Varicose Veins

Varicose veins
Straight to the point of care
Last updated: Mar 06, 2020

Table of Contents
Overview 3
Summary 3
Definition 3
Theory 4
Epidemiology 4
Aetiology 4
Pathophysiology 4
Classification 4
Case history 6
Diagnosis 7
Approach 7
History and exam 9
Risk factors 10
Investigations 11
Differentials 11
Criteria 12
Management 13
Approach 13
Treatment algorithm overview 16
Treatment algorithm 18
Emerging 26
Primary prevention 26
Secondary prevention 26
Patient discussions 26
Follow up 27
Monitoring 27
Complications 28
Prognosis 29
Guidelines 30
Diagnostic guidelines 30
Treatment guidelines 30
References 31
Images 37
Disclaimer 39
Varicose veins Overview
Summary
Very common condition that affects up to 40% of the population, but not all varicose veins are symptomatic.
Clinical presentation includes lower extremity pain, fatigue, itching and/or heaviness, which often worsen with
OVERVIEW
prolonged standing, associated with dilated tortuous veins.
Varicose veins can lead to significant quality of life impairment in affected individuals.
Underlying venous insufficiency can be documented by duplex ultrasound.
Treatment options for symptomatic varicose veins include endovenous thermal ablation, foam sclerotherapy,
and open surgery.
Compression hosiery should be reserved for those unsuitable for intervention, those who are unfit, and as
long-term management for those with chronic venous diseases or healed ulceration.
Chronic venous skin changes, superficial venous thrombosis, venous ulceration, and bleeding are
recognised complications.
Definition
Varicose veins are subcutaneous, permanently dilated veins 3 mm or more in diameter when measured in a
standing position; however, they may not be visible.[1]
This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Mar 06, 2020.
BMJ Best Practice topics are regularly updated and the most recent version of the topics
3
can be found on bestpractice.bmj.com . Use of this content is subject to our disclaimer (.
Use of this content is subject to our) . © BMJ Publishing Group Ltd 2023. All rights reserved.
Varicose veins Theory
Epidemiology
Prevalence estimates vary based on population, selection criteria, disease definition, and imaging
techniques. Generally, prevalence rates are higher in industrialised countries and in more developed
THEORY
regions.[3] Prevalence of visible varicose veins in the Western population aged over 15 years is 10% to 15%
in men and 20% to 25% in women.[4] Prevalence rates in the US are 15% (range from 7% to 40%) in men
and 27.7% (25% to 32%) in women.[5] Visible varicose veins are more prevalent in Hispanic people (26.3%)
and less prevalent in Asian people (18.7%).[6]
The prevalence of varicose veins increases with age. In one study, 40-year-olds had a prevalence of 22%,
50-year-olds a prevalence of 35%, and 60-year-olds a prevalence of 41%.[7]
A genetic link has been suggested. The risk of varicose veins developing if both parents are affected is 90%;
62% risk if one parent is affected and female offspring; 25% risk if one parent is affected and male offspring;
and if no parent is affected, the risk is 20%.[8]
Aetiology
Although many factors such as gender, pregnancy, occupation, weight, and race have been implicated as
predisposing factors for varicose veins, only a previous episode of deep vein thrombosis and genetic links
may be causative factors. The exact primary cause of varicose veins remains elusive.[3] [5]
Venous valve incompetence is the most common aetiology.[9] Because veins work against gravity, their
valves work by compartmentalising the blood, leading to better equalisation of pressures throughout the
veins and preventing reflux. Blood pools when valves do not function properly, leading to increased pressure
and distension of the veins.[10] However, it is not clear whether the valves fail because of vein dilation or
whether the veins dilate due to valve failure.
Progesterone is believed to lead to passive venous dilation, which may then lead to valvular dysfunction.
Oestrogen produces collagen fibre changes and smooth muscle relaxation, which both lead to vein
dilation.[3]
Pathophysiology
The venous system acts as both a reservoir and a conduit in the return of blood to the heart and lungs for
oxygenation and re-circulation. End capillary venous pressure is low (20 mmHg). Veins are thin-walled and
lack the muscular walls of arteries. Therefore, veins require assistance in blood return. This is provided by
valves and muscle pumps - as one walks, the muscle pumps contract and push blood against gravity, and
as the muscle pump relaxes, the fall of the blood is stopped by the valve system. When one of these factors
is not functioning properly, venous hypertension and insufficiency can ensue, possibly leading to varicose
veins.
A normal vein wall has three smooth muscle layers that all help to maintain its tone. Varicose veins
demonstrate marked proliferation of collagen matrix as well as decreased elastin, leading to distortion and
disruption of muscle fibre layers.[5]
Classification
4 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Mar 06, 2020.
Clinical, Etiological, Anatomical, and Pathophysiological (CEAP)
classification for chronic venous disorders[2]
1. Clinical classification
THEORY
• C0 - no visible or palpable signs of venous disease
• C1 - telangiectasis or reticular vein; veins less than 3 mm
• C2 - varicose veins; veins greater than 3 mm
• C3 - oedema
• C4a - pigmentation or eczema
• C4b - lipodermatosclerosis or atrophie blanche
• C5 - healed venous ulcer
• C6 - active venous ulcer
2. Etiology
• Ep - primary
• Es - secondary
• En - no venous cause identified
3. Anatomy
• As - superficial veins
• Ap - perforator veins
• Ad - deep veins
• An - no location identified
4. Pathophysiology
• Basic CEAP
• Pr - reflux
• Po - obstruction
• Pro - reflux and obstruction
• Pn - no pathophysiology identified
• Advanced CEAP
• Same as basic but in addition, 18 named venous segments can locate the pathology
5. Level of investigation
• L1 - clinical or handheld Doppler

