What are the symptoms and treatment options for varicose veins?

Symptoms of Varicose Veins

Varicose veins commonly cause localized symptoms including pain, burning, itching, and tingling at the site of the veins, as well as generalized symptoms such as aching, heaviness, cramping, throbbing, restlessness, and swelling in the legs, which typically worsen at the end of the day and after prolonged standing. 1

Common Symptoms

Varicose veins can present with various symptoms, though some patients may be asymptomatic. The clinical presentation typically includes:

Localized Symptoms:

• Pain at the site of varicose veins
• Burning sensation
• Itching
• Tingling

Generalized Symptoms:

• Aching in legs
• Heaviness in legs
• Cramping
• Throbbing
• Restlessness
• Swelling (edema)

These symptoms are often worse:

• At the end of the day
• After prolonged standing
• In warm weather
• During menstrual periods (in women)

Symptoms typically improve when patients sit and elevate their legs 1. Women are significantly more likely than men to report lower limb symptoms.

Risk Factors

Several factors increase the risk of developing varicose veins:

• Family history of venous disease
• Female sex
• Older age
• Chronically increased intra-abdominal pressure due to:
  • Obesity
  • Pregnancy
  • Chronic constipation
  • Abdominal tumors
• Prolonged standing
• Previous deep venous thrombosis
• Arteriovenous shunting 1

Potential Complications

While varicose veins often cause discomfort or cosmetic concerns, serious complications are rare but can include:

• Changes in skin pigmentation
• Eczema
• Infection
• Superficial thrombophlebitis
• Venous ulceration
• Loss of subcutaneous tissue
• Lipodermatosclerosis (hardening of the skin and subcutaneous tissues)
• Rare but significant external hemorrhage from vein perforation 1

Diagnostic Approach

When evaluating varicose veins, clinicians should:

1. Document the presence and extent of visible varicosities
2. Note any skin changes (pigmentation, eczema, ulceration)
3. Assess for edema
4. Consider using the CEAP classification system to characterize the severity:
   • C0: No visible signs
   • C1: Telangiectasias or reticular veins
   • C2: Varicose veins
   • C3: Edema
   • C4: Skin changes (pigmentation, eczema)
   • C5: Healed venous ulcer
   • C6: Active venous ulcer 1

For severe venous disease or when considering interventional therapy, venous duplex ultrasonography is the imaging modality of choice 1. This should be performed in the erect position by a specialist trained in ultrasonography 2.

Treatment Options

Treatment options range from conservative measures to interventional procedures:

Conservative Measures:

• Compression therapy (stockings, bandages)
• Elevation of affected leg
• Lifestyle modifications:
  • Avoiding prolonged standing
  • Regular exercise
  • Wearing non-restrictive clothing
  • Weight loss for obese patients
• Phlebotonics (e.g., horse chestnut seed extract) 1

Interventional Treatments:

• Thermal ablation:
  • External laser thermal ablation (for telangiectasias)
  • Endovenous thermal ablation (for larger vessels)
• Endovenous sclerotherapy
• Surgery (ligation and stripping or phlebectomy) 1

Endovenous thermal ablation has largely replaced traditional surgery as the standard of care, as it can be performed under local anesthesia and may have better outcomes with fewer complications 1. Best practice for treating truncal vein incompetence is endovenous thermal ablation 2.

Important Clinical Considerations

1. Symptom Progression: Symptoms typically worsen with disease progression, with increasing severity corresponding to higher CEAP clinical class 1.

2. Diagnostic Pitfall: Not all leg symptoms are due to varicose veins. Other conditions like peripheral arterial disease, musculoskeletal disorders, or neuropathy may present with similar symptoms.

3. Treatment Selection: The choice of treatment should be based on the severity of symptoms, the extent of venous disease, and patient preferences. Endovenous thermal ablation is now preferred over surgical stripping for most patients 1.

4. Pregnancy Consideration: External compression is the first-line treatment for varicose veins in pregnant women 1.

5. Monitoring: Following treatment, patients should be monitored with follow-up ultrasound to confirm successful vein closure and to detect any recurrence 2.