Description

The term varicose derives from the Latin 'varix', which means twisted. A varicose vein is usually tortuous and dilated.

Under normal circumstances, blood collected from superficial venous capillaries is directed upward and inward via one-way valves into superficial veins. These in turn drain via perforator veins, which pass through muscle fascia into deeper veins buried under the fascia. Leakage in a valve causes retrograde flow back into the vein. Unlike deep veins which are thick-walled and confined by fascia, superficial veins cannot withstand high pressure and eventually become dilated and tortuous. The failure of one valve puts pressure on its neighbours and may result in retrograde flow, and hence varicosity, of the entire local superficial venous network.^[1]

The superficial veins in the legs are normally involved, as these are most likely to come under hydrostatic pressure due to gravity.

Other pathological processes may also be involved, such as an inherent weakness of the vein wall. The influence of genetics has been confirmed by twin studies,^[2] and the genes involved are beginning to be identified.^[3]

Pregnancy brings its own problems, with hormonal factors increasing the pliability of the venous walls and the valves themselves. In later pregnancy, there is expansion of the circulating blood volume and this is compounded by pressure on the inferior vena cava from the growing uterus. One study found that one in six women with varicose veins had pelvic vein reflux.^[4] Another mechanism that sometimes comes into play is obstruction to venous outflow. This can be either intravascular, as in deep vein thrombosis (DVT), or extravascular from trauma or compression from surrounding structures such as tumours or a cirrhotic liver.

Epidemiology

Varicose veins are extremely common. In America, one branch of the Framingham Study found that the incidence was 2.6% in women and 2.0% in men.^[5] A Belgian systematic review found the prevalence in Western populations to be about 25% in women and 10% in men. A study conducted in London of people aged 35 to 70 concluded that the prevalence of varicose veins in men and women was 17% and 31% respectively.^[6]

The Framingham Study also confirmed that having more than two pregnancies was an independent risk factor, as was obesity (but only in women).^[5] Several studies have confirmed that varicose veins are more common with increasing age.^[7]

Presentation^[8]

History

It is important to establish at the initial consultation why the patient has presented. Patients with cosmetic concerns present less often than they used to, but are still occasionally seen with asymptomatic but unsightly tortuous veins or thread veins.

Commonly, patients will present with chronic sequelae such as itching, discomfort and heaviness of the legs, night cramps, oedema, burning sensations, paraesthesiae, exercise intolerance, or restless legs. Subjective symptoms are usually more severe in the early stages of the condition, less severe in middle stages and worse in latter years. The pain associated with larger varicose veins is usually described as a dull ache that is worse after prolonged standing. Aggravating factors may include pregnancy, exogenous hormones, menstruation and occasionally sexual intercourse.

Apart from the presenting symptoms, the history should include:

• History of previous venous problems, any visible abnormal veins, any history of varicosities in pregnancy
• Any risk factors such as family history of varicose veins, a job which involves prolonged standing, past history of trauma
• History of oedema, date of onset, any risk factors, any variation throughout day, degree of induration and location
• History of any previous hospital assessments or treatment
• History of any previous episodes of superficial or deep vein thrombosis or thrombophlebitis
• History of bleeding from varicose veins
• History of any cardiovascular comorbidity

Examination^[1][9]

• A complete examination should include a general assessment of the patient's cardiovascular status and abdominal examination to exclude secondary causes such as tumours which could be causing external venous compression.
• To map the areas of varicosity, examine the patient standing in the first instance. To confirm that a swelling is a varicose vein, gently press over the area. The vein will empty and then refill.
• Attempt to identify which vein the varicosities drain into. Varicosities of the short saphenous vein are normally seen below the knee and are distributed posterolaterally. Long saphenous vein varicosities may run the whole length of the leg and are distributed more medially.
• Inspect the skin for changes suggestive of chronic venous insufficiency. These may include ulcers, lipodermatitis, pigmentation, telangiectasia or eczema.
• Once you have finished the inspection, ask the patient to lie down and identify the saphenofemoral junction. One good way to do this is by locating the femoral artery, which lies between the anterior superior iliac spine and the pubic tubercle, by feeling for the pulse. The vein is medial to the artery and the saphenofemoral junction about two fingers' breadths below the inguinal ligament.
• Ask the patient to stand and tap the varicosity lower down the leg. A fluid thrill felt at the level of the valve indicates that it is incompetent.

Two tests have classically been used to assess valvular competency (Trendelenburg's test) and deep venous patency (Perthes' test). They have been superseded to a large extent by other noninvasive investigations (see below) but may still be relevant in a primary care setting.

