Key Facts

Varicose veins are dilated, tortuous superficial veins, most commonly affecting the lower limbs. They result from incompetent venous valves causing reflux and venous hypertension.

Epidemiology

• Prevalence: ~25-30% of Western adults
• Female > male (~2:1)
• Increases with age, parity, obesity
• Risk factors: family history, prolonged standing, obesity, pregnancy, DVT history

Aetiology

• Primary: idiopathic valve incompetence (most common); familial predisposition
• Secondary: post-thrombotic (DVT damage to valves), pelvic mass compressing veins, AV malformations

Pathophysiology

• Superficial venous valves become incompetent → reversal of blood flow (reflux)
• Venous hypertension in superficial system → vein wall dilatation and tortuosity
• Most commonly: saphenofemoral junction (SFJ) incompetence → GSV reflux
• Chronic venous hypertension → oedema, skin changes (lipodermatosclerosis, eczema), venous ulceration

Typical Presentation

• Visible dilated, tortuous veins on the legs
• Aching, heaviness, throbbing in legs — worse with prolonged standing, end of day
• Ankle swelling
• Itching, skin irritation

Complications

• Varicose eczema: dry, itchy, erythematous skin around veins
• Lipodermatosclerosis: fibrosis and hardening of skin in gaiter area (lower calf)
• Venous ulceration: shallow, irregular, painless-to-mildly-painful ulcers in gaiter area; often chronic
• Thrombophlebitis: inflamed, tender, hard vein segment
• Bleeding: even minor trauma can cause significant haemorrhage (high venous pressure); controlled by elevation and pressure
• DVT: associated but not directly caused by varicose veins

Examination Findings

• Visible varicose veins (standing examination)
• Distribution suggests GSV (medial leg) or SSV (posterior calf) involvement
• Skin changes: pigmentation, eczema, lipodermatosclerosis, atrophie blanche
• Venous ulceration: gaiter area (medial malleolus)
• Tap test, tourniquet test: traditional clinical tests; largely replaced by duplex USS

Red Flags

• Skin changes (CEAP C4-C6): require treatment referral
• Active or healed venous ulcer
• Significant bleeding from varicose veins
• Superficial thrombophlebitis extending towards deep system

Bedside

• Clinical examination standing: map distribution
• Handheld Doppler: identify reflux at SFJ/SPJ

Imaging

• Duplex ultrasonography: investigation of choice
  • Identifies site of reflux (SFJ, SPJ, perforators)
  • Maps superficial venous anatomy
  • Excludes concurrent DVT
  • Reflux >0.5 seconds in superficial veins is abnormal

CEAP Classification

Non-pharmacological

• Lifestyle: weight loss, exercise, avoid prolonged standing, leg elevation
• Compression stockings: for symptom relief; NOT first-line definitive treatment per NICE CG168
  • Used while awaiting intervention, during pregnancy, or if intervention declined/unsuitable
  • Class 2 (18-24 mmHg) most commonly prescribed

Pharmacological

• No pharmacological treatment for varicose veins themselves
• Venous ulcer management: compression bandaging (four-layer), wound dressings, treat infection if present
• Pentoxifylline 400mg TDS: may aid venous ulcer healing (adjunct to compression — NICE)

Surgical/Interventional

NICE CG168 treatment hierarchy:

1. Endothermal ablation (first-line): radiofrequency ablation (RFA) or endovenous laser therapy (EVLT)
   • Performed under local anaesthesia, day case
   • Closes the incompetent saphenous trunk
   • Recurrence rate: ~5-10% at 5 years
2. Ultrasound-guided foam sclerotherapy: if endothermal ablation unsuitable
   • Injection of sclerosant foam into varicose veins
   • Higher recurrence rate than ablation
3. Surgical stripping and ligation: if endothermal and foam unsuitable
   • High ligation of SFJ + stripping of GSV
   • Higher recurrence rate than endothermal ablation

Referral criteria (NICE CG168):

• Symptomatic primary or recurrent varicose veins
• Skin changes (C4-C6): pigmentation, eczema, lipodermatosclerosis, ulceration
• Superficial thrombophlebitis
• Bleeding from varicose veins

Referral Criteria

• C2 with symptoms: routine vascular referral
• C4-C6: prioritised referral
• Active venous ulcer: urgent referral for venous assessment and treatment
• Bleeding varicose veins: acute management (elevation + pressure), then referral

• Varicose veins are a chronic condition; treatment reduces symptoms but recurrence is common
• Endothermal ablation: ~90-95% success at 5 years
• Surgical stripping: ~80-85% success at 5 years
• Foam sclerotherapy: ~70-80% success at 5 years
• Venous ulcers: heal in ~50-70% at 6 months with compression; recurrence ~25-30% at 1 year
• Post-treatment: significant improvement in quality of life
• Untreated progressive venous disease: increasing skin damage, ulceration

NICE CG168 Treatment Hierarchy

Venous vs Arterial Ulcers