What is a varicose vein?

Varicose Veins: Definition, Diagnosis, and Management

Varicose veins are superficial vessels that are abnormally twisted, lengthened, or dilated, primarily caused by poorly functioning valves and decreased elasticity of the vein wall, leading to blood pooling and subsequent enlargement. 1

Definition and Pathophysiology

Varicose veins represent a manifestation of venous disease characterized by:

• Inefficient or defective valves within the vein
• Decreased elasticity of the vein wall
• Pooling of blood within the veins
• Subsequent enlargement and twisting of the veins

The term "varicose veins" encompasses both visible bulging veins on the legs and underlying incompetent veins that reflux and cause surface varicosities. Some cases involve "hidden varicose veins" where there is superficial venous reflux without visible bulging veins. 2

Epidemiology

• Affects up to 40% of adults 3
• More common in:
  • Obese individuals
  • Women who have had multiple pregnancies (more than two)
  • Prevalence ranges from 14% for large varices to 59% for small telangiectasias 4

Clinical Presentation

Varicose veins typically present with:

• Visible twisted, bulging veins (most commonly on legs)
• Pain and discomfort
• Heaviness in legs
• Swelling, particularly around ankles
• Skin changes in advanced cases

Without treatment, varicose veins usually deteriorate, potentially progressing to:

• Swollen ankles
• Skin damage
• Leg ulcers
• Superficial venous thrombosis
• Venous bleeds 2

Diagnosis

Duplex ultrasonography is the gold standard for diagnosis:

• Assesses saphenous junction incompetence
• Measures junction diameter
• Evaluates reflux extent
• Identifies incompetent perforating vein location and size 5

The American College of Radiology recommends confirming diagnosis with duplex ultrasound evaluation of:

• Deep venous system
• Great saphenous vein (GSV)
• Small saphenous vein (SSV)
• Accessory saphenous veins 5

Abnormal reflux is defined as retrograde venous flow lasting more than 500 milliseconds. 5

Management Options

Conservative Approaches

1. Lifestyle modifications:

   • Elevation of affected leg
   • Avoiding prolonged standing and straining
   • Regular exercise to activate calf muscle pumps
   • Wearing non-restrictive clothing
   • Decreased sodium intake
   • Weight loss
   • Skin care with emollients 5

2. Compression therapy:

   • Medical-grade compression stockings (20-30 mmHg) for mild to moderate disease
   • Higher compression (30-40 mmHg) for severe disease
   • Only first-line treatment recommended during pregnancy 5
   • Should be avoided when ankle-brachial index is <0.6 due to risk of arterial compromise 5

3. Pharmacological options:

   • Horse chestnut seed extract may provide symptomatic relief (available as over-the-counter dietary supplement) 5
   • Venoactive drugs can be considered for conservative therapy 6

Interventional Treatments

1. Endovenous thermal ablation:

   • Recommended as first-line treatment for symptomatic varicose veins with documented valvular reflux
   • Associated with fewer postoperative complications and earlier mobilization 5, 6

2. Radiofrequency ablation (RFA):

   • First-line treatment for saphenous vein incompetence
   • Particularly effective for vein diameters >4.5mm
   • High success rates and favorable safety profile
   • Potential complications include paresthesia, thrombophlebitis, nerve damage, and thrombotic complications (DVT risk 0.3-0.7%) 5

3. Sclerotherapy:

   • Recommended for smaller vessels:
     • Spider veins (≤1 mm)
     • Reticular veins (1-3 mm)
     • Telangiectasias
   • Agents include polidocanol, sodium tetradecyl, and hypertonic saline
   • May be more appropriate for veins <4.5mm in diameter 5
   • Effective for recurrences and complicated vein anatomy 6

4. Conventional surgery:

   • Associated with best long-term results 6
   • Includes stripping, avulsion, and powered phlebectomy 3

Post-Treatment Care

• Follow-up ultrasound within 1-2 weeks to confirm successful vein closure and rule out DVT
• Continue compression therapy (20-30 mmHg graduated compression stockings) for at least 2 years
• Maintain weight management, regular exercise, and daily use of compression stockings
• Monitor for signs of serious complications requiring urgent attention 5

Common Pitfalls and Caveats

1. Diagnostic pitfalls:

   • Failing to perform proper ultrasound evaluation before treatment
   • Not investigating for underlying venous reflux in seemingly cosmetic cases
   • Overlooking pelvic vein reflux as a potential cause

2. Treatment pitfalls:

   • Using compression therapy in patients with arterial insufficiency (ABI <0.6)
   • Treating only visible varicosities without addressing underlying reflux
   • Not providing adequate post-procedure care and follow-up

3. Patient education:

   • Importance of compliance with compression therapy
   • Recognition of signs of complications (DVT, infection)
   • Understanding the chronic nature of venous disease and potential for recurrence