Skip to content

BASICS

  • Varicose veins (VV): Dilated subcutaneous veins ≥3 mm diameter, usually in greater/lesser saphenous veins.
  • Part of chronic venous disease spectrum: from telangiectasias to chronic venous insufficiency and ulcers.
  • Venous hypertension from valve incompetence, venous obstruction, or increased intra-abdominal pressure.
  • Genetic predisposition: polygenic, with loci such as CASZ1 and 16q24 implicated.

EPIDEMIOLOGY

  • Prevalence: ~23% of adults in U.S.
  • More common in women, incidence increases with age.
  • High cost due to late complications (e.g., venous ulcers).

RISK FACTORS

  • Inherited: tall stature (>180 cm), congenital syndromes.
  • Acquired: age, DVT, pregnancy, decreased leg impedance.
  • Lifestyle: prolonged standing/sitting, smoking, obesity.
  • Hormonal: female gender (high estrogen states).
  • Socioeconomic: lower education level.

DIAGNOSIS

History

  • Symptoms: pain, tingling, burning, itching, leg cramping, heaviness.
  • Symptoms worsen at end of day/prolonged standing.
  • Women prone to symptom fluctuation due to hormones.

Physical Exam

  • Inspect standing patient: dilated, tortuous, blue/purple veins >3 mm.
  • Skin changes: erythema, eczema, hemosiderosis, atrophie blanche, lipodermatosclerosis, ulcers.
  • Palpate saphenofemoral junction for saphena varix.
  • Tests: Tap, cough (limited value), Trendelenburg and Perthes tests (older).
  • Duplex ultrasound: gold standard to assess valve competence, reflux, and anatomy.

Differential Diagnosis

  • Arthritis, peripheral neuropathy, DVT.
  • Arterial or neuropathic ulcers.
  • Inflammatory or malignant skin lesions.

CLASSIFICATION

  • CEAP classification:
  • C0: no signs
  • C1: telangiectasias/reticular veins
  • C2: varicose veins
  • C3: edema
  • C4a: pigmentation/eczema
  • C4b: lipodermatosclerosis/atrophie blanche
  • C5: healed venous ulcer
  • C6: active venous ulcer

TREATMENT

General Measures

  • Lifestyle: leg elevation, avoid prolonged standing/sitting, weight loss, exercise.
  • Compression stockings during daytime (20-30 mmHg).
  • Avoid noncompliance due to discomfort.

Medications

  • Phlebotonics (e.g., micronized purified flavonoid fraction, horse chestnut seed extract) may reduce symptoms.
  • Limited evidence; mainly adjunctive.

Procedures

  • Sclerotherapy: chemical or foam to obliterate veins; effective for telangiectasias and small varicosities.
  • Endovenous ablation:
  • Radiofrequency ablation (RFA)
  • Endovenous laser ablation (EVLA)
  • High success rates (84-94%) and less morbidity than surgery.
  • Surgery:
  • Stripping (less common due to minimally invasive alternatives)
  • CHIVA (ambulatory conservative hemodynamic treatment)
  • Stab phlebectomy
  • Mechanochemical endovenous ablation (MOCA): hybrid technique with rotating tip and sclerosant.

Special Considerations

  • Avoid in pregnancy and active DVT.
  • Compression therapy essential post-procedure.

ISSUES FOR REFERRAL

  • Symptomatic or recurrent VV.
  • Skin changes or ulceration.
  • Failed conservative management.
  • Suspected pelvic vein incompetence or complex venous disease.

ONGOING CARE

  • Regular follow-up for ulcer healing and symptom management.
  • Monitor for complications like ulceration, infection.

PROGNOSIS

  • Chronic condition; untreated leads to progression, ulcers, increased risk of DVT.
  • Recurrence after surgery up to 50% by 5 years.

COMPLICATIONS

  • Chronic edema, venous stasis dermatitis.
  • Lipodermatosclerosis, atrophie blanche.
  • Venous ulcers with risk of infection.
  • Recurrence after treatment.

REFERENCES

  1. Raetz J, Wilson M, Collins K. Varicose veins: diagnosis and treatment. Am Fam Physician. 2019;99(11):682-688.
  2. de Ávila Oliveira R, Riera R, Vasconcelos V, et al. Injection sclerotherapy for varicose veins. Cochrane Database Syst Rev. 2021;12(12):CD001732.
  3. Alsaigh T, Fukaya E. Varicose veins and chronic venous disease. Cardiol Clin. 2021;39(4):567-581.

ICD10

  • I83.90 Asymptomatic varicose veins of unspecified site
  • I83.009 Varicose veins of unspecified lower extremity with ulcer
  • I83.10 Varicose veins of unspecified lower extremity with inflammation

Clinical Pearls

  • RFA and EVLA have better outcomes and less morbidity compared to open surgery.
  • Compression therapy remains the cornerstone of conservative treatment.
  • Early intervention may prevent complications such as venous ulcers.