Varicose Veins: Comprehensive Overview
Pathophysiology
Varicose veins result from valvular incompetence and vein wall weakening driven by genetic predisposition, leading to increased intravenous pressure that progressively dilates and elongates the veins. 1
The underlying mechanism involves:
- Genetic predisposition combined with incompetent valves and weakened vascular walls creates the foundation for disease development 2
- Increased intravenous pressure from valvular failure causes blood to pool and reflux backward, progressively stretching the vein walls 1
- Inflammation plays a critical role in disease progression, with elevated interleukin levels promoting vascular wall inflammation and a procoagulant state 3
- Chronic venous hypertension from prolonged standing or increased intra-abdominal pressure (pregnancy, obesity, chronic cough, constipation) accelerates vein wall deterioration 2
The pathophysiology creates a self-perpetuating cycle: valvular incompetence → venous reflux → increased pressure → further vein wall weakening → worsening valvular incompetence 1
Etiology and Risk Factors
Non-Modifiable Risk Factors
- Family history of venous disease represents the strongest predictor, indicating genetic susceptibility to vein wall weakness 1, 2
- Female sex increases risk, likely related to hormonal influences on vein wall elasticity 1, 2
- Older age correlates with progressive vein wall degeneration and cumulative venous pressure exposure 1, 2
Modifiable Risk Factors
- Prolonged standing (occupational exposure) causes sustained venous hypertension without adequate muscle pump activation 4, 2
- Obesity increases intra-abdominal pressure and mechanical stress on leg veins 2, 3
- Pregnancy creates chronically increased intra-abdominal pressure and hormonal vein wall changes 1, 2
- Chronic cough and constipation cause repetitive increases in intra-abdominal pressure 2
High-Risk Populations Requiring Surveillance
- Previous venous thromboembolism (VTE) dramatically increases risk for both varicose vein progression and recurrent DVT 3
- Malignancy, estrogen use, recent hospitalization represent additional thrombophilic states 3
- Long-distance travel or immobilization with pre-existing varicose veins increases VTE risk 3
Clinical Presentation and Symptoms
Typical Symptoms
- Heavy, achy feeling in the legs that worsens with prolonged standing and improves with elevation 2
- Itching or burning sensation over affected veins 2
- Pain, swelling, and leg heaviness occurring daily and interfering with activities of daily living 5, 6
- Leg cramps, fatigue, and restlessness particularly at night 5
Physical Examination Findings
- Twisted, dilated veins most commonly on the lower extremities, visible when standing 2
- Edema in the lower legs and ankles, particularly at day's end 5, 6
- Skin changes indicating disease progression:
Serious Complications Requiring Immediate Evaluation
- Deep vein thrombosis (DVT) occurs in 0.3% of patients, presenting with severe unilateral leg pain, asymmetric marked edema, erythema, heat, or induration 5, 4, 3
- Pulmonary embolism occurs in 0.1% of cases 5
- Superficial venous thrombosis particularly when extending close to saphenofemoral or saphenopopliteal junction increases DVT risk 3
- Leg ulcers from chronic venous insufficiency (C5-C6 disease) 2, 7
- Venous bleeding from skin breakdown over varicosities 7
Diagnostic Approach
Mandatory Diagnostic Testing Before Treatment
Duplex ultrasound is mandatory before any interventional therapy, performed in standing position for optimal visualization. 1, 7
Required documentation includes 5, 1:
- Exact vein diameter at specific anatomic landmarks (minimum 2.5mm for sclerotherapy, ≥4.5mm for thermal ablation)
- Reflux duration ≥500 milliseconds at saphenofemoral or saphenopopliteal junction
- Assessment of deep venous system patency to exclude DVT
- Identification of all refluxing segments including tributary veins and perforators
- Ultrasound must be performed within past 6 months before treatment 5
Special Diagnostic Considerations
- Pelvic vein reflux requires transvaginal duplex ultrasound using the Holdstock-Harrison protocol in women, or venography/cross-sectional imaging in men 7
- Posterior thigh varicosities require standing position with patient facing away from examiner for optimal visualization 1
Treatment Algorithm
Step 1: Conservative Management (Required 3-Month Trial)
A documented 3-month trial of medical-grade gradient compression stockings (20-30 mmHg minimum pressure) with symptom diary is required before any interventional therapy. 5, 1, 4
Conservative measures include 5, 2:
- Medical-grade graduated compression stockings (20-30 mmHg) worn during all waking hours, reducing daily leg volume increase by 31-37% 4
- Leg elevation above heart level for 15-30 minutes, 3-4 times daily 4, 2
- Regular exercise to activate muscle pump and promote venous return 5, 2
- Weight loss if applicable to reduce intra-abdominal pressure 5, 2
- Avoidance of prolonged standing with sitting breaks every 30-60 minutes 4, 2
- Physical counter-pressure maneuvers every 15-20 minutes during unavoidable standing 4
Critical pitfall: Over-the-counter compression stockings provide insufficient pressure (<20 mmHg) and should not be used 4. Stockings too tight around the knee paradoxically increase DVT risk by preventing venous return 4.