Trendelenburg's test. The Trendelenburg's test can sometimes distinguish patients with superficial venous reflux from those with incompetent deep venous valves. The patient should lie flat with the leg elevated, allowing the veins to empty. A tourniquet is applied to the thigh at the saphenous opening. If the valve is competent, the vein should fill from below. If the valve is incompetent, the vein will fill from above on removing the tourniquet. This can be repeated at various levels, until the location of an incompetent vale is located.

Perthes' manoeuvre. Perthes' manoeuvre is used to distinguish antegrade flow from retrograde flow in superficial varicosities. Antegrade flow is an indicator of collateral flow around a deep venous obstruction. A tourniquet is applied to a varicose leg in such a way that the superficial veins are compressed without pressure being applied to the deep vessels. The patient is then asked to stand repeatedly on tip-toe, activating the calf muscles. Normally this would empty the varicosities but, in the presence of deep vein obstruction, they would paradoxically become congested.

Differential diagnosis^[1]

• Cellulitis
• Osler-Weber-Rendu syndrome (telangiectasia, recurrent epistaxis and a positive family history - also known as hereditary haemorrhagic telangiectasia)
• Superficial phlebitis
• DVT

Investigations^[1]

Imaging

Hand-held Doppler
This non-invasive test is a more accurate means of assessing whether a vein is dilated but carrying blood in an antegrade direction or whether it is a true varicosity with retrograde flow. The Doppler probe is positioned directly along the axis of of vein at 45° and the vein is tapped gently. A strong Doppler signal confirms that the probe is correctly positioned. Compression of the limb below the probe will produce a sound indicating flow in the direction of the valve. In incompetent veins, a signal is also produced when the pressure is released, indicating retrograde flow. This can be repeated at several levels until no retrograde flow is detected. All veins suspected by inspection or palpation of being varicose should be tested in this manner. If no veins are obviously dilated, simply record whether any retrograde flow can be detected along the length of the long and short saphenous veins.

Duplex ultrasound This uses a combination of Doppler and conventional ultrasound and gives a more accurate assessment than Doppler alone. It is used in patients with significant varices, although some authorities maintain that it should be used in all patients as a screening procedure.

Colour-flow imaging This is sometimes called triplex ultrasonography and is a further refinement in which Doppler information is translated into colour images. It is a highly sensitive technique which can demonstrate minor valve leakages and incompetence in small perforator veins.

Physiological tests of venous function

These may be helpful as an adjunct to imaging in complex cases.

• Venous refilling time - the time necessary for the lower leg to fill with blood after it has been maximally emptied by the calf-muscle pump.
• Maximum venous outflow - this is the time taken for a leg distended by a tourniquet to empty and is a measure of possible venous obstruction.
• Muscle pump ejection fraction - this is used to detect failure of the muscle pump to expel blood from the lower leg.

Associated diseases

• DVT,^[10] any condition causing calf-muscle pump failure (eg neuromuscular disease, muscle wasting conditions).^[11]
• Arterial disease - one study found that varicose veins are a risk factor for arterial disease (but not hypertension).^[12]
• Thrombophilia - another study found that patients with this condition had a higher incidence of varicose veins than controls.^[13]

Staging

Various classification systems have been used, the original being the C linical picture, E tiology, A natomic distribution and P athophysiology (CEAP) classification, devised by the Consensus Committee of the American Venous Forum. This included such features as the number and extent of varicosities, the presence of skin changes and the disabling effect of any symptoms. The original system was published in 1994^[14] and updated a decade later.^[15]

Management

Primary care^[8]

It is important to determine why the patient is presenting for treatment. One third of patients have symptoms unrelated to varicose veins, or may simply be seeking advice about possible complications or deterioration.

Lifestyle changes The evidence base addressing the issue of lifestyle changes such as weight loss and exercise is limited but they are most likely to be of benefit in preventing the initial development of varicosities and their complications, rather than reversing the disease process once it is established (see Prevention). Patients should be advised to avoid prolonged standing and keep the leg(s) elevated when possible.

Compression stockings^[16] Evidence suggests that compression stockings improve symptoms. It is important to exclude arterial disease before these are prescribed. Class 1 (light) or class 2 (medium) below-knee stockings are usually sufficient, the choice depending on the severity of the varicosities and the tolerability of the compression. Thigh-length stockings may be beneficial if the varicosities extend above the knee. Patients should be made aware that stockings may not prevent new varicosities from developing nor existing ones from getting worse. The evidence base supporting their use during pregnancy is weaker but some women may find them helpful in controlling symptoms.

