What are Varicose Veins
Varicose veins are veins that have become enlarged, bulged, and twisted. They most often appear in the legs.
- Varicose veins are veins that are enlarged (more than 3-mm diameter while standing) and distorted. They are common in legs, and they are part of a spectrum of chronic venous disorders of the lower extremities 1
- May present as a cosmetic concern or may be associated with heaviness, throbbing, aching, or leg fatigue; symptoms are exacerbated by standing for long periods and relieved by elevation of legs
- Diagnosis is made primarily by duplex venous ultrasonography
- Treatment is aimed at reducing symptoms, improving cosmesis, and correcting associated reflux and venous valve incompetence
- In general, 3 approaches are used, often in combination: endothermal ablation, sclerotherapy, and surgery (high ligation of the saphenous vein followed by stripping or phlebectomy)
- US, European, and UK guidelines favor endothermal ablation, when feasible 2 3 4
- Recurrence is common
What are the causes?
This condition is caused by damage to the valves in the vein. These valves help blood return to your heart. When they are damaged and they stop working properly, blood may flow backward and back up in the veins near the skin, causing the veins to get larger and appear twisted.
The condition can result from any issue that causes blood to back up, like pregnancy, prolonged standing, or obesity.
What increases the risk?
This condition is more likely to develop in people who are:
- On their feet a lot.
What are the signs or symptoms?
Symptoms of this condition include:
- Bulging, twisted, and bluish veins.
- A feeling of heaviness. This may be worse at the end of the day.
- Leg pain. This may be worse at the end of the day.
- Swelling in the leg.
- Changes in skin color over the veins.
How is this diagnosed?
This condition may be diagnosed based on your symptoms, a physical exam, and an ultrasound test.
How is this treated?
Treatment for this condition may involve:
- Avoiding sitting or standing in one position for long periods of time.
- Wearing compression stockings. These stockings help to prevent blood clots and reduce swelling in the legs.
- Raising (elevating) the legs when resting.
- Losing weight.
- Exercising regularly.
If you have persistent symptoms or want to improve the way your varicose veins look, you may choose to have a procedure to close the varicose veins off or to remove them.
Treatments to close off the veins include:
- Sclerotherapy. In this treatment, a solution is injected into a vein to close it off.
- Laser treatment. In this treatment, the vein is heated with a laser to close it off.
- Radiofrequency vein ablation. In this treatment, an electrical current produced by radio waves is used to close off the vein.
Treatments to remove the veins include:
- Phlebectomy. In this treatment, the veins are removed through small incisions made over the veins.
- Vein ligation and stripping. In this treatment, incisions are made over the veins. The veins are then removed after being tied (ligated) with stitches (sutures).
Follow these instructions at home:
- Walk as much as possible. Walking increases blood flow. This helps blood return to the heart and takes pressure off your veins. It also increases your cardiovascular strength.
- Follow your health care provider’s instructions about exercising.
- Do not stand or sit in one position for a long period of time.
- Do not sit with your legs crossed.
- Rest with your legs raised during the day.
- Follow any diet instructions given to you by your health care provider.
- Wear compression stockings as directed by your health care provider. Do not wear other kinds of tight clothing around your legs, pelvis, or waist.
- Elevate your legs at night to above the level of your heart.
- If you get a cut in the skin over the varicose vein and the vein
- Lie down with your leg raised.
- Apply firm pressure to the cut with a clean cloth until the bleeding stops.
- Place a bandage (dressing) on the cut.
Contact a health care provider if:
- The skin around your varicose veins starts to break down.
- You have pain, redness, tenderness, or hard swelling over a vein.
- You are uncomfortable because of pain.
- You get a cut in the skin over a varicose vein and it will not stop bleeding.
- Varicose veins are veins that have become enlarged, bulged, and twisted. They most often appear in the legs.
- This condition is caused by damage to the valves in the vein. These valves help blood return to your heart.
- Treatment for this condition includes frequent movements, wearing compression stockings, losing weight, and exercising regularly. In some cases, procedures are done to close off or remove the veins.
- Treatment for this condition may include wearing compression stockings, elevating the legs, losing weight, and engaging in regular activity. In some cases, procedures are done to close off or remove the veins.
