Varicose Veins

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oPatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.

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; however, further research is required.[2][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.

Varicose veins
Varicose veins on leg

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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] Prevalence studies are rare and the range reported is wide (2-56% in men and 1-60% in women) due to variations of study population, selection criteria, methods of measurement and disease definition.[6] One Finnish study reported an incidence  rate of 13.5 per 1,000 person years (8.5 for men and 19.2 for women).[7] 

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.[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 the 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[10] 

  • 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 with them 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 symphisis pubis, by feeling for the pulse. The vein is medial to the artery and the saphenofemoral junction about two fingers' breadth 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 non-invasive investigations (see 'Investigations', below) but may still be relevant in a primary care setting. The Royal College of Surgeons in England expects its membership candidates to abandon Trendelenburg's, Perthes' and tap testing in favour of hand-held Doppler assessment but that they should understand the principles behind the techniques.[11] 

Trendelenburg's test
This 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 removal of the tourniquet. This can be repeated at various levels, until the location of an incompetent vale is located.

Perthes' manoeuvre
This 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 tiptoe, activating the calf muscles. Normally this would empty the varicosities but, in the presence of deep vein obstruction, they would paradoxically become congested.

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.[12] 

Duplex ultrasound
This uses a combination of Doppler and conventional ultrasound and gives a more accurate assessment than Doppler alone. It is recommended by the National Institute for Health and Care Excellence (NICE) as the assessment of choice for diagnosis of varicose veins and the extent of truncal reflux (this is reflux in the large tortuous (truncal) veins prominent under the skin), and to plan treatment for people with suspected primary or recurrent varicose veins.[13] 

Colour-flow imaging
Sometimes called triplex ultrasonography, this 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.[14] 

Physiological tests of venous function[15] 

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 - the time taken for a leg distended by a tourniquet to empty. It is a measure of possible venous obstruction.
  • Muscle pump ejection fraction - used to detect failure of the muscle pump to expel blood from the lower leg.
  • DVT, any condition causing calf-muscle pump failure (eg, neuromuscular disease, muscle wasting conditions).[13][16] 
  • Arterial disease - one study found that varicose veins are a risk factor for arterial disease (but not hypertension).[17]
  • Thrombophilia - another study found that patients with this condition had a higher incidence of varicose veins than those who did not.[18]

Various classification systems have been used, the original being the Clinical picture, Etiology, Anatomical distribution and Pathophysiology (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 and updated a decade later.[19][20]

Primary care 

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', below). Patients should be advised to avoid prolonged standing and keep the leg(s) elevated when possible.

Compression stockings[9] 
NICE does not recommend treatment with compression stockings unless interventional treatment is not appropriate.[13] If compression stockings are to be used, it is important to exclude arterial disease before prescribing them, by measuring the ankle-brachial pressure index (ABPI) using a Doppler. 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. Open-toed stockings may be appropriate for people who have problems with their feet, such as arthritis or fungal infection of the toes. They should be taken off at night and replaced every three to six months. Patients should be made aware that stockings may not prevent new varicosities from developing or 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.

If compression stockings are offered after interventional treatments, they should not be worn for longer than seven days.

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[13] 

Although conventional surgery is still performed, NICE recommends, for confirmed varicose veins with truncal reflux, minimally invasive procedures such as radiofrequency ablation, endovenous laser therapy or foam sclerotherapy should be considered first.

Endothermal ablation
Radiofrequency ablation involves sealing the lumen of the long saphenous vein by delivering radiofrequency energy via a catheter under ultrasound guidance. An alternative is endovenous laser therapy.which works by delivering high-intensity laser through a sheathed wire guided into the vein.

Ultrasound-guided foam sclerotherapy
This is recommended if endothermal ablation is unsuitable. It involves imaging-guided injection of sclerosant in foam form. Sodium tetradecyl sulfate is a typical sclerosant and the gas used is usually carbon dioxide or air. It is recommended that incompetent varicose tributaries be treated at the same time.

If foam sclerotherapy is unsuitable, consider conventional surgery.

Avulsion
This is a very old technique in which small incisions are made over each varicosity and that part of the vein is excised using a vein hook or forceps.[22] 

Stripping[23] 
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. It 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
This 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.[24] 

Injection sclerotherapy[23] 
Once used as first-line treatment for new varicosities, this is now being employed less frequently due to concerns about skin staining and ulceration. It is only indicated for below-knee varices and is mainly used for persistent or recurrent veins after surgery. It has largely been replaced by foam sclerotherapy.