• L2 - non-invasive (duplex ultrasound, plethysmography)
• L3 - invasive or complex (venography, CT, or MRI)
This staging system is extensive, but the clinical component is the only aspect in common use.
5
Case history
Case history #1
THEORY
A 45-year-old woman presents with complaints of heaviness and fatigue in her legs. She does not
experience the symptoms when she first awakens, but they become more noticeable and prominent as
the day progresses and with prolonged standing. When she is standing for most of the day she notes
swelling in both legs. The symptoms are concentrated over her medial calf, where she has prominent
tortuous veins. She first noted dilated veins about 20 years ago when she was pregnant. Initially they
did not cause her any discomfort but they have progressively enlarged and over the past 10 years have
become increasingly painful. She recalls that her mother had similar veins in her legs.
Other presentations
Patients may also present with thrombophlebitis, bleeding, and venous ulceration. Thrombophlebitis
presents as severe pain and erythema, hyperpigmentation, and hardening of the vein. It is more correctly
called superficial venous thrombosis and is on the venous thromboembolism (VTE) spectrum; there is a
risk of developing deep vein thrombosis despite use of anticoagulation.
Varicose veins Diagnosis
Approach
The history and physical examination are key components for the diagnosis of varicose veins. This is
complemented by mandatory duplex ultrasonography to assess for reflux, not only in the varicosities but also
in the truncal veins.
History
Patients may present with varied symptoms, and many may be asymptomatic. Some of the more common
symptoms include heaviness or fatigue in the lower extremities and ankle oedema, especially with
prolonged standing. Burning and itching of the skin over the veins, restless legs, and leg cramps (usually
nocturnal) may also be present. Symptoms are generally worse during pregnancy or menstruation.
Patients will often find relief with elevation of the leg or while wearing compression hosiery. During the
evaluation, patients should be questioned regarding previous interventions on their veins as well as
history of trauma, deep vein thrombosis, ulcerations, or bleeding from varicosities. Most varicose veins do
not progress to complications such as ulceration.[12]
Examination
With the patient standing, the skin is examined visually and by palpation for irregularities and bulges
consistent with varicose veins. The extent, size, and location of the dilated veins should be noted, along
with skin changes such as haemosiderin depositions, lipodermatosclerosis (C4b), and areas of active
(C6) or healed (C5) ulceration. Thrombophlebitis presents as severe pain, erythema (and superficial
pigmentation), and vein induration. Hyperpigmentation, lipodermatosclerosis (area of induration because
of fibrosis of subcutaneous fat), or ulcers are indicative of long-standing venous insufficiency.
DIAGNOSIS
Varicose veins
From the collection of Maureen K. Sheehan, MD; used with permission
7
DIAGNOSIS Varicose veins Diagnosis
Haemosiderin deposition
Imaging
Duplex ultrasound imaging uses B mode imaging and Doppler assessment to diagnose venous
insufficiency by evaluating valvular function in various segments of the truncal veins as well as in the
varicosities. B mode imaging is used to rule out deep vein thrombosis and persistent obstruction in
the venous system. Venous duplex ultrasound scans are performed in the standing position and take
approximately 20 minutes per leg. Repeated calf compressions are used to identify reflux of blood.
History and exam

Key diagnostic factors
presence of risk factors (common)
• Key risk factors include increasing age, family history, female sex, increasing numbers of births, and
deep vein thrombosis.
dilated tortuous veins (common)

• With the patient standing, the skin is examined visually and by palpation for irregularities and bulges
consistent with varicose veins.
Varicose veins
The extent, size, and location of the dilated veins should be noted.
Other diagnostic factors
DIAGNOSIS
leg fatigue or aching with prolonged standing (common)
• Not present at beginning of day, improves with elevation.
leg cramps (common)

• Usually nocturnal. May be related to varicose veins and thus may improve with treatment; however,
can be multi-factorial in aetiology.
restless legs (common)

• Characterised by a compulsive urge to move the legs, though this can be multifactorial.
haemosiderin deposition (common)

• Clinical sign of venous hypertension and is irreversible. It is an indication of high risk for ulceration,
with the haemosiderin causing inflammation and damaging the soft tissues.
• Can occur without venous incompetence in the context of morbid obesity (which reduces venous
outflow).
9
corona phlebectatica (common)
• Multiple fine vein branches that suggest underlying chronic venous insufficiency.
itching (uncommon)
• Occurs with prolonged standing or exercise.
lipodermatosclerosis (uncommon)
• Clinical sign of venous hypertension and is irreversible. It is an indication of high risk for ulceration
and is the result of haemosiderin causing inflammation and damaging the soft tissues. This leads to
scarred and fibrotic tissues.
ankle swelling (uncommon)

• Detectable in affected leg with prolonged standing. This is common and represents C3 class disease.
ulceration (uncommon)
• Varicose ulcers are indicative of long-standing venous insufficiency; however, most varicose veins do
not progress to complications such as ulceration.[12]
• Ulceration is an indication for urgent referral.
bleeding from varices (uncommon)

• Patients should be asked about bleeding from the varices; however, most varicose veins do not
progress to complications such as haemorrhage.[12]
• This should generate an urgent referral, and still leads to occasional deaths in the frail.
Risk factors
Strong
increasing age
DIAGNOSIS
• Prevalence increases with age.[7]
family history
• One of the most important risk factors for developing varicose veins. Studies in both the US and
France have shown that a family history of varicose veins in an immediate family member increases
the risk of developing varicose veins.[11]
female sex
• Majority of studies have demonstrated a greater prevalence in women than in men; however, this may
be due to presentation bias. Despite the greater prevalence in women, the presenting level of disease
in men has been found to be worse.[3]
increasing numbers of births

