Varicose Veins

Varicose veins, or varicoses, are a condition where superficial veins become enlarged and twisted. They typically develop in the legs, just under the skin, and can be merely a cosmetic issue; however, they may also cause discomfort such as fatigue, pain, itching, and nighttime leg cramps.

Complications can include bleeding, skin ulcers, and superficial thrombophlebitis. Varices in the scrotum are termed varicocele, and those around the anus are known as haemorrhoids. The physical, social, and psychological effects of varicose veins can lower a patient's quality of life.

Left leg of a male affected by varicose veins

Causes

Varicose veins often have no specific cause but are linked to risk factors such as obesity, lack of exercise, leg trauma, family history of the condition, and pregnancy. They can result from chronic venous insufficiency due to weak or damaged valves in the veins. They are diagnosed primarily through examination and ultrasound.

How a varicose vein forms in a leg. Figure A shows a normal vein with a working valve and normal blood flow. Figure B shows a varicose vein with a deformed valve, abnormal blood flow, and thin, stretched walls. The middle image shows where varicose veins might appear in a leg.

Signs and Symptoms

Signs and symptoms associated with varicose veins include:

• Aching, heavy legs
• Appearance of spider veins (telangiectasia) in the affected leg
• Ankle swelling
• A brownish-yellow shiny skin discolouration near the affected veins
• Redness, dryness, and itchiness of areas of skin, termed stasis dermatitis or venous eczema
• Muscle cramps when making sudden movements, such as standing
• Abnormal bleeding or healing time for injuries in the affected area
• Lipodermatosclerosis or shrinking skin near the ankles
• Restless legs syndrome
• Atrophie blanche, or white, scar-like formations
• Burning or throbbing sensation in the legs

People with varicose veins might have a positive D-dimer blood test result due to chronic low-level thrombosis within dilated veins.

Complications

While most varicose veins are benign, severe cases can lead to significant complications such as pain, tenderness, heaviness, skin conditions like dermatitis, skin ulcers, development of carcinoma or sarcoma in longstanding venous ulcers, severe bleeding from minor trauma, blood clotting within affected veins (superficial thrombophlebitis), and acute fat necrosis.

Diagnosis

Clinical Test

Clinical tests may include the Trendelenburg test to determine the site of venous reflux and the nature of the saphenofemoral junction.

Investigations

Traditionally, imaging techniques were used if deep venous insufficiency was suspected. Currently, lower limbs venous ultrasonography is recommended for all patients with varicose veins for better assessment and lower recurrence rates.

Stages

The CEAP Classification, developed in 1994 by the American Venous Forum, outlines stages from C0 (no visible signs) to C6 (active venous ulcer), with sub-stages indicating symptomatic or asymptomatic conditions.

Treatment

Active Treatment

Active treatments include surgery, laser and radiofrequency ablation, ultrasound-guided foam sclerotherapy, cyanoacrylate glue, mechanochemical ablation, and endovenous steam ablation. No significant differences have been found between treatments, though radiofrequency ablation might offer better long-term benefits.

Conservative Treatment

The National Institute for Health and Clinical Excellence (NICE) recommends referral to a vascular service for treatment of symptomatic varicose veins. Conservative treatments like support stockings should be used only if treatment isn't possible. Symptoms can be managed through leg elevation, regular exercise, wearing graduated compression stockings, and using intermittent pneumatic compression devices. Diosmin/hesperidin and other flavonoids, as well as anti-inflammatory medication, can also be helpful.

Procedures

• Stripping: Removal of saphenous vein main trunk, with complications like deep vein thrombosis, pulmonary embolism, and wound infections.
• Sclerotherapy: Use of sclerosants to shrink veins, effective for both spider veins and larger varicose veins under ultrasound guidance.
• Endovenous Thermal Ablation: Includes laser, radiofrequency, and steam treatments, with fewer complications compared to open surgery.
• Medical Adhesive: Injection of cyanoacrylate to seal veins, offering a success rate of about 96.8%.
• Echotherapy Treatment: High-intensity focused ultrasound therapy, a non-invasive method allowing immediate return to daily activities.

Comparison of healthy and varicose veins

Epidemiology

Varicose veins are most common after age 50, more prevalent in females, and have a hereditary component. They are also observed in smokers, those with chronic constipation, and individuals with occupations requiring prolonged standing.

Self-assessment MCQs (single best answer)

What are varicose veins?

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Which of the following is NOT a typical symptom of varicose veins?

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Which imaging technique is currently recommended for better assessment of varicose veins?

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Which of the following conditions is a type of varices found around the anus?

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What is the primary cause of varicose veins?

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Which treatment involves using sclerosants to shrink varicose veins?

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Which classification system is used to outline the stages of varicose veins?

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Which of the following is considered a conservative treatment for varicose veins?

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Which complication is NOT associated with varicose veins?

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Which of the following is a risk factor for developing varicose veins?

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