- Recurrence is common; contributing factors cannot necessarily be controlled and include neovascularization and natural progression of disease
- Varicose veins are veins that are enlarged (more than 3-mm diameter while standing) and distorted 1
- They are most common in the superficial veins of the lower extremities but can occur elsewhere
- Varicosities occur as part of a spectrum of chronic venous disorders of the lower extremities
- CEAP (class, etiology, anatomy, pathophysiology) classification includes varicosities and other chronic venous disorders, which may exist concurrently. For an individual, assign classification for each category according to the most advanced finding they exhibit 5
- Clinical classification
- C0: no visible or palpable signs of venous disease
- C1: telangiectasias (less than 1-mm diameter) or reticular veins (1- to 3-mm diameter) 1
- C2: varicose veins (greater than 3-mm diameter) 1
- C3: edema
- C4a: pigmentation and/or eczema
- C4b: lipodermatosclerosis and/or atrophie blanche
- C5: healed venous ulcer
- C6: active venous ulcer
- CS: symptomatic
- CA: asymptomatic
- Etiologic classification
- Ec: congenital
- Ep: primary
- Es: secondary
- En: no venous etiology identified
- Anatomic classification
- As: superficial veins
- Ap: perforator veins
- Ad: deep veins
- An: no venous location identified
- Pathophysiologic classification
- Pr: reflux
- Po: obstruction
- Pr,o: reflux and obstruction
- Pn: no venous pathophysiology identifiable
- Clinical classification
- Complete characterization includes a designation from each element of the classification (eg, C4bSEpAsPr) 5
- From Sun Y et al: Feasibility and safety of foam sclerotherapy followed by a multiple subcutaneously interrupt ligation under local anaesthesia for outpatients with varicose veins. Int J Surg. 42:49-53, 2017. Figure 2A.Severe, large varicosities on posterior and medial side of right leg. – 65-year-old man with severe, large varicosities on posterior and medial side of right leg.
- From Sun Y et al: Feasibility and safety of foam sclerotherapy followed by a multiple subcutaneously interrupt ligation under local anaesthesia for outpatients with varicose veins. Int J Surg. 42:49-53, 2017. Figure 3A.Large superficial varicose veins with incompetent greater saphenous veins in both lower extremities. – 69-year-old man with large superficial varicose veins with an incompetent greater saphenous veins in both lower extremities and a worsen condition in left side.
- Many patients are asymptomatic but regard varicosities as a cosmetic concern
- Other patients experience a variety of symptoms, generally worsened by prolonged standing or at the end of the day, that are relieved by elevation:
- Sense of heaviness or fullness in legs
- Tingling, throbbing, aching, or burning pain
- Superficial pruritus
- Restless legs
- Leg fatigue
- Positive family history or identifiable risk factors (eg, previous deep vein thrombosis, smoking) may be elicited
- Examine patient while they are standing; inspect each leg with patient’s weight shifted to other leg
- Spider telangiectasias (less than 1-mm diameter) and reticular veins (1- to 3-mm diameter) may appear as superficial networks of tiny red or purple vessels; spider telangiectasias are common in thighs, in posterior aspect of knees, and around ankles
- Varicosities (more than 3-mm diameter) may appear ropelike and tortuous; erythema, tenderness, or induration may suggest superficial thrombosis
- Varicosities in groin and perineal areas suggest more proximal disease (eg, iliac, gonadal, inferior vena caval)
- Bruit or thrill suggests a vascular malformation (eg, arteriovenous fistula)
- Presence of corona phlebectatica (fanlike network of small dilated vessels on ankle’s medial or lateral aspect), nonpitting edema, skin changes (eg, eczema, lipodermatosclerosis, atrophie blanche), open or healed ulcerations may indicate more advanced venous disease
- Examine the arterial pulses to assess possibility of concomitant arterial disease
- Assess ankle mobility, as restriction may reduce foot pump effect, contributing to venous insufficiency and varicosities
Causes and Risk Factors
- Primary cause(s) and sequence of events leading to varicosity are unknown, but several factors are thought to play a role: 1
- Structural abnormalities (macro- and microscopic) and/or inflammation in the vein wall
- Venous hypertension resulting from valvular incompetence and reflux, inadequate muscle pump function, and in some cases, proximal obstruction due to thrombosis or extrinsic compression (eg, by a mass or major artery)
Risk factors and/or associations
- Risk increases with age
