C2	Varicose veins
C3	Oedema
C4a	Pigmentation / eczema
C4b	Lipodermatosclerosis / atrophie blanche
C5	Healed venous ulcer
C6	Active venous ulcer

Symptoms

Aching pain in the leg, worse towards end of day, worse with prolonged standing, relieved by elevation
Night cramps
Ankle swelling (oedema) towards the end of the day
Itching (venous eczema)
Skin discolouration (haemosiderin pigmentation)
Heaviness / fatigue in the legs
Bursting pain on walking - suggests underlying deep vein thrombosis

Note: Symptoms do not always correlate with the size of varicosities - severely symptomatic patients may have few visible veins and vice versa. - S Das, p.105

Clinical Examination

Inspection (patient standing)

Distribution of varicosities guides source:
- Medial thigh and calf → GSV incompetence
- Posterolateral calf → SSV incompetence
- Anterolateral thigh/calf → AAGSV incompetence
Skin changes: pigmentation, eczema, lipodermatosclerosis, ulceration
Saphena varix - dilated SFJ presenting as a painless groin lump; disappears supine; impulse on coughing; can mimic inguinal hernia

Special Tests (Classical - mainly historical now)

Test	Method	Significance
Trendelenburg test	Leg elevated, tourniquet applied at groin, patient stands - veins fill from below	Identifies SFJ incompetence
Multiple tourniquet test	Multiple tourniquets at different levels	Locates incompetent perforators
Schwartz test (Percussion)	Tap vein at one point, impulse felt at another	Incompetent valves between fingers
Morrissey cough impulse test	Leg elevated then patient coughs; impulse felt at saphenous opening	SFJ incompetence
Fegan's method	Palpate gaps in deep fascia along varicose line	Locates incompetent perforators
Perthes test	Tourniquet above knee while patient exercises	Assesses deep vein patency

Abdominal Examination

Always examine the abdomen for secondary causes - pregnant uterus, fibroid, ovarian cyst, colorectal tumour - S Das, p.108.

Investigations

Duplex ultrasound scanning is the gold standard investigation and has replaced all handheld Doppler and tourniquet tests. It should be performed on all patients prior to intervention. - Bailey and Love, p.1052

Duplex aims to establish:

Presence of reflux in deep and superficial systems
Exact distribution and extent of reflux including affected junctions and perforators
Presence of deep vein obstruction
Suitability of incompetent veins for treatment (diameter, tortuosity, depth)
Identification of re-entrant perforators

A 7.5-13 MHz linear transducer is used. The 'Mickey Mouse' sign (transverse view at groin) identifies the GSV and common femoral vein medial to the artery. The 'saphenous eye' sign is the transverse view of the GSV within its fascial compartment.

Complications

Chronic complications:

Venous eczema (varicose eczema)
Lipodermatosclerosis
Haemosiderin pigmentation
Atrophie blanche
Venous (varicose) ulcer - classically at the medial malleolus ("gaiter area")

Acute complications:

Superficial vein thrombosis (thrombophlebitis) - painful, indurated cord; rarely causes pulmonary embolism (thrombus firmly attached to wall)
Bleeding - varicose vein rupture (can be severe; treat with leg elevation and direct pressure)

Treatment

Conservative (Non-Interventional)

Compression hosiery (graduated stockings)
Lifestyle advice: weight loss, avoid prolonged standing, leg elevation
Emollients for skin care

Interventional Options

1. Endovenous Laser Ablation (EVLA)

A laser fibre is introduced into the vein under ultrasound guidance
Thermal energy (around 60-80 J/cm) is delivered to ablate the vein wall under tumescent anaesthesia
No consensus on optimal power or pullback speed
Good evidence of durable closure
Performed as a day-case procedure

2. Radiofrequency Ablation (RFA)

Same principle as EVLA but uses electromagnetic current
Most popular device: ClosureFast™ (Medtronic) - reaches 120°C for 20-second treatment cycles, coil withdrawn in steps
Available in 3 cm and 7 cm coil lengths

EVLA vs RFA: Evidence is generally equivocal. Both have very high 5-year closure rates. Choice often comes down to operator preference. Both are superior to conventional surgery in terms of recovery time, complications, and patient satisfaction. - Bailey and Love, p.1055

A 2024 meta-analysis (Jiang et al., J Vasc Surg Venous Lymphat Disord) compared radiofrequency ablation vs laser ablation and confirmed broadly equivalent outcomes with minor differences in technique-specific complications.

3. Ultrasound-Guided Foam Sclerotherapy (UGFS)

A sclerosant (e.g., sodium tetradecyl sulphate, polidocanol) is mixed with gas to create foam
Foam is injected under duplex guidance into the incompetent vein
Less durable than thermal ablation but useful for tortuous veins, residual disease, and patients unsuitable for thermal treatment
Can be repeated

4. Mechanical/Chemical Ablation (MOCA) and Cyanoacrylate Glue

Newer non-thermal, non-tumescent techniques
ClariVein (MOCA) - rotating wire tip plus liquid sclerosant
VenaSeal - medical-grade cyanoacrylate glue injected to seal the vein
Advantages: no tumescent anaesthesia needed, faster recovery, no nerve injury from heat

5. Conventional Surgery (now largely replaced)

High ligation and stripping - ligation of the SFJ + stripping of the GSV
Stab (ambulatory) phlebectomy - micro-incisions to remove varicosities (often combined with endovenous procedures)
CPT codes: 37700 (ligation/division of GSV at SFJ), 37765-37766 (stab phlebectomy)
Higher morbidity, longer recovery; reserved for when endovenous techniques are not suitable

Treatment for Recurrent Varicose Veins

A 2024 systematic review and meta-analysis (Bontinis et al., Int Angiol) examined interventions for recurrent varicose veins from SFJ/GSV and found endovenous techniques to be effective, though evidence for recurrent disease is less robust than for primary disease.

Management Summary

Situation	Preferred Approach
Primary GSV/SSV incompetence	Endovenous thermal ablation (EVLA or RFA) ± phlebectomy
Tortuous/small veins	Foam sclerotherapy
Telangiectasias	Liquid sclerotherapy / laser
Unsuitable for endovenous	Surgery (high ligation + stripping)
Recurrent disease	UGFS or re-do endovenous/surgery
Post-DVT secondary varicosities	Conservative/compression (treat underlying disease first)

Key Points

Varicose veins affect ~30% of adults; female predominance
Primary mechanism: valvular incompetence → reflux → venous hypertension
GSV system is affected in ~60% of cases; SSV in ~20%
Duplex ultrasound is mandatory before any intervention
Endovenous techniques (EVLA, RFA) are the current standard of care - superior to open surgery
EVLA and RFA have equivalent outcomes; choice is operator preference
Compression hosiery is effective for symptom management but does not cure varicose veins
Always exclude secondary causes (DVT, pelvic mass) before treating

Sources: Bailey and Love's Short Practice of Surgery, 28th Ed., pp.1049-1060; S Das Manual on Clinical Surgery, 13th Ed., pp.105-111; Pfenninger and Fowler's Procedures for Primary Care, 3rd Ed.

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