• Pregnancy increases both total body fluid and intra-abdominal pressure, which may cause venous
distension. In addition, the increase in oestrogen, progesterone, and relaxin increases vein
capacitance by increasing venous relaxation.[11]
deep vein thrombosis
• May cause valvular damage and dysfunction in the deep veins, leading to increased pressure in
tributaries with subsequent distension and varicose vein formation.
Weak
occupation with prolonged standing
• Occupations with prolonged standing are thought to predispose to venous insufficiency.[5]
obesity
• Appears to be a positive risk factor, more in women than in men.[5]
Investigations
1st test to order
Test Result
duplex ultrasound assesses for reversed flow;
roughly, valve closure
• Reflux is roughly defined as valve closure >0.5 second in the
time >0.5 second is
superficial system and >1.0 second in the deep system. For best
indicative of reflux, while
sensitivity, reflux should be measured with the patient standing and
with the leg in external rotation. With duplex ultrasound, specific valve closure time >1.0
second is indicative of
segments affected by reflux can be delineated as superficial and
reflux in the deep system
deep truncal veins, perforators, and tributaries can all be visualised.
Proximal venous reflux can be detected through use of a Valsalva
manoeuvre, while more distal reflux can be elicited by compressing
the leg above the Doppler to see if blood is forced back towards the
feet. Reflux in perforator veins is controversial.[13] Duplex ultrasound
can be performed not only to assess for valve closure time but also to
rule out deep vein thrombosis.
DIAGNOSIS
Differentials
Condition Differentiating signs / Differentiating tests

symptoms
Telangiectasias • Also known as spider veins. • Veins are smaller in size (<1
These are small veins that mm). No evidence of reflux
generally do not cause any on duplex examination.
symptoms but are mainly a
cosmetic concern.
Reticular veins • Permanently dilated • Veins range between 1 mm

intradermal veins. May and 3 mm in diameter. No
be tortuous. Usually evidence of reflux on duplex
asymptomatic. examination.
11
Criteria
Clinical, Etiological, Anatomical, and Pathophysiological (CEAP)
criteria[14]
Varicose veins are 3 mm or more in diameter in the upright position. Ultrasound shows reversed flow. Valve
closure time >0.5 second in the superficial system is indicative of reflux. Valve closure time >1.0 second is
indicative of reflux in the deep system.
DIAGNOSIS
Varicose veins Management
Approach
The main interventional treatment options for varicose veins include endovenous ablation, foam
sclerotherapy, phlebectomy, and open surgery.[15] [16] [17]
Compression stockings may be offered if interventional treatment is unsuitable (e.g., in pregnancy) or if the
patient is unwilling to have intervention. These need to be replaced and re-measured every 3 months.
All treatment outcomes can be improved with adjunctive lifestyle modifications such as weight loss, leg
elevation, and exercise (especially aqua-aerobics).
All venous ulcers need urgent specialist review, arterial and venous assessment, venous incompetence
treatment, and compression therapy. This increases the rate of healing and reduces the rate of recurrence.
Tributary insufficiency
If the patient only has varicosities (insufficiency of tributaries) without major venous trunk reflux,
phlebectomy of affected veins via stab avulsion, or foam sclerotherapy of the affected veins, is all that
is necessary.[15] Phlebectomy can be achieved via small incisions with removal of the veins, and this
can easily be performed under local anaesthetic in an ambulatory procedure. Patients need to be
counselled that, although current varicosities will be treated and removed, they will very likely develop new
varicosities in other veins in the future, as varicose veins are a progressive disease.
Foam sclerotherapy is the ultrasound-guided injection of a foamed solution, such as polidocano or sodium
tetradecyl sulfate, which causes endothelial cell death and vein inflammation, leading to vein occlusion.
Treatment for recurrence is repeated phlebectomy or foam sclerotherapy.
Superficial truncal system insufficiency

If the superficial axial system (the great saphenous vein, the small saphenous vein, or the anterior
accessory saphenous vein) is involved, the patient will require treatment of the axial system. Typically,
endovenous thermal ablation (radiofrequency or laser ablation) is offered as a first-line option, followed by
ultrasound-guided foam sclerotherapy if endovenous ablation is unsuitable, or open surgery (stripping and
ligation) if neither are suitable.[16] [15] [17]
Ablative procedures and foam sclerotherapy are routinely performed under local anaesthetic, or as a day
case under general anaesthetic. Surgery can also be performed as a day case under general or regional
anaesthetic.
Radiofrequency and endovenous laser ablation have been shown to be as effective as open surgery,
but with decreased postoperative pain and recovery time.[15] [18] [19] [20] [21] [22] [23] [24] [25]
Radiofrequency ablation has been shown to have reduced pain profiles compared with laser treatment;
however, multiple new laser wavelengths have improved the pain profile.[26] [27]
Five-year results of a randomised clinical trial of conventional surgery, endovenous laser ablation, and
MANAGEMENT
ultrasound-guided foam sclerotherapy found that endovenous laser ablation and conventional surgery
were more effective than foam sclerotherapy.[25] However, while foam sclerotherapy has been shown
to have lower technical success rates and disease-specific quality of life scores, it has similar generic
quality of life outcomes and significantly lower procedural cost and impact.[28] [29] Long-term follow-up of
13
endovenous thermal ablation has shown no significant difference in recurrence or symptom relief between
surgery and endovenous ablation.[28]
Patients may undergo concomitant truncal vein and varicosity treatment at the initial intervention, as this
may reduce the need for further procedures and improve the quality of life.[30] [31]
Recurrence after radiofrequency or endovenous laser ablation can be treated with repeat endovenous
approach, foam sclerotherapy, or stripping and ligation.
Recurrence after stripping and ligation may be the result of a duplicate system (which should be excluded
on the initial venous duplex map), and which can be treated via repeat stripping and ligation (though this
is a significantly complex procedure) or one of the endovenous approaches.
Perforating veins
Clinical practice guidelines from the Society for Vascular Surgery and the American Venous Forum
recommend the treatment of perforating veins with reflux when located near healed or active venous
ulcers (CEAP class 5-6). These guidelines also recommend against perforator treatment in CEAP class
1 to 2 patients. The value of perforator treatment in CEAP class 3 to 4 disease remains unclear.[32]
Subfascial endoscopic perforator surgery (SEPS), open perforator surgery, sclerotherapy, and thermal
ablation have all been used for perforator closure. Treatment of perforators in CEAP class 3 to 4 disease
in patients with venous ulcers should be considered after superficial reflux treatment and compression
have failed. The success of thermoablation procedures is around 60% to 80%, with better occlusion
rates with repeated therapy. Ultrasound-guided foam sclerotherapy has a lower thrombosis rate, but
may be easier to perform for varicosities located near the ulcer bed in addition to the feeding perforator.
Successful closure of pathological perforators using these techniques may improve ulcer healing and
decrease recurrence.[33] However, up to 80% of incompetent perforators will revert to competence after
successful ablation of truncal vein incompetence.[34]
Deep vein insufficiency

