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Introduction

Varicose veins (from the Latin word ‘varix’, which means twisted) are dilated, tortuous veins which mainly occur in the superficial venous system of the legs.1

Varicose veins have a high prevalence with approximately a third of the population developing them at some point in their lives.2

Often, they are asymptomatic or only a cosmetic concern. However, some patients can experience severe aching and/or itching in the affected areas, impairing their quality of life.3

Patients with varicose veins can develop complications including venous ulceration, bleeding, and permanent changes to skin pigmentation.3


Aetiology

Anatomy

Superficial veins drain into the deep venous system via perforator veins that penetrate muscle fascia in the legs (mainly at the saphenofemoral and saphenopopliteal junctions).

Blood flow can only move unidirectionally towards the deep veins due to the presence of one-way valves in the superficial veins. This is to overcome the hydrostatic pressure imposed on distal blood by gravity, the effect of which is greatest in the lower limbs.1,3

Pathophysiology

Varicose veins develop due to the incompetence of the one-way valves, leading to the leakage, retrograde flow and consequently, pooling of blood in the superficial venous system.

Additionally, the weaker, thinner walls of the superficial veins (as opposed to the stronger and thicker walls of the deep veins) make them more prone to the effects of the high-pressure build-up of blood leading to distension of the venous walls and tortuosity of the affected venous segment.3,4

This manifests as bulging of the skin over the affected vein (figure 1).

A diagram of varicose veins
Figure 1. Normal vein (A) and varicose vein (B). The varicose vein is dilated, tortuous and causing the skin superficial to it to bulge.10

Causes of varicose veins

Most varicose veins are idiopathic.

Secondary causes arise from mechanisms of venous outflow obstruction which can either be:3

  • Intravascular (e.g. a deep vein thrombosis)
  • Extravascular (e.g. pelvic masses, including tumours, fibroids and pregnancy)

Progesterone and oestrogen are also believed to have vasodilatory properties which can predispose to or worsen already existing varicose veins.5


Risk factors

The main risk factors for developing varicose veins are:1,3,6,7

  • Family history of varicose veins (90% risk if both parents are affected)
  • Older age (especially 40 years and above)
  • Pregnancy (higher parity equals higher risk)
  • Female sex
  • History of deep vein thrombosis (DVT)

Other risk factors include obesity, prolonged standing/sitting (including an occupation involving this), previous lower limb fracture and being Caucasian.3


Clinical features

History1,2,3

Varicose veins are commonly asymptomatic or initially just a cosmetic concern with patients worrying about the visible and often palpable tortuous veins in their legs.

Typical (usually chronic) symptoms that can develop with worsening varicose veins include:

  • Pain (often described as a dull ache or burning of the skin)
  • Leg fatigue, discomfort, or worsening pain after prolonged standing (with associated relief after leg elevation)
  • Leg cramps (usually nocturnal)
  • Restless legs
  • Skin discolouration over the affected areas (haemosiderin deposition)
  • Heaviness of the legs

Less common symptoms include:

  • Itching after prolonged standing (venous eczema)
  • Ankle oedema
  • Lipodermatosclerosis

Severe presentations are uncommon but require urgent referral to vascular services. These include:

  • Ulceration: indicates serious chronic venous insufficiency
  • Haemorrhage: especially if the variceal segments are large, traumatised, or over bony prominences
  • Thrombophlebitis: presenting with severe pain, erythema, and vein induration

Other important areas to cover in the history include:

  • Past medical history: previous interventions or surgery on the affected leg, pregnancy, ulcerations, trauma, pelvic masses (including uterine fibroids and cancer), previous DVT, past hospital stays, cardiovascular disease, previous lower limb fracture
  • Family history: varicose veins, venous disease, cardiovascular disease
  • Social history: occupations or activities that involve prolonged standing or sitting

Clinical examination1,2,3,4

A thorough peripheral venous examination should be performed.

