What are the symptoms and treatment options for varicose veins?

Symptoms of Varicose Veins

Varicose veins present with both localized symptoms at the site of affected veins (pain, burning, itching, tingling) and generalized leg symptoms (heaviness, cramping, throbbing, restlessness, swelling) that characteristically worsen at day's end after prolonged standing and improve with leg elevation. 1

Primary Symptom Categories

Localized Symptoms

• Pain, burning, itching, and tingling occur directly at the site of varicose veins due to valvular reflux and increased intravenous pressure 1
• Skin tightness and irritation develop as venous dysfunction progresses, indicating worsening disease 1

Generalized Lower Extremity Symptoms

• Heaviness, cramping, throbbing, and restlessness affect the entire leg, particularly after prolonged standing 1
• Leg swelling (edema) results from chronic venous hypertension 1, 2
• Fatigue and pruritus interfere with daily activities and work productivity 2

Temporal Pattern Recognition

Symptoms follow a predictable daily pattern: they worsen progressively throughout the day, especially after prolonged standing, and improve when sitting with legs elevated 1. This temporal variation is a key diagnostic feature distinguishing venous symptoms from other leg pathology.

Progressive Skin Changes

As varicose veins advance, more severe manifestations develop 1:

• Skin pigmentation changes (hyperpigmentation/hemosiderin staining) indicate chronic venous stasis 1, 3
• Venous eczema (stasis dermatitis) reflects ongoing inflammation 1
• Lipodermatosclerosis represents advanced skin damage with fibrosis and hardening 1, 3
• Venous ulceration occurs in severe cases, representing CEAP classification C5-C6 disease 3

Risk Factors for Symptom Progression

Certain factors predict worsening symptoms and should prompt earlier intervention 1:

• Family history of venous disease
• Female sex and older age
• Chronically increased intra-abdominal pressure (obesity, pregnancy, chronic constipation)
• Occupations requiring prolonged standing

Treatment Options Based on Disease Severity

Conservative Management (First-Line for Mild Disease)

Medical-grade compression stockings (20 mmHg or greater) for at least 3 months represent the cornerstone of conservative therapy 1, 4. However, compression therapy alone has inadequate evidence for CEAP C2-C4 disease, though it provides value in C5-C6 disease with ulceration 5.

• Leg elevation above heart level improves venous return and reduces symptoms 1
• Weight loss in obese patients alleviates intra-abdominal pressure 1
• Phlebotonics (horse chestnut seed extract, flavonoids) may provide symptomatic relief, though long-term efficacy studies are lacking 1, 6

Interventional Treatment Algorithm

Endovenous thermal ablation has largely replaced surgery as the standard of care for larger vessels (≥4.5mm diameter) with documented reflux ≥500 milliseconds at the saphenofemoral or saphenopopliteal junction 1, 5. This approach offers similar efficacy (91-100% occlusion rates at 1 year) with fewer complications, improved quality of life, and faster recovery compared to traditional surgery 5, 7.

Treatment Sequence by Vessel Size:

• Truncal veins ≥4.5mm with junctional reflux: Endovenous thermal ablation (radiofrequency or laser) as first-line 5, 7
• Tributary veins 2.5-4.5mm: Foam sclerotherapy (72-89% occlusion at 1 year) or ambulatory phlebectomy 5
• Reticular veins and telangiectasias (<2.5mm): Sclerotherapy or external laser therapy 1, 8

When to Proceed Directly to Intervention

Referral for interventional treatment should not be delayed for prolonged compression therapy trials when valvular reflux is documented, particularly in patients with:

• Burning and skin tightness indicating disease progression 1
• CEAP C4c disease with corona phlebectasia or stasis dermatitis 5
• Venous ulceration (C5-C6), where compression alone is insufficient 5

Diagnostic Evaluation

Venous duplex ultrasonography is mandatory when venous disease is severe or interventional therapy is considered 1, 7. The ultrasound must document:

• Reflux duration (≥500 milliseconds indicates pathologic reflux) 5, 4
• Vein diameter at specific anatomic landmarks 5
• Location and extent of incompetent segments 1
• Deep venous system patency to exclude thrombosis 7

Critical Pitfalls to Avoid

• Delaying referral for interventional treatment when documented valvular reflux exists, particularly with progressive skin changes 1
• Failing to recognize that burning, tightness, and skin changes indicate disease progression requiring escalation of care 1
• Overlooking serious complications such as superficial thrombophlebitis, venous ulceration, or lipodermatosclerosis that require urgent intervention 1
• Treating tributary veins alone without addressing saphenofemoral junction reflux, which leads to high recurrence rates (20-28% at 5 years) 5
• Using sclerotherapy as monotherapy for large truncal veins, which has inferior long-term outcomes compared to thermal ablation at 1-, 5-, and 8-year follow-up 5

Expected Outcomes with Treatment

Endovenous thermal ablation achieves 91-100% technical success rates with 96% patient satisfaction, though approximately 7% experience temporary nerve damage from thermal injury 5. Deep vein thrombosis occurs in 0.3% of cases and pulmonary embolism in 0.1% 5. Combined approaches treating both truncal and tributary veins provide the most comprehensive symptom relief and lowest recurrence rates 5, 7.