  • 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.[26] 

Untreated, varicose veins tend to become larger over time and patients with significant reflux are prone to develop chronic venous ulceration.[25] Long-term studies of the outcome of surgical treatment have been less than encouraging. 15-25% of varicose vein surgery is for recurrence.[23] Studies suggest a 90-98% occlusion with radiofrequency ablation after two years.[27] The closure rate for endovenous laser treatment after two years was 93.4%.[28] For foam sclerotherapy , the clinical recurrence rate with significant symptoms was 4% at five years.[29] 

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]

Further reading & references

  1. Meissner MH; Lower extremity venous anatomy. Semin Intervent Radiol. 2005 Sep;22(3):147-56. doi: 10.1055/s-2005-921948.
  2. Ng MY, Andrew T, Spector TD, et al; Linkage to the FOXC2 region of chromosome 16 for varicose veins in otherwise healthy, unselected sibling pairs.; J Med Genet. 2005 Mar;42(3):235-9.
  3. Krysa J, Jones GT, van Rij AM; Evidence for a genetic role in varicose veins and chronic venous insufficiency. Phlebology. 2012 Oct;27(7):329-35. doi: 10.1258/phleb.2011.011030. Epub 2012 Feb 3.
  4. Marsh P, Holdstock J, Harrison C, et al; Pelvic vein reflux in female patients with varicose veins: comparison of Phlebology. 2009 Jun;24(3):108-13.
  5. Brand FN, Dannenberg AL, Abbott RD, et al; The epidemiology of varicose veins: the Framingham Study.; Am J Prev Med. 1988 Mar-Apr;4(2):96-101.
  6. Kuhlmann A, Prenzler A, Hacker J, et al; Impact of radiofrequency ablation for patients with varicose veins on the budget of the German statutory health insurance system. Health Econ Rev. 2013 Apr 3;3(1):9. doi: 10.1186/2191-1991-3-9.
  7. Makivaara LA, Jukkola TM, Sisto T, et al; Incidence of varicose veins in Finland. Vasa. 2004 Aug;33(3):159-63.
  8. Milic D; Prevalence and socioeconomic data in chronic venous disease: how useful are they in planning appropriate management?, Medicographia, 2010
  9. Compression stockings; NICE CKS, September 2012 (UK access only)
  10. Varicose Veins Exam; Clinicalexam.com
  11. Bhasin N, Scott DJ; How should a candidate assess varicose veins in the MRCS clinical examination? A vascular viewpoint. Ann R Coll Surg Engl. 2006 May;88(3):309-12.
  12. Vowden K et al; Hand-held Doppler Ultrasound: The assessment of lower limb arterial and venous disease, 2004
  13. Varicose veins in the legs: The diagnosis and management of varicose veins; NICE clinical guideline (July 2013)
  14. Ultrasound and Color Doppler imaging of vascular diseases; Ultrasound-images.com
  15. Ibegbuna V, Delis KT, Nicolaides AN; Haemodynamic and clinical impact of superficial, deep and perforator vein incompetence. Eur J Vasc Endovasc Surg. 2006 May;31(5):535-41. Epub 2006 Jan 4.
  16. Conley J, Diagnosis and Treatment of Venous Insufficiency and Varicose Veins, 2013
  17. Makivaara LA, Ahti TM, Luukkaala T, et al; Persons with varicose veins have a high subsequent incidence of arterial disease: Angiology. 2007 Dec-2008 Jan;58(6):704-9.
  18. Darvall KA, Sam RC, Adam DJ, et al; Higher prevalence of thrombophilia in patients with varicose veins and venous J Vasc Surg. 2009 May;49(5):1235-41.
  19. No authors listed; Classification and grading of chronic venous disease in the lower limbs. A consensus statement. Ad Hoc Committee, American Venous Forum.; J Cardiovasc Surg (Torino). 1997 Oct;38(5):437-41.
  20. Eklof B, Rutherford RB, Bergan JJ, et al; Revision of the CEAP classification for chronic venous disorders: consensus statement.; J Vasc Surg. 2004 Dec;40(6):1248-52.
  21. Varicose veins; NICE CKS, October 2008
  22. O'Sullivan HD; The Treatment of Varicose Veins of the Lower Limb by Avulsion. Br Med J. 1910 Apr 16;1(2572):921.
  23. Varicose veins; Surgical-tutor.org, 2013
  24. Kabnick LS, Ombrellino M; Ambulatory phlebectomy. Semin Intervent Radiol. 2005 Sep;22(3):218-24. doi: 10.1055/s-2005-921955.
  25. Nicholls SC; Sequelae of untreated venous insufficiency. Semin Intervent Radiol. 2005 Sep;22(3):162-8. doi: 10.1055/s-2005-921960.
  26. Subramonia S, Lees TA; The treatment of varicose veins. Ann R Coll Surg Engl. 2007 Mar;89(2):96-100.
  27. Radiofrequency ablation of varicose veins; NICE, 2013
  28. Endovenous laser treatment of the long saphenous vein; NICE (2004)
  29. Ultrasound-guided foam sclerotherapy for varicose veins; Interventional procedure guidance NICE (Feb 2013)

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.

Original Author:
Dr Laurence Knott
Current Version:
Peer Reviewer:
Prof Cathy Jackson
Document ID:
969 (v23)
Last Checked:
05/09/2013
Next Review:
04/09/2018