When to refer Refer according to local policies, if available, and always consider the patient's general health and comorbidities when assessing appropriateness of referral. 

• Emergency referral where there is active bleeding from a varicose vein that has eroded the skin.
• Urgent referral if there is a history of active bleeding, and still a risk of further bleeding. Patients with progressive leg ulcers or painful ulcers despite treatment should also be fast tracked.
• Consider (routine) referral for:
  • Patients with recurrent superficial thrombophlebitis.
  • An active or healed ulcer or progressive skin changes, where it is thought that the person might benefit from venous surgery. Also consider vascular surgery referral if the person has venous skin problems and significant arterial insufficiency (ankle-brachial pressure index less than 0.8).
  • It may also be appropriate to refer patients with varicose vein symptoms where the severity, site and size of the problem means their quality of life is considerably impaired.

Treatment options in secondary care^[1]

Although conventional surgery is still performed, minimally invasive procedures such as radiofrequency ablation, endovenous laser therapy and foam sclerotherapy are becoming increasingly popular.^[17] One systematic review concluded that endovenous laser therapy and radiofrequency ablation was as safe and effective as surgery, particularly in the treatment of saphenous veins.^[18]

Avulsion. In this process, small incisions are made over each varicosity and that part of the vein is excised using a vein hook or forceps.

Stripping. A wire, plastic or metal rod is passed through the lumen of the saphenous vein and pulled until the entire vein is stripped out of the leg. Inversion stripping is a refinement of this method in which the vein is turned in on itself during removal.

Partial stripping to the knee may cause less neurological trauma than stripping to the ankle and preserves venous tissue that may subsequently be required for vein grafting techniques (eg coronary artery bypass graft). It is the current preferred invasive method.

Ambulatory phlebectomy can be performed, using local anaesthetic, as an outpatient procedure. Small multiple incisions are made in the skin overlying the vein, which is hooked out and extracted in a piece-meal fashion. The technique is particularly suitable for tortuous veins inaccessible to fine-wire techniques such as laser ablation. Contra-indications are reflux at the saphenofemoral or saphenopopliteal junctions, which must be treated by other means.^[19]

Radiofrequency ablation.^[20] This involves sealing the lumen of the long saphenous vein by delivering radiofrequency energy via a catheter under ultrasound guidance.

Endovenous laser therapy. This works by delivering high-intensity laser through a sheathed wire guided into the vein. Reports suggest that the outcome is equal to or better than stripping.^[21]

Injection sclerotherapy. Once used as first-line treatment for new varicosities, this is now being employed less frequently due to concerns about skin staining and ulceration.^[22] Some randomised trials also suggest that sclerotherapy may have a higher recurrence than surgery but the data need further evaluation.^[23] Randomised trials suggest that injection using a mixture of sodium tetradecyl sulfate and polidocanol resulted in improved symptoms (night cramps, pains, fatigue and heaviness) and reduction in oedema compared with either sclerosant alone.^[24] Using the sclerosant in foam rather than liquid form allows for injection of a lower volume of liquid but does not seem to affect recurrence rates in the long-term.^[25]

Complications^[1][22]

• Complications directly relating to varicose veins include haemorrhage and thrombophlebitis.
• Complications relating to the increased pressure arising from chronic venous incompetence (venous hypertension) include venous ulcers, oedema, skin pigmentation, varicose eczema, atrophie blanche (smooth white areas of atrophic scar tissue with telangiectasia) and lipodermatosclerosis (areas of induration arising from fibrosis of subcutaneous fat).
• Potential complications of treatment include DVT and pulmonary embolus, paraesthesiae from injury to the sural nerve or the saphenous nerve and the development of haematomas. Skin burns have been known to occur if radiofrequency catheters are placed too near the skin.

Prognosis

Untreated, varicose veins tend to become larger over time and patients with significant reflux are prone to develop chronic venous ulceration.^[26] Long-term studies of the outcome of surgical treatment have been less than encouraging with a ten-year recurrence rate of approximately 70%. It remains to be seen whether newer techniques such as radiofrequency ablation and laser treatment can improve upon this figure.^[27]

Prevention

Certain factors such as genetic predisposition, gender and increasing age are unavoidable. The Framingham data suggest that weight control, adequate physical exercise, avoidance of smoking, avoidance of sedentary activities and control of hypertension may all be significant in preventing the development of varicose veins.^[5]