What are the potential complications of varicose veins and how are they managed?

Complications of Varicose Veins

Varicose veins can progress to serious complications including superficial thrombophlebitis, skin changes (hyperpigmentation, stasis dermatitis, lipodermatosclerosis), venous ulceration, and venous bleeding, though progression from simple varicosities to ulcers is not guaranteed even with extensive disease. 1, 2

Spectrum of Complications

Early to Moderate Complications

• Superficial thrombophlebitis develops when varicose veins become inflamed and clotted, presenting as painful, tender, cord-like structures along the affected vein 1

• Chronic venous edema occurs from prolonged venous hypertension, typically worsening at the end of the day after prolonged standing and improving with leg elevation 1

• Skin pigmentation changes (hyperpigmentation/hemosiderin staining) result from red blood cell extravasation and hemoglobin breakdown in the dermis, appearing as brownish discoloration typically around the ankles and lower third of the leg 1, 2

• Stasis dermatitis manifests as itching, burning, tightness, and skin irritation with erythematous, scaly patches in areas of venous hypertension 1

Advanced Complications

• Lipodermatosclerosis represents severe skin fibrosis and subcutaneous tissue hardening, creating an "inverted champagne bottle" appearance of the lower leg from chronic inflammation and tissue remodeling 1, 2

• Venous leg ulceration typically occurs near the medial malleolus in areas of highest venous pressure, representing the most severe manifestation of chronic venous insufficiency 1, 3

• Venous bleeding can occur spontaneously from superficial varicosities, particularly with minor trauma, and may be significant due to elevated venous pressure 1

Pathophysiology of Progression

The progression involves a vicious cycle where structural changes in valves and venous walls interact with hemodynamic forces, leading to reflux and venous hypertension 3. Matrix metalloproteinases (MMPs) play a central role by increasing proteolysis of collagen and elastin in the vein wall, causing progressive weakening and dilation 4. This process is modulated by venous hydrostatic pressure, hypoxia, tissue metabolites, and inflammation 4.

Risk Factors for Complication Development

• Family history of venous disease significantly increases risk of progression 1
• Female sex, older age, and chronically increased intra-abdominal pressure (obesity, pregnancy, chronic constipation) accelerate disease progression 1
• Prolonged standing occupations worsen venous hypertension and accelerate complications 1
• Sedentary lifestyle and obesity contribute to disease progression 4

Management Based on Complication Severity

For Symptomatic Varicose Veins Without Skin Changes (CEAP C2-C3)

• Medical-grade compression stockings (20-30 mmHg minimum) for at least 3 months represent first-line conservative management 1
• Leg elevation above heart level when resting improves venous return and reduces symptoms 1
• Weight loss if obese reduces intra-abdominal pressure and venous hypertension 1
• Referral for interventional treatment should not be delayed when valvular reflux is documented on duplex ultrasound, as endovenous thermal ablation has largely replaced surgery as standard of care 1

For Skin Changes (CEAP C4)

• Patients with C4 disease (skin changes including pigmentation, eczema, lipodermatosclerosis) require intervention to prevent progression to ulceration, even when severe pain is not the primary complaint 5
• Compression therapy remains essential but should be combined with definitive treatment of underlying venous reflux 3
• Endovenous thermal ablation for truncal vein incompetence combined with treatment of incompetent perforating veins using transluminal occlusion of perforator (TRLOP) approach 6

For Venous Ulceration (CEAP C5-C6)

• Compression therapy with bandages for initial treatment followed by maintenance with medical compression stockings is essential 3
• Appropriate wound care with moisture-retentive dressings is indicated 7
• Correction of venous reflux by endovenous thermal ablation or surgery should be considered in every case, as treating underlying reflux improves ulcer healing and prevents recurrence 3
• Sulodexide has shown benefits in venous leg ulcers and chronic venous insufficiency by improving venous smooth muscle contraction 4

For Superficial Thrombophlebitis

• Conservative management with compression, elevation, and anti-inflammatory medications for localized disease 1
• Duplex ultrasound to assess extent and rule out deep vein thrombosis extension 6
• Anticoagulation may be required if thrombus extends close to deep venous system 1

Critical Diagnostic Considerations

• Venous duplex ultrasonography in the erect position is mandatory when venous disease is severe or interventional therapy is being considered 1, 6
• Ultrasound should document reflux duration (≥500 milliseconds indicates pathologic reflux), vein diameter, location of incompetent valves, and assessment of deep venous system 5
• Investigation should be performed by a specialist trained in ultrasonography, optimally not the treating physician, to ensure objective assessment 6

Common Pitfalls in Managing Complications

• Delaying referral for interventional treatment in favor of prolonged compression therapy when valvular reflux is documented leads to unnecessary disease progression 1
• Failing to recognize that symptoms like burning and tightness indicate progression of venous disease requiring evaluation 1
• Overlooking the potential for serious complications such as superficial thrombophlebitis, venous ulceration, or spontaneous bleeding 1
• Treating visible varicosities without investigating and treating underlying truncal vein reflux, leading to high recurrence rates of 20-28% at 5 years 5, 3

Treatment Outcomes and Recurrence

• Traditional surgical treatment has 5-year recurrence rates of 20-28%, highlighting the importance of proper treatment sequencing and addressing all sources of reflux 5
• Endovenous thermal ablation demonstrates 91-100% occlusion rates at 1 year with improved quality of life and fewer complications compared to surgery 5
• Chronic venous insufficiency requires "chronic management" with ongoing compression therapy and monitoring for recurrence 3
• Participation in a venous registry for monitoring and reporting outcomes should be considered mandatory for optimal long-term management 6