If the patient has deep system insufficiency giving rise to varicosities without evidence of superficial
truncal vein insufficiency, treatment of the varicosities with phlebectomy or foam sclerotherapy may be
performed; however, compression therapy will be necessary for long-term control, and is key in all cases
where compression is possible. Patients with deep system insufficiency should be counselled that they
may not have complete symptomatic relief through treatment of the varicosities, but can expect at least
partial relief of their symptoms.[15] [17]
Patients with deep vein insufficiency and superficial truncal vein insufficiency may be treated with
endovenous thermal ablation, foam sclerotherapy, or open surgery. Compression therapy should be
utilised in addition to intervention to improve patient quality of life and prevent progression.[35]
In patients with co-existent superficial and segmental deep venous reflux, superficial venous surgery
alone corrects the deep venous insufficiency in almost 50% of limbs, and is associated with ulcer healing
in 77% of limbs at 12 months. This finding suggests an extended role for superficial venous surgery in the
management of patients with complicated venous disease.[36] In specialist centres, open deep venous
MANAGEMENT
reconstruction may be considered in severe cases.
Deep vein obstruction
In cases of significant rates of recurrence or unusual features, assessment of iliac vein stenosis or
occlusion may also improve symptomatology and clinical severity from the potential use of iliac vein
stenting, or open deep venous reconstruction; however, these require long-term use of anticoagulation
and compression hosiery. Any intervention on the superficial system in these patients should be assessed
very carefully in specialist centres.
MANAGEMENT
15
Treatment algorithm overview

Please note that formulations/routes and doses may differ between drug names and brands, drug
formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
Ongoing ( summary )
symptomatic superficial vein
insufficiency, no evidence of
peripheral vascular disease
or superficial axial truncal
insufficiency: tributary insufficiency
only
1st phlebectomy or foam sclerotherapy

peripheral vascular disease or
superficial tributary insufficiency:
truncal axial insufficiency only
1st endovenous thermal ablation

(radiofrequency or laser)
2nd foam sclerotherapy
3rd open surgery (stripping and ligation)

peripheral vascular disease: truncal
axial and tributary insufficiency

(radiofrequency or laser) and phlebectomy
or foam sclerotherapy
2nd foam sclerotherapy of truncal and

tributary veins
3rd open surgery (stripping and ligation) and

phlebectomy

peripheral vascular disease:
perforator veins with reflux located
near healed or active venous ulcers
1st foam sclerotherapy or endovenous

thermal ablation
plus compression therapy: bandage or

MANAGEMENT
stockings
2nd perforator surgery

stockings
Ongoing ( summary )
deep vein insufficiency without
superficial truncal vein insufficiency
but with superficial tributary
insufficiency

stockings
deep vein insufficiency with



stockings

stockings

stockings

superficial vein insufficiency
1st compression therapy: bandage or

stockings
2nd open surgical deep vein reconstruction

(rarely needed)
deep vein obstruction
1st stenting or reconstruction
MANAGEMENT
17
Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug
formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
Ongoing
peripheral vascular disease
or superficial axial truncal
insufficiency: tributary insufficiency
only
» Phlebectomy may be achieved by stab

avulsion of portions of varicose vein, through
small stab incisions not requiring suture closure.
Foam sclerotherapy involves injection of a
foamed solution such as sodium tetradecyl
sulfate or polidocanol into small veins, followed
by compression.
» Recurrence requires repeat phlebectomies or

foam sclerotherapy.
» Complications include haematoma, deep

venous thrombosis, infection, skin pigmentation,
and poor cosmetic outcome. Foam sclerotherapy
has had scattered reports of stroke after
intervention.[37]
» Patients should also be counselled on

lifestyle modifications, including weight loss, leg
elevation, and exercise.[38]
peripheral vascular disease or
superficial tributary insufficiency:
truncal axial insufficiency only

» Radiofrequency ablation (RFA): generally

performed on the great saphenous vein (GSV),
anterior accessory saphenous vein (AASV), or
small saphenous vein (SSV). Special probes
are available for use in perforator veins if
needed. The vein is accessed under ultrasound
guidance. In the case of the GSV, the RFA probe
MANAGEMENT
is passed up to just below the epigastric vein,

remaining 2 cm below the saphenofemoral
junction (SFJ). It is slowly withdrawn in
segments or continuously while energy from
radiofrequency causes closure of the vein.
Patients may still require phlebectomies for
Ongoing
varicosities. Complications include endothermal
heat-induced thrombosis (EHIT), phlebitis,
thermal skin injury, and paraesthesias. These
occur infrequently.
» Endovenous laser therapy (EVLT): generally

performed on GSV, AASV, or SSV but may be
possible in branch varicosities as well. The vein
is accessed under ultrasound guidance. In the
case of GSV, a laser probe is passed up to just
below the epigastric vein, remaining below the
SFJ. The fibre is slowly withdrawn while the laser
is on, causing thrombosis and destruction of the
vein. Patients may still require phlebectomies
for varicosities. Complications include EHIT,
phlebitis, thermal skin injury, and paraesthesias.
These occur infrequently.[39]

» Involves injection of liquid solution such as

sodium tetradecyl sulfate or polidocanol that is
foamed with air and then injected into varicose
vein under ultrasound guidance. Complications
include pigmentation, headaches, and visual
changes. It has a higher recurrence rate than
radiofrequency ablation, endovenous laser
therapy, or surgery, but is much faster and
cheaper.[22] [40] [41]

» The main goal of stripping and ligation is to

permanently remove the varicose vein. It is
performed when the greater saphenous vein
or small saphenous vein has reflux that gives
rise to the varicose veins. Complications include
bleeding, infection, saphenous nerve injury, and
neovascularisation.