- May be more common in women than men, although studies are inconsistent
- Many patients have a positive family history, but no specific genetic cause or pattern has been identified, with rare exception 2
- The Kippel-Trenaunay syndrome is a congenital condition characterized by cutaneous hemangiomas, hypertrophy of soft tissue and bone (usually confined to 1 body area such as a limb), and venous malformations (including varicosities, often at unusual sites) (OMIM: %149000) 6
Other risk factors/associations
- Previous deep vein thrombosis
- Thrombotic disorders
Primary diagnostic tools
- Diagnosis is suggested by history and physical examination; work-up is aimed at defining extent and determining source of the varicosities, and at determining whether there is a correctable or underlying cause
- Guidelines recommend applying a clinical score (eg, revised Venous Clinical Severity Score) based on symptoms and physical findings to establish a baseline against which to compare progression over time and/or effects of intervention 2 3
- Duplex venous ultrasonography is the first-choice test to evaluate depth and extent of disease and to detect presence of obstruction and/or reflux 2 3 4
- Conventional contrast venography is indicated in planning and performing endovenous or open surgery 3
- CT venography, magnetic resonance venography, or intravascular ultrasonography may be helpful in patients with suspected iliac vein obstruction, vascular anomalies, traumatic sequelae, compression by an extravascular mass, or suspicion of pelvic venous disease such as pelvic congestion syndrome 2 3
- Although largely supplanted by intravascular ultrasonography for evaluation of suspected outflow obstruction, plethysmography may be a helpful measure in patients with varicose veins in whom inadequate muscle pump function is suspected 3
- Obtain a platelet count in patients whose varicose veins appear to be related to deep vein thrombosis, especially if thrombosis occurred at a young age, at an unusual location, or recurrently 3
- Baker cyst
- Distended fluid-filled bursa in the popliteal space
- May present as a visible and/or palpable mass; may be mobile on examination
- Unlike varicose veins, may be associated with knee effusion and decreased range of motion
- Distinction can be made with ultrasonography
- Arterial aneurysm
- Focal dilation of an artery; in the lower extremity, occurs most commonly in femoral and popliteal arteries
- Like varicose veins, may be asymptomatic or may cause some discomfort; may be visible as an enlarged tortuous vascular structure
- Unlike varicose veins, aneurysms are pulsatile
- Distinction can be made by the pulsatile nature of an aneurysm and is confirmed by ultrasonography
- Arteriovenous fistula
- Connection between artery and vein, which may be congenital or may result from surgery or trauma
- As with varicose veins, vein may enlarge owing to increased intravascular pressure, and enlarged segment may be visible
- Unlike varicose veins, pulsation is usually evident and a bruit may be audible
- Diagnosis can be made by ultrasonography
- Relieve symptoms
- Improve cosmetic appearance
- Correct venous reflux and insufficiency to prevent progression of disease
- Admission after treatment of varicose veins is rarely necessary, but it may be advisable following open surgery
- Admission may be necessary for uncontrolled bleeding due to trauma or rupture of a varicosity
Recommendations for specialist referral
- Consult a specialist (eg, vascular surgeon, interventional radiologist) for varicosities that are refractory to conservative measures, or when interventional treatment is preferred over conservative management to achieve cosmetic improvement
Interventional therapy is treatment of choice in symptomatic patients 2 3 4
Various interventional approaches are available: 2 3
- Proximal ligation followed by either venous stripping or (increasingly) phlebectomy to remove varicose veins
- Endovenous ablation by radiofrequency or laser (ie, endothermal ablation)
- Sclerotherapy, which involves injecting solution directly into vein
- For patients with extensive varicosities or involvement of multiple veins, several techniques may be applied in 1 multistage procedure (eg, ablation of axial vein, phlebectomy of varicosities)
- Interventional treatment is rapidly evolving; newer chemical agents, novel devices, and combination approaches (eg, mechanicochemical ablation) have been introduced and may become widely used 11
- Some of these treatments allow avoidance of heat and/or of tumescent anesthesia commonly used in endothermal ablation
Choice of procedure depends on extent and level of underlying venous insufficiency and tortuosity of varicosities, but some general recommendations exist:
- For varicose veins
- US, 3 European, 2 and British 4 guidelines favor endothermal ligation over sclerotherapy or surgery to treat saphenous vein disease
- European 2 and NICE 4 guidelines recommend foam sclerotherapy over surgery
- CHIVA (cure conservatrice et hemodynamique de l’insufficience veineuse en ambulatoire) is a complex surgical approach that seeks to relieve reflux while preserving the saphenous system by ligating strategic points along the saphenous veins to redirect flow to the deep veins; guidelines recommend its use only in select patients by practitioners with special training and experience in the method 2 3
- When obstruction or incompetence of the deep venous system is contributory, additional procedures may be necessary to supplement treatment of superficial vasculature: 2
- Percutaneous angioplasty (balloon dilation) with stent placement is commonly used to achieve and maintain patency in an obstructed vein
- Incompetent valves can be repaired or a vein segment with competent valves can be inserted to replace the incompetent segment; in some cases, a new valve can be created from a thickened adjacent vein wall
- Rarely done; limited to specialty centers
- For telangiectasias and reticular veins
Evidence for efficacy of the following procedures is difficult to synthesize because of differing outcome measures and observation periods:
- A Cochrane Review in 2014 suggested that endovenous ablation and foam sclerotherapy were at least as effective as surgery for treating great saphenous vein disease. Since then, several additional large studies have been published: 12
- Comparison of surgery (ligation, stripping, and phlebectomy), endovenous laser ablation, and foam sclerotherapy conducted on 798 patients concluded that the procedures generated equivalent results in overall quality of life and clinical success at 6 months after procedure. Disease-specific quality of life and ablation rates were lower after foam sclerotherapy, and complications were less frequent after laser ablation 13
- Another comparison of the 3 procedures (surgery, endovenous laser ablation, and foam sclerotherapy) at 12-month follow-up found similar improvements in quality of life among the 3 groups but higher rates of residual reflux in the nonsurgical arms 14
- A 5-year study comparing ligation and stripping, laser ablation, radiofrequency ablation, and foam sclerotherapy found that recanalization occurred more frequently after foam sclerotherapy, and there was more clinical recurrence after laser ablation and surgery 15
- Similarly, another 5-year study comparing surgery, endovenous laser ablation, and sclerotherapy found that surgery and laser ablation achieved better long-term rates of saphenous vein occlusion than sclerotherapy 16
- A Cochrane Review comparing CHIVA to conventional surgery found low to moderate evidence indicating that CHIVA is associated with fewer recurrences and side effects 17
- Finally, a small 15-year noncomparative observational study of radiofrequency ablation revealed continued clinical success without recurrence in 88% of patients 18
- Evidence for lower leg outcomes (short saphenous vein) is less extensive; a Cochrane Review found moderate to low-quality evidence that laser ablation is more effective than surgery 19
Conservative therapy relies primarily on use of compression stockings and lifestyle measures to improve comfort and reduce progression
- The guideline produced by Society for Vascular Surgery and the American Venous Forum 3 recommends graded compression stockings with an ankle pressure of 20 to 30 mm Hg; European Society for Vascular Surgery 2 recommends elastic stockings but does not provide further detail; NICE 4 guidelines recommend against compression stockings unless interventional measures are not feasible
- In the United States, some insurers require a trial of compression stockings before interventional management can be authorized
Lifestyle measures are applicable to all patients, whether treated conservatively or interventionally, and include avoidance of prolonged sitting or standing, regular physical activity, elevation of the feet to heart level for 30 minutes 4 times daily, and smoking cessation and weight loss, if applicable 1
Medical therapy is generally indicated only for advanced venous disease and not for CEAP class 1 or 2 (telangiectasias, varicosities) 3
Nondrug and supportive care
Compression stockings 3
- It is unclear whether compression stockings provide significant benefit for CEAP class 2 patients (varicose veins without more advanced venous disease), or what degree of pressure is optimal