The varicosities should be assessed with the patient standing at first and then with them lying down.

Varicose segments usually comprise areas of the great and short saphenous veins and the full lengths of both veins should be assessed from the front, the sides and from behind.

Inspection

Assess the size, location, and extension of the dilated veins.

Look for associated signs and complications:

  • Chronic venous insufficiency: ulceration (both active and healed), eczema, haemosiderin deposition, lipodermatosclerosis and atrophie blanche.
  • Complications: bleeding and superficial vein thrombosis (see complications).

Palpation

Gently press over the distended vein. The vein should empty then refill after a brief period of time, but thrombosed varicosities will be firm and possibly tender.

Assess for bumps and bulges that might correspond with varicose veins, keeping note of the size, shape, length, and location of the veins:

  • Determining these characteristics will help exclude other venous problems (see differential diagnoses).
  • Press the calf gently to feel for calf tenderness.
  • Make sure to carefully examine the integrity of the skin in the ‘gaiter’ area and feel for signs of chronic venous insufficiency, especially venous ulcers.

To complete the physical examination, it is imperative to assess the patient’s cardiovascular health and to carry out an abdominal examination to exclude secondary causes such as pelvic or abdominal tumours or other factors that could be causing distal venous obstruction.

Figure 2. Examples of varicose veins.11,12

 


Differential diagnoses

Differential diagnoses to consider include:3

  • Telangiectasias: veins <1 mm in diameter
  • Reticular veins: veins 1 – 3 mm in diameter (can also be tortuous)

Less likely but important causes to rule out include DVT, cellulitis, and superficial thrombophlebitis.

Rare congenital disorders of which varicose veins are a typical component include Klippel-Trénaunay syndrome and Parkes Weber syndrome.


Investigations

Varicose veins are usually a clinical diagnosis and investigations are not required. 

However, a duplex ultrasound scan can confirm the diagnosis of varicose veins by assessing for the reflux of blood in less obvious cases. Ultrasound also helps rule out a DVT and can be useful when planning management.2,3

Importantly, an ankle-brachial pressure index (ABPI) can exclude peripheral arterial disease before compression therapy is considered. 


Diagnosis

The main diagnostic criteria for varicose veins are the presence of dilated and tortuous veins and a history of risk factors.1,2,3

These should be supported by a detailed history exploring the symptoms and predisposing factors, as well as a thorough clinical examination to identify features of chronic venous insufficiency that could have led to the development of varicose veins and/or any complications that may have resulted from them.

Classification

The ‘clinical, aetiology, anatomical and pathophysiology’ (CEAP) classification system is the standardised, comprehensive classification system used for chronic venous disorders.8.9


Management

Management of varicose veins consists of both surgical and conservative options.

In addition, lifestyle changes are encouraged including exercise and weight loss.

Varicose veins are likely to recur after treatment, but for most patients, treatment offers relief from symptoms for a significant period (with the length varying from patient to patient).

Referral to vascular services

In general, patients with non-bleeding varicosities who suffer from primary or recurrent varicose veins associated with typical symptoms, or have signs of complications, should be referred to a vascular service.

Patients with a CEAP classification of C2 to C3 may be considered for routine referral, whereas patients with a C4 to C6 should be considered for urgent vascular surgery review.

Any patient with bleeding varicose veins and/or significant ulceration should be referred to a vascular service for consideration of urgent intervention.

Conservative management

The main non-surgical option for managing varicose veins is compression therapy using bandages or stockings. 

However, compression therapy is not recommended by NICE unless surgical intervention is declined or considered inappropriate. One such case where it can be deemed not suitable is pregnancy. In this situation, only non-surgical options should be considered unless exceptional circumstances warrant surgical intervention.

Before using compression therapy, it is important to exclude arterial insufficiency by performing an ankle-brachial pressure index (ABPI).

Surgical management

Surgical management involves endovenous techniques or open surgery.