MANAGEMENT
peripheral vascular disease: truncal
axial and tributary insufficiency
19
Ongoing
(radiofrequency or laser) and phlebectomy
or foam sclerotherapy
» Patients may undergo concomitant truncal vein

and varicosity treatment as this may reduce the
need for further procedures and improve quality
of life.[30] [31]

occur infrequently.


by compression.

sclerotherapy.
» Complications include haematoma, deep vein

MANAGEMENT
thombosis, infection, skin pigmentation, and poor

cosmetic outcome. Foam sclerotherapy has had
scattered reports of stroke after intervention.[37]
Ongoing
2nd foam sclerotherapy of truncal and
tributary veins
» Foam sclerotherapy involves injection of a

by compression.

sclerotherapy.
» Complications include haematoma, deep vein

thombosis, infection, skin pigmentation, and poor
cosmetic outcome. Foam sclerotherapy has had
scattered reports of stroke after intervention.[37]

3rd open surgery (stripping and ligation) and
phlebectomy

neovascularisation.


peripheral vascular disease:
perforator veins with reflux located
near healed or active venous ulcers
1st foam sclerotherapy or endovenous thermal

ablation
» The success of thermoablation procedures is

around 60% to 80%, with better occlusion rates
MANAGEMENT
with repeated therapy. Ultrasound-guided foam

sclerotherapy has a lower thrombosis rate, but
may be easier to perform for varicosities located
near the ulcer bed in addition to the feeding
perforator. Successful closure of pathologic
perforators using these techniques may improve
21
Ongoing
ulcer healing and decrease recurrence.[33]
However, up to 80% of incompetent perforators
will revert to competence after successful
ablation of truncal vein incompetence.[34]
stockings
Treatment recommended for ALL patients in
selected patient group
» Compression therapy should be utilised in
addition to intervention to improve patient quality
of life and prevent progression.[35]
2nd perforator surgery
» Subfascial endoscopic perforator surgery

or open perforator surgery may be used for
perforator closure.
stockings
addition to intervention to improve healing rates
and improve patient quality of life.[35]
but with superficial tributary
insufficiency

by compression.

foam sclerotherapy.
» Complications include haematoma, deep

venous thrombosis, infection, skin pigmentation,
and poor cosmetic outcome. Foam sclerotherapy
has had scattered reports of stroke after
intervention.[37]

MANAGEMENT

stockings
Ongoing
deep vein insufficiency with


occur infrequently.


stockings
MANAGEMENT

23
Ongoing
» Involves injection of liquid solution such as
sodium tetradecyl sulfate or polidocanol that is
foamed with air and then injected into varicose
vein under ultrasound guidance. Complications
include pigmentation, headaches, and visual
changes. It has a higher recurrence rate than
radiofrequency ablation, endovenous laser
therapy, or surgery, but is much faster and
cheaper.[22] [40] [41]

stockings

neovascularisation.

stockings
superficial vein insufficiency
1st compression therapy: bandage or

stockings
» Compression therapy should be utilised

to improve patient quality of life and prevent
MANAGEMENT
progression.[35]
2nd open surgical deep vein reconstruction
(rarely needed)
Ongoing
» Open deep venous reconstruction may be
considered in severe cases. This is highly
specialised.
deep vein obstruction
1st stenting or reconstruction
» In cases of significant rates of recurrence

or unusual features, assessment of iliac
vein stenosis or occlusion may also improve
symptomatology and clinical severity from the
potential use of iliac vein stenting, or open
deep venous reconstruction; however, these
require long-term use of anticoagulation and
compression hosiery. Any intervention on the
superficial system in these patients should be
assessed very carefully in specialist centres.
MANAGEMENT
25
Emerging
Non-thermal non-tumescent endovenous ablation
Options for non-thermal non-tumescent endovenous ablation include using mechanochemical ablation
(MOCA) or cyanoacrylate glue (CAG) occlusion.[42] [43] [44] Early evidence suggests equivalent quality of
life outcomes with a reduced pain profile compared with endothermal ablation with no difference between
MOCA and CAG yet found on head to head comparison.[45]
Primary prevention
Although no measures have been shown to prevent varicose veins, avoidance of prolonged sitting or
standing, weight loss (if applicable), exercise, and intermittent leg elevation may all be helpful.
Secondary prevention
Prolonged standing, especially in one place, should be avoided. If unavoidable, compression stockings
should be worn. If there is continued evidence of reflux (i.e., deep system insufficiency), compression
stockings should be worn during the day. The use of compression stockings at night is unnecessary. If
obese, patients should be advised to lose weight.
Patient discussions
Following endovenous ablation alone, patients may wear compression stockings during the day for
1 week, though this may not lead to any significant benefit. After additional phlebectomies, use of
compression stockings can lead to reduced postoperative pain.[48] After intervention, patients can return
to normal activities; however, they should avoid strenuous leg activity such as running, weighted leg
exercises, or cycling for 1 week.
MANAGEMENT
Varicose veins Follow up
Monitoring
Monitoring
FOLLOW UP
Following intervention, the patient requires repeat duplex only if symptoms recur. Full outcomes of the
intervention may take up to 6 months.
27
Complications
Complications Timeframe Likelihood

FOLLOW UP
chronic venous insufficiency long term medium
Increased dilation of venous system leading to axial system reflux.
haemorrhage long term low
Erosion of varices can lead to bleeding that may require surgical intervention.
venous ulceration long term low
Increased dilation of the venous system and increased pressure may lead to venous hypertension.
Treatment of the superficial axial system, if involved, will help. Perforator incompetence may also
contribute to ulceration, but the benefit of treating incompetent perforating veins is less clear.[47]
lipodermatosclerosis long term low
Secondary to changes in the microcirculatory system. Capillaries become elongated, fibrotic, and leaky.
haemosiderin deposition long term low
Secondary to changes in the microcirculatory system. Capillaries become elongated, fibrotic, and leaky.
Complications Timeframe Likelihood
FOLLOW UP
Haemosiderin deposition
Prognosis
Although there are small variations in overall efficacy depending on the type of intervention, generally
resolution of symptoms occurs in >95% of patients. However, patients need to be counselled that new
varicosities will very likely occur with time, as varicose veins are a progressive disease and therefore new
varicosities do not necessarily represent treatment failure.[46]
29
Varicose veins Guidelines
Diagnostic guidelines
United Kingdom
Varicose veins: diagnosis and management (ht tp://www.nice.org.uk/guidance/

