What are the potential complications of untreated varicose veins?

Potential Complications of Untreated Varicose Veins

Untreated varicose veins typically deteriorate over time, progressing from cosmetic concerns to serious complications including skin damage, leg ulcers, superficial venous thrombosis, and potentially life-threatening venous bleeding. 1

Progressive Disease Course

Varicose veins are not a static condition—they usually worsen without treatment, following a predictable pattern of deterioration. 1 The natural history involves:

• Progressive venous hypertension leading to increasingly severe symptoms and complications over time 2
• Worsening symptoms including pain, heaviness, cramping, throbbing, restlessness, and swelling that intensify at day's end, especially after prolonged standing 3
• No guaranteed stepwise progression from spider veins to ulcers, though severe complications can develop even from extensive varicosities 4

Major Complications

Skin Changes and Ulceration

• Hyperpigmentation and lipodermatosclerosis develop as venous disease advances, representing moderate-to-severe venous insufficiency 4, 3
• Stasis dermatitis with skin irritation, tightness, and eczema occurs from chronic venous hypertension 3, 5
• Venous leg ulcers represent advanced disease (CEAP C6), with underlying reflux contributing to poor wound healing 5, 1

Thrombotic Events

• Superficial venous thrombosis (phlebitis) occurs in 3.6% of patients waiting for treatment, causing painful inflammation of varicose veins 6, 1
• Deep vein thrombosis risk exists, though the exact incidence in untreated varicose veins is not well-quantified in the provided evidence 2

Hemorrhagic Complications

• Spontaneous venous bleeding can occur from varicose veins, representing a potentially life-threatening complication 1
• Bleeding events occurred in 1.8% of patients during a median 60-week wait for treatment 6

Symptom Progression and Quality of Life Impact

The burden of untreated varicose veins extends beyond physical complications to significantly impair daily functioning and psychological well-being. 6

Physical Symptoms

• Localized symptoms including pain, burning, itching, and tingling at varicose vein sites worsen over time 3
• Generalized leg symptoms such as heaviness, cramping, and swelling interfere with activities of daily living 3
• Worsening pain (12.7%) and swelling (6.2%) develop as minor harm during treatment delays 6

Quality of Life Deterioration

• Significant QoL impairment demonstrated by median AVVQ score of 23.2 and CIVIQ-14 score of 33 in patients awaiting treatment 6
• Psychological harm reported in 6.9% of patients, affecting mental health and well-being 6
• Reduced productivity and life quality from chronic symptoms and functional limitations 7

Risk Factors for Accelerated Progression

Certain patient characteristics increase the likelihood of rapid deterioration:

• Family history of venous disease predisposes to worsening symptoms 3
• Female sex and older age correlate with disease progression 3
• Prolonged standing and obesity accelerate venous hypertension and complications 3, 7
• Chronically increased intra-abdominal pressure worsens venous reflux 3

Severity Stratification by CEAP Classification

The CEAP classification system helps predict complication risk, with higher stages associated with worse outcomes:

• C2 (varicose veins): Symptomatic but not advanced disease 5
• C3 (edema): Indicates progression requiring intervention 5
• C4 (skin changes): Patients require intervention to prevent further progression, even without severe pain 5, 3
• C5-C6 (healed or active ulceration): Rising CEAP stage significantly associated with worsening harm (p < 0.0001) 6

Evidence from Treatment Delays

A prospective study of 275 patients waiting >1 year for varicose vein procedures revealed the tangible harm of non-treatment:

• Major harm in 6.9% including phlebitis, bleeding, and ulceration 6
• Minor harm in 18.9% with worsening pain and swelling 6
• Median wait time of 60 weeks demonstrated progressive deterioration during observation 6

Critical Clinical Pitfalls

Common errors in managing untreated varicose veins include:

• Delaying referral for interventional treatment when valvular reflux is documented, favoring prolonged compression therapy alone 3
• Failing to recognize warning signs such as burning, tightness, and skin changes indicating disease progression 3
• Overlooking potential for serious complications including thrombophlebitis, ulceration, and lipodermatosclerosis 3
• Assuming benign course when varicose veins can lead to potentially life-threatening complications despite appearing benign initially 7

When Urgent Evaluation Is Needed

Patients should seek immediate medical attention for:

• Worsening burning and tightness of skin with varicose veins 3
• New skin changes including pigmentation, eczema, or ulceration 3
• Painful, red, warm veins suggesting superficial thrombophlebitis 1
• Spontaneous bleeding from varicose veins 1

Treatment Benefits vs. Conservative Management

Evidence strongly supports intervention over observation for symptomatic varicose veins:

• Significant advantage of treatment over conservative management with compression stockings or venotropic drugs for patients with symptoms or signs 1
• Endovenous thermal ablation has largely replaced surgery with 91-100% occlusion rates at 1 year, preventing progression 5
• Only 8.7% would decline surgery during a pandemic, indicating patient recognition of disease burden 6