Varicose Veins Complications
Varicose veins can lead to serious complications including superficial thrombophlebitis, deep vein thrombosis (DVT), pulmonary embolism, leg ulcers, bleeding (varicorrhage), and post-thrombotic syndrome, with the most severe being venous ulceration and thromboembolic events. 1, 2, 3
Major Complications and Their Clinical Significance
Thromboembolic Complications
Superficial venous thrombosis occurs commonly and carries significant risk for DVT progression, particularly when the thrombus extends close to the saphenofemoral or saphenopopliteal junction. 3
Deep vein thrombosis develops in approximately 0.3% of patients with varicose veins, with pulmonary embolism occurring in 0.1% of cases. 4
The risk of DVT increases substantially in patients with additional risk factors including previous VTE, malignancy, estrogen use, pregnancy/postpartum, recent hospitalization (within 6 months), advanced age, and obesity. 3
Post-thrombotic syndrome develops in 22.8% of patients at 2 years, 28% at 5 years, and 29.1% at 8 years following DVT, characterized by leg pain, skin changes, and swelling. 5
After a first episode of proximal DVT, the cumulative incidence of mild-to-moderate post-thrombotic syndrome is approximately 50% and severe post-thrombotic syndrome 23%. 5
Skin and Tissue Complications
Venous ulcers represent one of the most serious complications of varicose veins, significantly impacting quality of life and requiring aggressive intervention. 5, 2
Stasis dermatitis, hyperpigmentation, and lipodermatosclerosis develop as chronic venous hypertension progresses, indicating CEAP classification C4 disease that requires intervention to prevent ulcer formation. 4, 6
Varicorrhage (spontaneous bleeding from varicose veins) occurs as a complication, particularly in patients with advanced disease. 7
Inflammatory and Infectious Complications
Superficial thrombophlebitis develops as an inflammatory complication, with patients experiencing pain, erythema, and induration along the affected vein. 2, 3
Infection risk increases with advanced venous disease, particularly in the presence of skin breakdown or ulceration. 1
Inflammation serves as a common denominator linking varicose veins to DVT, with elevated interleukin levels promoting a procoagulant state and thrombus formation in deep veins. 3
Risk Factors for Complications
Patient-Specific Risk Factors
Older adults face increased complication risk, with thromboprophylaxis recommended after invasive varicose vein procedures in patients older than 60 years. 3
Women have higher prevalence of varicose veins (25% versus 15% in men), though complication rates appear similar between sexes. 2, 7
Obesity significantly increases complication risk, with more than half of patients with varicose veins being overweight or obese, and a greater presence of C5 or C6 ulcers among obese patients. 7
Multiple pregnancies increase risk through hormonal effects and increased venous pressure, with 69% of patients reporting positive family history suggesting strong genetic predisposition. 1, 7
Situational Risk Factors
Prolonged immobilization and long-distance travel (air or road) substantially increase VTE risk in patients with varicose veins. 3
Prolonged standing (more than 4 hours daily) correlates with greater presence of venous ulcers (C5 or C6 classification). 7
Invasive treatment of varicose veins temporarily increases DVT risk during and immediately after procedures, requiring consideration of thromboprophylaxis in high-risk patients. 3
Management Strategies to Prevent Complications
Conservative Management
Graduated compression stockings (20-30 mmHg) reduce the risk of developing post-thrombotic syndrome by 50% after a first episode of venous thrombosis. 5
Leg elevation, regular exercise (particularly walking and ankle flexion exercises), weight loss, and avoidance of prolonged standing represent first-line conservative measures. 8, 1
Modification of cardiovascular risk factors and reduction of peripheral edema help prevent progression to advanced disease. 1
Interventional Treatment to Prevent Progression
Endovenous thermal ablation (radiofrequency or laser) achieves 91-100% occlusion rates at 1 year and should be performed for symptomatic varicose veins with documented reflux to prevent progression to ulceration. 4
Treatment of saphenofemoral and saphenopopliteal junction reflux is critical for long-term success, as untreated junctional reflux leads to persistent downstream pressure and tributary vein recurrence rates of 20-28% at 5 years. 4
Foam sclerotherapy demonstrates 72-89% occlusion rates at 1 year for tributary veins and represents appropriate adjunctive treatment following thermal ablation of main trunks. 4
Thromboprophylaxis Considerations
Thromboprophylaxis after invasive varicose vein procedures is recommended in patients older than 60 years and those with additional thrombophilic risk factors. 3
Anticoagulation with low molecular weight heparin is indicated only when DVT is confirmed by ultrasound, not for venous insufficiency alone. 8
Early postoperative duplex scans (2-7 days) are mandatory after endovenous ablation to detect endovenous heat-induced thrombosis. 4
Warning Signs Requiring Immediate Evaluation
Severe and sudden unilateral leg pain, asymmetric marked edema, erythema, heat, or induration suggest DVT and require immediate ultrasound evaluation. 8
Symptoms of pulmonary embolism (chest pain, shortness of breath, hemoptysis) represent medical emergencies requiring immediate intervention. 8
Superficial thrombophlebitis extending close to the saphenofemoral or saphenopopliteal junction requires urgent evaluation due to high risk of DVT progression. 3
Common Pitfalls in Management
Delaying intervention in patients with CEAP C4 disease (skin changes) allows progression to ulceration, which is far more difficult to treat than preventing it through early endovenous ablation. 4
Treating tributary veins with sclerotherapy without addressing underlying saphenofemoral or saphenopopliteal junction reflux results in recurrence rates of 20-28% at 5 years. 4
Underestimating VTE risk during prolonged immobilization or travel in patients with varicose veins, particularly those with additional risk factors. 3
Failing to recognize that severe skin complications can develop even without stepwise progression from spider veins, requiring vigilant monitoring of all patients with varicose veins. 6