Are varicose veins an arterial vascular disease, and when is referral to a vascular specialist indicated?

Varicose Veins: Venous—Not Arterial—Disease and Referral Criteria

Varicose veins are a venous disease caused by valvular incompetence in the superficial venous system, not an arterial vascular condition. 1, 2 The underlying pathophysiology involves genetic predisposition, incompetent valves, weakened vascular walls, and increased intravenous pressure leading to progressive vein dilation and elongation. 3, 2

Understanding the Disease Process

• Varicose veins result from venous hypertension secondary to superficial venous valvular reflux, affecting 14-24% of adults with large varices and up to 59% with smaller telangiectasias. 4, 5
• The condition represents a spectrum of chronic venous disorders ranging from cosmetic spider veins to severe complications including edema, skin changes, and ulceration—though progression through all stages is not guaranteed. 6
• Risk factors include family history of venous disease, female sex, older age, chronically increased intra-abdominal pressure (including pregnancy), and prolonged standing. 3, 2

When to Refer to a Vascular Specialist

Immediate Referral Criteria (Do Not Delay for Compression Trial)

Refer immediately when duplex ultrasound documents valvular reflux ≥500 milliseconds at the saphenofemoral or saphenopopliteal junction, regardless of symptom severity. 1, 2 This represents the single most important criterion because untreated junctional reflux drives disease progression and tributary vein recurrence rates of 20-28% at 5 years. 1

• Patients with CEAP C4 disease (skin changes including pigmentation, eczema, stasis dermatitis, or lipodermatosclerosis) require intervention to prevent progression even when severe pain is not the primary complaint. 1, 2
• Patients with venous ulceration (CEAP C5-C6) should proceed directly to endovenous ablation therapy without mandatory compression trials, as ulceration represents severe disease warranting immediate intervention. 1
• Patients with lifestyle-limiting symptoms (pain, heaviness, swelling interfering with work, sleep, or daily activities) despite any trial of conservative management. 1, 7

Referral After Conservative Management Failure

For patients with CEAP C2-C3 disease (varicose veins with or without edema but without skin changes), refer after a documented 3-month trial of medical-grade gradient compression stockings (20-30 mmHg) with persistent symptoms. 1, 3

• Document exact symptom diary during the compression trial, including frequency and functional impact. 1
• Compression therapy alone has no proven benefit in preventing post-thrombotic syndrome or treating established venous insufficiency when significant reflux is present. 1, 3

Required Pre-Referral Diagnostic Workup

Obtain venous duplex ultrasound before referral when interventional therapy is being considered. 1, 2 The ultrasound must document:

• Exact vein diameter at specific anatomic landmarks (≥4.5 mm for thermal ablation, ≥2.5 mm for sclerotherapy). 1
• Reflux duration at saphenofemoral and saphenopopliteal junctions (pathologic threshold ≥500 milliseconds). 1, 3
• Assessment of deep venous system patency to exclude deep vein thrombosis. 1
• Location and extent of all refluxing segments. 1, 3

What the Vascular Specialist Will Offer

Evidence-Based Treatment Algorithm

Endovenous thermal ablation (radiofrequency or laser) is first-line treatment for saphenofemoral or saphenopopliteal junction reflux when vein diameter ≥4.5 mm with reflux ≥500 ms, achieving 91-100% occlusion rates at 1 year. 1, 3

• Thermal ablation has largely replaced surgical stripping due to similar efficacy with improved early quality of life, reduced hospital recovery, and fewer complications (reduced bleeding, hematoma, wound infection, and paresthesia). 1
• Approximately 7% experience temporary nerve damage from thermal injury, though most resolve. 1, 3
• Deep vein thrombosis occurs in 0.3% and pulmonary embolism in 0.1% of cases. 1

Foam sclerotherapy (including Varithena) is second-line or adjunctive treatment for tributary veins, residual refluxing segments, or veins 2.5-4.5 mm diameter, with 72-89% occlusion rates at 1 year. 1

• Sclerotherapy has fewer thermal complications but higher long-term recurrence compared to thermal ablation. 1, 3
• Common side effects include phlebitis, new telangiectasias, residual pigmentation, and transient colic-like pain resolving within 5 minutes. 1
• Vessels <2.5 mm have poor outcomes with only 16% patency at 3 months. 1

Ambulatory phlebectomy is appropriate for larger tributary veins (>4 mm) and must be performed concurrently with treatment of junctional reflux to prevent recurrence. 1

Common Pitfalls to Avoid

• Never delay referral for prolonged compression trials when duplex ultrasound documents junctional reflux ≥500 ms—this represents documented structural disease requiring intervention. 1, 2
• Never treat tributary veins with sclerotherapy or phlebectomy without addressing upstream junctional reflux—untreated saphenofemoral junction reflux causes persistent downstream pressure leading to 20-28% recurrence at 5 years. 1, 3
• Never assume varicose veins are purely cosmetic—symptoms like burning, tightness, heaviness, and aching indicate venous dysfunction requiring evaluation, and skin changes signal disease progression. 2
• Never confuse varicose veins with arterial disease—this is a venous condition managed by vascular specialists trained in venous interventions, not arterial revascularization. 4, 8

Conservative Management While Awaiting Referral

• Prescribe medical-grade gradient compression stockings (20-30 mmHg minimum) for symptom relief. 1, 8
• Advise leg elevation when resting, regular calf-pump exercise, weight loss if overweight, and avoidance of prolonged standing. 1, 2
• Consider horse chestnut seed extract (aescin) for short-term symptomatic benefit, though long-term efficacy data are lacking and FDA approval is absent. 2, 8