Both techniques aim to treat the origin of the varicose veins, which involves either eliminating the saphenofemoral or saphenopopliteal junctions or ligating thigh or calf perforators.

In theory, this should eliminate the patient’s symptoms. However, most clinicians will advocate adjunctive therapy to remove all visible tortuous veins in the lower leg as well as treating the truncal incompetence.

Endovenous techniques

Endovenous techniques aim to block the faulty veins, which has the same benefit as removing them. It is preferred to open surgery as these techniques are minimally invasive.

Options include:

  • Endothermal ablation (first line) involves either radiofrequency ablation or endovenous laser treatment
  • Ultrasound-guided foam sclerotherapy (second line)
  • Rarer techniques, such as the use of glue, steam, and mechanochemical devices

Open surgery

Open surgery is only considered if endovenous techniques are deemed inappropriate.

Options include:

  • Ligation and stripping: incompetent veins are tied off (ligated) and removed (stripped)
  • Phlebectomy (stab avulsions): varicose veins are pulled out through small incisions

Complications

The most important complications associated with varicose veins are bleeding and deep vein thrombosis. These complications require urgent intervention.1,2,3,4

Other complications include superficial thrombophlebitis, changes to skin pigmentation, ulceration, and impaired quality of life.


Key points

  • Varicose veins are dilated, tortuous superficial veins mostly affecting the lower limbs.
  • The main risk factors predisposing to varicose vein formation are having a family history of varicose veins, pregnancy, older age, being female and having a history of DVT.
  • Due to their unsightly appearance and associated symptoms, many people experience impaired quality of life.
  • A thorough history and clinical examination are necessary to establish the risk of complications and to rule out life-threatening conditions (e.g. DVT).
  • Treatment is usually surgical (via an endovenous or open technique) but is unlikely to prevent the varicose veins from recurring in the long term.
  • Serious complications are rare but may include bleeding and deep vein thrombosis.

Reviewer

Mr Craig Nesbitt MBChB MD FRCS

Consultant Vascular and Endovascular Surgeon


Editor

Dr Chris Jefferies


References

  1. NICE CKS. Varicose veins. Last revised in 2020. Available from: [LINK].
  2. NICE. Varicose veins: diagnosis and management (CG168). Published in 2013. Available from: [LINK].
  3. BMJ Best Practice. Varicose veins. Last reviewed in September 2020. Available from: [LINK].
  4. Patient.info. Varicose Veins. Last reviewed in 2016. Available from: [LINK].
  5. Beebe-Dimmer JL, Pfeifer JR, et al. The epidemiology of chronic venous insufficiency and varicose veins. Annals of Epidemiology. Published in 2005. Available from: [LINK].
  6. Cornu-Thenard A, Boivin P, et al. Importance of the familial factor in varicose disease. Clinical study of 134 families. Journal of Dermatologic Surgery and Oncology. Published in 1994. Available from: [LINK]
  7. Laurikka JO, Sisto T, et al. Risk indicators for varicose veins in forty- to sixty-year-olds in the Tampere varicose vein study. World Journal of Surgery. Published in 2002. Available from: [LINK]
  8. Zegarra TI, Tadi P. CEAP Classification of Venous Disorders. Treasure Island (FL): StatPearls Publishing. Last updated in 2020. Available from: [LINK]
  9. Eklöf B, Rutherford RB, et al. Revision of the CEAP classification for chronic venous disorders: consensus statement. Journal of Vascular Surgery. Published in 2004. Available from: [LINK]
  10. National Heart, Lung and Blood Institute. Varicose veins. Licence: [Public domain]. Available from: [LINK]
  11. Thomas Kriese. Adapted by Geeky Medics. Varicose veins. Licence: [CC BY 2.0]. Available from: [LINK].
  12. Nini00. Adapted by Geeky Medics. Licence: [CC BY-SA 3.0]. Available from: [LINK].

 

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