Important exception: Patients with varicose veins and ulceration (C5-C6 disease) do not require a trial of compression therapy before referral for endovenous thermal ablation, as existing evidence suggests intervention should not be delayed 5
Step 2: Interventional Treatment Selection Based on Vein Size and Reflux
First-Line: Endovenous Thermal Ablation for Main Truncal Veins
Endovenous thermal ablation (radiofrequency or laser) is first-line treatment for great saphenous vein or small saphenous vein with diameter ≥4.5mm and documented saphenofemoral or saphenopopliteal junction reflux ≥500ms, achieving 91-100% occlusion rates at 1 year. 5, 1, 7
Indications for thermal ablation 5:
- Vein diameter ≥4.5mm measured by ultrasound
- Reflux duration ≥500 milliseconds at junctional level
- Symptomatic disease causing functional impairment despite conservative management
- Skin changes (C4-C6 disease) indicating need for intervention to prevent progression
- Similar efficacy with 91-100% technical success rates
- Fewer complications including reduced bleeding, hematoma, wound infection, and paresthesia
- Faster recovery with earlier mobilization
- 96% patient satisfaction in early studies
Complications to counsel patients about 5, 1:
- Temporary nerve damage in approximately 7% from thermal injury, though most resolves
- Deep vein thrombosis in 0.3% of cases
- Pulmonary embolism in 0.1% of cases
- Skin discoloration, hematoma, infection as minor complications
- Early postoperative duplex scan (2-7 days) mandatory to detect endovenous heat-induced thrombosis
Critical principle: Treating junctional reflux is mandatory before or concurrent with tributary treatment to prevent recurrence rates of 20-28% at 5 years. 5, 1
Second-Line: Foam Sclerotherapy for Tributary and Smaller Veins
Foam sclerotherapy (including Varithena/polidocanol) is appropriate for tributary veins, accessory saphenous veins, or residual refluxing segments with diameter ≥2.5mm, achieving 72-89% occlusion rates at 1 year. 5, 1, 7
Indications for sclerotherapy 5:
- Vein diameter 2.5-4.4mm (vessels <2.0mm have only 16% patency at 3 months)
- Tributary veins after or concurrent with junctional thermal ablation
- Residual refluxing segments following previous ablation
- Contraindication to thermal ablation or patient preference
Advantages over thermal ablation 5:
- Fewer thermal complications including no risk of thermal injury to skin, nerves, muscles
- No tumescent anesthesia required
- Can treat tortuous veins not amenable to catheter-based techniques
Disadvantages 5:
- Lower long-term success rates compared to thermal ablation
- Higher recurrence rates at 1-, 5-, and 8-year follow-ups when used alone for junctional reflux
- Chemical sclerotherapy alone has worse outcomes than thermal ablation for main trunks
- Phlebitis, new telangiectasias, residual pigmentation at treatment sites
- Transient colic-like pain resolving within 5 minutes
- Deep vein thrombosis exceedingly rare but possible
- Systemic dispersion of sclerosant in high-flow situations (rare)
FDA-approved Varithena dosing: Maximum 5mL per injection, 15mL per treatment session, with mandatory ultrasound guidance 5
Third-Line: Ambulatory Phlebectomy (Stab Phlebectomy)
Ambulatory phlebectomy is medically necessary as adjunctive treatment for symptomatic bulging varicose tributary veins when performed concurrently with treatment of saphenofemoral junction reflux. 5, 7
- Larger tributary veins (>4mm) where sclerotherapy may be less effective
- Bulging varicosities causing cosmetic concern or symptoms
- Performed at time of truncal vein ablation for comprehensive treatment
Advantages 5:
- Updated surgical techniques reduce scarring, blood loss, and complications
- Immediate removal of symptomatic varicosities
Complications 5:
- Skin blistering from dressing abrasions (most common)
- Temporary sensory nerve injury causing anesthesia
- Critical anatomic consideration: Avoid common peroneal nerve near fibular head during lateral calf phlebectomy to prevent foot drop
Fourth-Line: Surgical Ligation and Stripping
Surgical ligation and stripping are reserved for cases where endovenous techniques are not feasible, though they have been largely replaced by thermal ablation due to higher complication rates and longer recovery. 5, 6
Traditional surgery outcomes 5:
- 20-28% recurrence rate at 5 years
- More complications including bleeding, infection, nerve injury
- Longer hospital recovery compared to endovenous techniques
Step 3: Treatment of Incompetent Perforating Veins
Significant incompetent perforating veins should be treated by thermal ablation using the transluminal occlusion of perforator (TRLOP) approach. 7
Step 4: Treatment of Pelvic Vein Reflux
Incompetent pelvic veins refluxing into symptomatic varicose veins in the genital region or leg should be treated by coil embolization. 7
Special Clinical Scenarios
Post-Ablation Recurrence or Residual Disease
- Serial ultrasound required to document new abnormalities in previously treated areas 5
- Foam sclerotherapy appropriate for residual refluxing segments and tributary veins after primary ablation 5
- Repeat thermal ablation may be needed for recurrent junctional reflux
Patients with Skin Changes (C4-C6 Disease)
- Intervention required to prevent progression even when severe pain is not the primary complaint 5
- Combined approach with thermal ablation for main trunks and sclerotherapy for tributaries provides comprehensive treatment 5
- Ulceration (C5-C6) warrants immediate referral without compression trial 5
High-Risk Surgical Specialties
- Mandatory compression stocking use during surgical procedures for thoracic and pediatric surgeons with prolonged standing 4
- Thromboprophylaxis after invasive varicose vein procedures recommended in patients >60 years or with thrombophilic states 3
Prevention Strategies for High-Risk Individuals
Occupational Modifications
- Sitting breaks every 30-60 minutes during prolonged standing 4
- Physical counter-pressure maneuvers every 15-20 minutes during unavoidable standing 4
- Medical-grade graduated compression stockings (20-30 mmHg) during all work hours for those with occupational risk or family history 4
Post-DVT Prevention
- Compression stockings reduce post-thrombotic syndrome risk by 50% after first DVT episode 4
Monitoring and Follow-Up
Participation in a venous registry for outcome monitoring should probably be mandatory for treating physicians. 7
Follow-up requirements 5:
- Early postoperative duplex scan (2-7 days) after thermal ablation to detect complications
- Longer-term imaging (3-6 months) to assess treatment success
- Serial ultrasound for patients with recurrent symptoms after previous treatment