What is the pathophysiology, assessment, and management of varicose veins?

Varicose Veins: Pathophysiology, Assessment, and Management

Endovenous thermal ablation (radiofrequency or laser) is the recommended first-line treatment for varicose veins with saphenous vein reflux due to its higher efficacy, lower complication rates, faster recovery times, and better patient outcomes. 1

Pathophysiology

Varicose veins are superficial vessels that become abnormally twisted, lengthened, or dilated due to inefficient or defective valves within the veins 2. This valvular incompetence leads to:

• Retrograde blood flow (reflux)
• Venous hypertension
• Vascular wall weakening and dilation
• Progressive vein tortuosity

The pathophysiology involves a vicious cycle between structural changes in valves and venous walls and hemodynamic forces leading to reflux and venous hypertension 3. This can progress to chronic venous insufficiency (CVI), which represents advanced symptoms like edema, skin changes, or leg ulcers.

Inflammation plays a significant role in varicose veins, with increased levels of interleukins and inflammatory markers that can promote a procoagulant state 4. This inflammatory component may explain the connection between varicose veins and increased risk of venous thromboembolism.

Assessment and Diagnosis

Clinical Evaluation

• Identify risk factors: family history, advanced age, obesity, multiple pregnancies, prolonged standing/sitting, oral contraceptives 5
• Assess symptoms: pain, heaviness, swelling, itching, night cramps
• Examine for visible varicosities, edema, skin changes, or ulceration
• Use CEAP classification system to categorize severity:
  • Clinical appearance (C0-C6)
  • Etiology (primary, secondary)
  • Anatomical distribution
  • Pathophysiology (reflux, obstruction)

Diagnostic Testing

• Duplex ultrasound: Gold standard first-line imaging test 1
  • Performed in standing position or 60° Trendelenburg position
  • Diagnostic criteria: reflux duration >500 ms and vein size >4.5 mm
  • Evaluates entire venous system (deep veins, perforators, accessory saphenous veins)
  • Rules out deep vein thrombosis

A comprehensive assessment must include evaluation of the entire venous system to avoid incomplete diagnosis and treatment failure 1.

Management

Conservative Management

• Compression therapy (30-40 mmHg graduated compression stockings) for symptom relief and edema management 1
• Lifestyle modifications:
  • Weight management
  • Regular exercise
  • Leg elevation
  • Non-restrictive clothing
  • Early mobilization

Interventional Treatment

1. First-line treatment: Endovenous thermal ablation (radiofrequency or laser) for saphenous vein reflux 1
2. Adjunctive treatments:
   • Ultrasound-guided foam sclerotherapy for tributary veins and varicosities
   • Microphlebectomy for visible varicosities
3. Surgical options (only when endovenous options are contraindicated):
   • Modified Trendelenburg procedure
   • Traditional surgical approaches (higher recurrence rates of 15-35% within 2 years) 1

Post-Procedure Management

• Ultrasound within 1-2 weeks after procedure to confirm successful vein closure and rule out complications 1
• Patient education about signs of serious complications requiring urgent attention
• Regular follow-up to monitor disease progression and adjust treatment plans

Special Considerations and Pitfalls

1. Incomplete assessment: Failure to evaluate the entire venous system can lead to treatment failure 1

2. Underlying causes: Undiagnosed cardiac conditions like tricuspid regurgitation can lead to recurrent varicose veins 1

3. Thrombotic risk: Varicose veins may increase risk for deep vein thrombosis, particularly in patients with:

   • Previous venous thromboembolism
   • Malignancy
   • Estrogen use
   • Pregnancy/postpartum
   • Recent hospitalization
   • Advanced age
   • Obesity 4

4. Procedural complications: Increased risk for DVT during and after invasive treatment of varicose veins, especially in patients over 60 years or with thrombophilic states 4

5. Recurrence: High recurrence rates after years, particularly with traditional surgical approaches, necessitating "chronic management" with compression therapy 3

The management of varicose veins requires a step-wise approach starting with confirmation of diagnosis using duplex ultrasound, followed by endovenous thermal ablation as first-line treatment, with consideration of adjunctive treatments and conservative management as needed 1.