cg168)
Published by: National Institute for Health and Care Excellence Last published: 2013
Treatment guidelines
United Kingdom
Endovenous mechanochemical ablation for varicose veins (ht tps://

www.nice.org.uk/guidance/ipg557)
GUIDELINES
Varicose veins: diagnosis and management (ht tp://www.nice.org.uk/guidance/

cg168)
Ultrasound-guided foam sclerotherapy for varicose veins (ht tp://

guidance.nice.org.uk/IPG440)
Randomised clinical trial, observational study and assessment of cost-

effectiveness of the treatment of varicose veins (REACTIV trial) (ht tp://
www.journalslibrary.nihr.ac.uk/hta/volume-10/issue-13)
Published by: Health Technology Assessment NHS R&D HTA Last published: 2006
Programme
North America
Management of venous leg ulcers (ht tps://vascular.org/research-quality/

guidelines-and-reporting-standards/clinical-practice-guidelines)
Published by: 2014 Last published: Society for
Vascular Surgery; American
Venous Forum
The care of patients with varicose veins and associated chronic venous
diseases (ht tps://vascular.org/research-quality/guidelines-and-reporting-
standards/clinical-practice-guidelines)
Published by: 2011 Last published: Society for
Vascular Surgery; American
Venous Forum
Varicose veins References
Key articles
• Gloviczki P, Comerota AJ, Dalsing MC, et al. The care of patients with varicose veins and associated
REFERENCES
chronic venous diseases: clinical practice guidelines of the Society for Vascular Surgery and
the American Venous Forum. J Vasc Surg. 2011 May;53(5 Suppl):2S-48S. Full text (http://
www.sciencedirect.com/science/article/pii/S0741521411003272?via%3Dihub) Abstract (http://
www.ncbi.nlm.nih.gov/pubmed/21536172?tool=bestpractice.bmj.com)
• National Institute for Health and Care Excellence. Varicose veins: diagnosis and management. July
2013 [internet publication]. Full text (https://www.nice.org.uk/guidance/cg168)
• Wittens C, Davies AH, Bækgaard N, 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. 2015 Jun;49(6):678-737. Full text (https://www.doi.org/10.1016/j.ejvs.2015.02.007) Abstract
(http://www.ncbi.nlm.nih.gov/pubmed/25920631?tool=bestpractice.bmj.com)
• van der Velden SK, Biemans AA, De Maeseneer MG, et al. Five-year results of a randomized clinical
trial of conventional surgery, endovenous laser ablation and ultrasound-guided foam sclerotherapy in
patients with great saphenous varicose veins. Br J Surg. 2015 Sep;102(10):1184-94. Abstract (http://
• Brittenden J, Cooper D, Dimitrova M, et al. Five-year outcomes of a randomized trial of treatments

for varicose veins. N Engl J Med. 2019 Sep 5;381(10):912-22. Abstract (http://www.ncbi.nlm.nih.gov/
pubmed/31483962?tool=bestpractice.bmj.com)
• Gohel MS, Heatley F, Liu X, et al. A randomized trial of early endovenous ablation in
venous ulceration. N Engl J Med. 2018 May 31;378(22):2105-14. Full text (https://
www.doi.org/10.1056/NEJMoa1801214) Abstract (http://www.ncbi.nlm.nih.gov/pubmed/29688123?
tool=bestpractice.bmj.com)
• Brittenden J, Cotton SC, Elders A, et al. A randomized trial comparing treatments for varicose
veins. N Engl J Med. 2014 Sep 25;371(13):1218-27. Full text (http://www.nejm.org/doi/full/10.1056/
NEJMoa1400781#t=article) Abstract (http://www.ncbi.nlm.nih.gov/pubmed/25251616?
References
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31
3. Beebe-Dimmer JL, Pfeifer JR, Engle J, et al. The epidemiology of chronic venous insufficiency
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Med. 2009 May 28;360(22):2319-27. Abstract (http://www.ncbi.nlm.nih.gov/pubmed/19474429?
14. Allegra C, Antignani PL, Bergan JJ, et al. The "C" of CEAP: suggested definitions and refinements:
an International Union of Phlebology conference of experts. J Vasc Surg. 2003;37:129-131. Abstract
15. Gloviczki P, Comerota AJ, Dalsing MC, et al. The care of patients with varicose veins and associated
chronic venous diseases: clinical practice guidelines of the Society for Vascular Surgery and
the American Venous Forum. J Vasc Surg. 2011 May;53(5 Suppl):2S-48S. Full text (http://
www.sciencedirect.com/science/article/pii/S0741521411003272?via%3Dihub) Abstract (http://
REFERENCES
16. National Institute for Health and Care Excellence. Varicose veins: diagnosis and management. July
2013 [internet publication]. Full text (https://www.nice.org.uk/guidance/cg168)
17. Wittens C, Davies AH, Bækgaard N, 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. 2015 Jun;49(6):678-737. Full text (https://www.doi.org/10.1016/j.ejvs.2015.02.007) Abstract
18. Siribumrungwong B, Noorit P, Wilasrusmee C, et al. A systematic review and meta-analysis