- A systematic review of compression stockings for patients with uncomplicated varicose veins indicated that the stockings improved symptoms but did not slow progress or prevent recurrence 20
- A subsequent Cochrane Review found insufficient evidence to determine benefit of compression stocking, but the patient population included some with more advanced disease (CEAP classes 3 and 4) 21
- Compression stockings are often prescribed for a short period following surgical or endovascular treatments, but recommendations are not standardized
Regular physical activity is an important aspect of postprocedure recovery for all procedures: patients are advised to walk for a few minutes every waking hour beginning day of procedure
- Under ultrasonographic guidance, a specialized catheter is inserted into the target vein and guided cephalad
- Thermal energy (in the form of radiofrequency or laser) is delivered by catheter, beginning at the cephalad end of the venous segment and continued as catheter tip is drawn caudally
- Tumescent anesthesia (instillation of large volumes of anesthetic, epinephrine, and diluent into area surrounding vein) ensures immobility of vein and provides compression to collapse treated segment as catheter is drawn caudally
- Reflux duration exceeding 500 msec in the great saphenous, small saphenous, or accessory saphenous veins, causing varicosities with or without symptoms
- Tortuous vessel anatomy that is not amenable to cannulation
- Veins adherent to overlying skin
- Deep vein thrombosis
- Female gender, older than 66 years, and history of superficial phlebitis increase risk for this complication following laser ablation 22
- Endovenous heat-induced thrombosis
- Superficial phlebitis
- Cutaneous burn
- Injection of sclerosant into target vein(s) to obliterate the lumen
- Sclerosing agents may be hyperosmolar solutions, detergents, or corrosive agents and may be injected as liquid or foam; foam appears to be more effective for larger vessels, and liquid for telangiectasias 23
- Can be applied to small localized areas by direct needle injection, or by ultrasonographically guided catheter when deep or long segments require treatment
- Treatment of telangiectasias, varicosities, or saphenous incompetence to relieve symptoms or improve cosmesis
- Headache, transient visual disturbance
- Deep vein thrombosis
- Superficial phlebitis
- Telangiectatic matting
- Cutaneous necrosis
- Stroke is rare, but reported with foam sclerosants
- Generally consists of proximal ligation of the greater saphenous vein at the saphenofemoral junction and ligation of its upper tributaries, followed by vein stripping or phlebectomy
- Vein stripping entails attachment of the proximal end of the vein to a device that invaginates and pulls the vein caudally through an incision a few centimeters below the knee
- Phlebectomy involves a series of incisions perpendicular to the vein, through which segments of vein are extracted; powered phlebectomy can be done via a fiberoptic scope equipped to mobilize, resect, and suction large or complex varicosities
- Tumescent anesthesia is often used
- Ligation and stripping or phlebectomy is primarily indicated in patients with tortuous veins not amenable to less invasive approaches
- Phlebectomy is often used following endovenous ablation to remove residual symptomatic varicosities
- Lymphatic pseudocyst
- Deep vein thrombosis
- Pregnant patients
- Interventional treatment is not recommended for pregnant patients
- A Cochrane Review found some benefit to water immersion and reflexology; use of rutosides (herbal remedy) was also associated with symptom relief, but the numbers were small and safety in pregnancy is not established 24
- Duplex ultrasonography is recommended 24 to 72 hours after endothermal ablation to look for evidence of thrombosis 3
- 1 to 2 weeks after phlebectomy, duplex ultrasonography is performed
Complications and Prognosis
- Superficial thrombophlebitis is a fairly common complication that may recur
- Protuberant varicosities are at risk for ulceration and trauma; severe bleeding can ensue
- Recurrence is fairly common, regardless of intervention type, and occurs in up to 35% of patients at 2 years and 65% at 11 years; contributing factors include procedure failure, neovascularization, and natural disease progression 2
- For treated veins that remain occluded at 1 year, prognosis for the next 3 to 5 years is good 25
Screening and Prevention
- Prevention is limited to avoidance of controllable risk factors (eg, cigarette smoking, obesity)
Wittens C et al: Editor’s Choice – Management of chronic venous disease: clinical practice guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg. 49(6):678-737, 2015