of randomised controlled trials comparing endovenous ablation and surgical intervention in
patients with varicose vein. Eur J Vasc Endovasc Surg. 2012 Aug;44(2):214-23. Abstract (http://
19. Murad MH, Coto-Yglesias F, Zumaeta-Garcia M, et al. A systematic review and meta-analysis of
the treatments of varicose veins. J Vasc Surg. 2011 May;53(5 Suppl):49S-65S. Abstract (http://
20. Biemans AAM, Nijsten TEC. A randomized comparative study of the three most commonly performed
treatments for varicose veins: results after one year. Ned Tijdschr Dermatol Venereol. 2012;22:78-84.
21. Carradice D, Mekako AI, Mazari FA, et al. Randomized clinical trial of endovenous laser
ablation compared with conventional surgery for great saphenous varicose veins. Br J
Surg. 2011 Apr;98(4):501-10. Abstract (http://www.ncbi.nlm.nih.gov/pubmed/21283981?
22. Biemans AA, Kockaert M, Akkersdijk GP, et al. Comparing endovenous laser ablation,
foam sclerotherapy, and conventional surgery for great saphenous varicose veins. J Vasc
Surg. 2013 Sep;58(3):727-34.e1. Abstract (http://www.ncbi.nlm.nih.gov/pubmed/23769603?
23. Brittenden J, Cotton SC, Elders A, et al. Clinical effectiveness and cost-effectiveness of foam
sclerotherapy, endovenous laser ablation and surgery for varicose veins: results from the Comparison
of LAser, Surgery and foam Sclerotherapy (CLASS) randomised controlled trial. Health Technol
Assess. 2015 Apr;19(27):1-342. Full text (https://www.ncbi.nlm.nih.gov/books/NBK285233) Abstract
24. Nandhra S, El-sheikha J, Carradice D, et al. A randomized clinical trial of endovenous laser ablation
versus conventional surgery for small saphenous varicose veins. J Vasc Surg. 2015 Mar;61(3):741-6.
25. van der Velden SK, Biemans AA, De Maeseneer MG, et al. Five-year results of a randomized clinical
trial of conventional surgery, endovenous laser ablation and ultrasound-guided foam sclerotherapy in
patients with great saphenous varicose veins. Br J Surg. 2015 Sep;102(10):1184-94. Abstract (http://
33
26. Shepherd AC, Gohel MS, Brown LC, et al. Randomized clinical trial of VNUS ClosureFAST
radiofrequency ablation versus laser for varicose veins. Br J Surg. 2010 Jun;97(6):810-8. Full text
(https://www.doi.org/10.1002/bjs.7091) Abstract (http://www.ncbi.nlm.nih.gov/pubmed/20473992?
REFERENCES
27. Kabnick LS, Sadek M. Fiber type as compared to wavelength may contribute more to improving
postoperative recovery following endovenous laser ablation. J Vasc Surg Venous Lymphat
Disord. 2016 Jul;4(3):286-92. Abstract (http://www.ncbi.nlm.nih.gov/pubmed/27318047?
28. Brittenden J, Cooper D, Dimitrova M, et al. Five-year outcomes of a randomized trial of treatments
for varicose veins. N Engl J Med. 2019 Sep 5;381(10):912-22. Abstract (http://www.ncbi.nlm.nih.gov/
29. Marsden G, Perry M, Bradbury A, et al. A Cost-effectiveness analysis of surgery, endothermal

ablation, ultrasound-guided foam sclerotherapy and compression stockings for symptomatic
varicose veins. Eur J Vasc Endovasc Surg. 2015 Dec;50(6):794-801. Full text (https://
www.doi.org/10.1016/j.ejvs.2015.07.034) Abstract (http://www.ncbi.nlm.nih.gov/pubmed/26433594?
30. Carradice D, Mekako AI, Hatfield J, et al. Randomized clinical trial of concomitant or sequential
phlebectomy after endovenous laser therapy for varicose veins. Br J Surg. 2009 Apr;96(4):369-75.
31. Lane TR, Kelleher D, Shepherd AC, et al. Ambulatory varicosity avulsion later or synchronized
(AVULS): a randomized clinical trial. Ann Surg. 2015 Apr;261(4):654-61. Abstract (http://
32. O'Donnell TF Jr, Passman MA, Marston WA, et al. Management of venous leg ulcers: clinical practice
guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg. 2014
Aug;60(suppl 2):3S-59S. Full text (http://www.jvascsurg.org/article/S0741-5214(14)00851-9/fulltext)
33. Dillavou ED, Harlander-Locke M, Labropoulos N, et al. Current state of the treatment of
perforating veins. J Vasc Surg Venous Lymphat Disord. 2016 Jan;4(1):131-5. Abstract (http://
34. O'Donnell TF Jr. Part two: against the motion. Venous perforator surgery is unproven and does
not reduce recurrences. Eur J Vasc Endovasc Surg. 2014 Sep;48(3):242-6. Full text (https://
www.doi.org/10.1016/j.ejvs.2014.06.045) Abstract (http://www.ncbi.nlm.nih.gov/pubmed/25132057?
35. Gohel MS, Heatley F, Liu X, et al. A randomized trial of early endovenous ablation in
venous ulceration. N Engl J Med. 2018 May 31;378(22):2105-14. Full text (https://
www.doi.org/10.1056/NEJMoa1801214) Abstract (http://www.ncbi.nlm.nih.gov/pubmed/29688123?
36. Adam DJ, Bello M, Hartshorne T, et al. Role of superficial venous surgery in patients with combined
superficial and segmental deep venous reflux. Eur J Vasc Endovasc Surg. 2003 May;25(5):469-72.
REFERENCES
37. Sarvananthan T, Shepherd AC, Willenberg T, et al. Neurological complications of
sclerotherapy for varicose veins. J Vasc Surg. 2012 Jan;55(1):243-51. Full text (https://
www.doi.org/10.1016/j.jvs.2011.05.093) Abstract (http://www.ncbi.nlm.nih.gov/pubmed/21840152?
38. Leopardi D, Hoggan BL, Fitridge RA, et al. Systematic review of treatments for varicose veins. Ann
Vasc Surg. 2009 Mar;23(2):264-76. Abstract (http://www.ncbi.nlm.nih.gov/pubmed/19059756?
39. Van Den Bos RR, Neumann M, De Roos KP, et al. Endovenous laser ablation-induced complications:
review of the literature and new cases. Dermatol Surg. 2009 Aug;35(8):1206-14. Abstract (http://
40. Rasmussen LH, Lawaetz M, Bjoern L, et al. Randomized clinical trial comparing endovenous laser
ablation, radiofrequency ablation, foam sclerotherapy and surgical stripping for great saphenous
varicose veins. Br J Surg. 2011 Aug;98(8):1079-87. Abstract (http://www.ncbi.nlm.nih.gov/
41. Brittenden J, Cotton SC, Elders A, et al. A randomized trial comparing treatments for varicose
veins. N Engl J Med. 2014 Sep 25;371(13):1218-27. Full text (http://www.nejm.org/doi/full/10.1056/
NEJMoa1400781#t=article) Abstract (http://www.ncbi.nlm.nih.gov/pubmed/25251616?
42. Bootun R, Lane TR, Davies AH. The advent of non-thermal, non-tumescent techniques for
treatment of varicose veins. Phlebology. 2016 Feb;31(1):5-14. Abstract (http://www.ncbi.nlm.nih.gov/
43. Vähäaho S, Mahmoud O, Halmesmäki K, et al. Randomized clinical trial of mechanochemical and
endovenous thermal ablation of great saphenous varicose veins. Br J Surg. 2019 Apr;106(5):548-54.
44. Gibson K, Morrison N, Kolluri R, et al. Twenty-four month results from a randomized trial of
cyanoacrylate closure versus radiofrequency ablation for the treatment of incompetent great
saphenous veins. J Vasc Surg Venous Lymphat Disord. 2018 Sep;6(5):606-13. Full text (https://
www.doi.org/10.1016/j.jvsv.2018.04.009) Abstract (http://www.ncbi.nlm.nih.gov/pubmed/29914814?
45. Lane T, Bootun R, Dharmarajah B, et al. A multi-centre randomised controlled trial comparing
radiofrequency and mechanical occlusion chemically assisted ablation of varicose veins - final results
of the Venefit versus Clarivein for varicose veins trial. Phlebology. 2017 Mar;32(2):89-98. Abstract
46. Perrin MR, Labropoulos N, Leon LR Jr. Presentation of the patient with recurrent varices after
surgery (REVAS). J Vasc Surg. 2006 Feb;43(2):327-34. Full text (http://www.jvascsurg.org/article/
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S0741-5214(05)01881-1/fulltext) Abstract (http://www.ncbi.nlm.nih.gov/pubmed/16476610?
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47. O'Donnell TF Jr, Passman MA, Marston WA, et al. Management of venous leg ulcers: clinical practice
guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg.
2014;60(suppl):3S-59S. Full text (http://www.jvascsurg.org/article/S0741-5214(14)00851-9/fulltext)
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2011;40:15-19.
Varicose veins Images
Images
Figure 1: Varicose veins
IMAGES
37
IMAGES Varicose veins Images
Figure 2: Haemosiderin deposition

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Contributors:
// Authors:
Alun H Davies, MA, DM, DSc, FRCS, FHEA, FEBVS, FACPh

Professor of Vascular Surgery and Honorary Consultant Vascular Surgeon
Department of Surgery and Cancer, Imperial College London, Imperial Vascular Unit, Imperial College
Healthcare NHS Trust, London, UK
DISCLOSURES: AHD declares that he has no competing interests.
Tristan RA Lane, MBBS, BSc, PhD, FRCS

Clinical Lecturer and Post CCT Fellow in Vascular Surgery
Department of Surgery and Cancer, Imperial College London, Imperial Vascular Unit, Imperial College
Healthcare NHS Trust, London, UK
DISCLOSURES: TRAL declares that he has no competing interests.
// Acknowledgements:
Professor Alun Davies and Mr Tristan Lane would like to gratefully acknowledge Dr Luis R. Leon Jr, Dr
Maureen K. Sheehan, and Dr Boulos Toursarkissian, previous contributors to this topic.
DISCLOSURES: LRL, MKS and BT declare that they have no competing interests.
// Peer Reviewers:
Paul Tisi, MBBS, MS, FRCSEd

Medical Director/Consultant Vascular Surgeon
Bedford Hospital, Bedford, UK
DISCLOSURES: PT declares that he has no competing interests.
Nick Morrison, MD, FACS, FACPh

Director
Morrison Vein Institute, Scottsdale, AZ
DISCLOSURES: NM declares that he has no competing interests.

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Varicose veins

Straight to the point of care

Last updated: Mar 06, 2020

Underlying venous insufficiency can be documented by duplex ultrasound.

• L1 - clinical or handheld Doppler

History and exam

dilated tortuous veins (common)

Other diagnostic factors

leg cramps (common)

restless legs (common)

haemosiderin deposition (common)

ankle swelling (uncommon)

bleeding from varices (uncommon)

• Prevalence increases with age.[7]

increasing numbers of births

Condition Differentiating signs / Differentiating tests

Reticular veins • Permanently dilated • Veins range between 1 mm

Treatment for recurrence is repeated phlebectomy or foam sclerotherapy.

Superficial truncal system insufficiency

Deep vein insufficiency

reconstruction may be considered in severe cases.

Treatment algorithm overview

1st phlebectomy or foam sclerotherapy

symptomatic superficial vein

1st endovenous thermal ablation

2nd foam sclerotherapy

3rd open surgery (stripping and ligation)

symptomatic superficial vein

1st endovenous thermal ablation

2nd foam sclerotherapy of truncal and

3rd open surgery (stripping and ligation) and

symptomatic superficial vein

1st foam sclerotherapy or endovenous

plus compression therapy: bandage or

2nd perforator surgery

plus compression therapy: bandage or

1st phlebectomy or foam sclerotherapy

plus compression therapy: bandage or

deep vein insufficiency with

1st endovenous thermal ablation

plus compression therapy: bandage or

2nd foam sclerotherapy

plus compression therapy: bandage or

3rd open surgery (stripping and ligation)

plus compression therapy: bandage or

deep vein insufficiency without

1st compression therapy: bandage or

2nd open surgical deep vein reconstruction

deep vein obstruction

1st stenting or reconstruction

1st phlebectomy or foam sclerotherapy

» Phlebectomy may be achieved by stab

» Recurrence requires repeat phlebectomies or

» Complications include haematoma, deep

» Patients should also be counselled on

1st endovenous thermal ablation

» Radiofrequency ablation (RFA): generally

is passed up to just below the epigastric vein,

» Endovenous laser therapy (EVLT): generally

» Patients should also be counselled on

» Involves injection of liquid solution such as

» Patients should also be counselled on

» The main goal of stripping and ligation is to