What is the management of varicose veins in the Emergency Room (ER)?

From the Guidelines

Management of varicose veins in the ER should focus on symptom relief, ruling out complications, and referring patients for outpatient follow-up with a vascular surgery or vein specialist for definitive management. For patients presenting with uncomplicated varicose veins experiencing pain or discomfort, initial management includes elevation of the affected limb and application of compression stockings (20-30 mmHg) as first-line treatment, especially in pregnant women 1. Administration of NSAIDs such as ibuprofen 400-600 mg every 6-8 hours for pain relief can also be considered. If there is significant inflammation, a short course of oral anti-inflammatory medication may be prescribed. The patient should be advised to avoid prolonged standing or sitting and to elevate their legs when possible. Lifestyle modifications, such as weight loss, exercise, and wearing nonrestrictive clothing, can also improve symptoms 1. For patients with signs of superficial thrombophlebitis, treatment includes NSAIDs, compression therapy, and possibly a short course of low molecular weight heparin. If there are signs of deep vein thrombosis (DVT) like significant unilateral leg swelling, warmth, and pain, immediate ultrasound evaluation is necessary. Severe bleeding from ruptured varicose veins requires direct pressure, elevation, and possibly suturing. Most patients with uncomplicated varicose veins should be referred for outpatient follow-up with vascular surgery or a vein specialist for definitive management options including sclerotherapy, endovenous ablation, or surgical intervention 1. Some key points to consider in management include:

• Elevation of the affected limb to improve symptoms
• Application of compression stockings as first-line treatment
• Administration of NSAIDs for pain relief
• Lifestyle modifications to improve symptoms
• Referral for outpatient follow-up with a vascular surgery or vein specialist for definitive management. Emergency intervention is rarely needed for varicose veins unless complications like DVT, severe bleeding, or ulceration with infection are present 1.

From the Research

Management of Varicose Veins in the ER

• The management of varicose veins involves a combination of diagnostic tests and treatment options, with the goal of alleviating symptoms and preventing complications 2, 3.
• Diagnostic tests for varicose veins include duplex ultrasound scanning of the deep and superficial veins, which is recommended as the gold standard test for diagnosing saphenous vein incompetence in patients with varicose veins and chronic venous insufficiency 3, 4.
• Treatment options for varicose veins include endovenous thermal ablation, which is recommended as the primary treatment for truncal vein incompetence 2, 4.
• Other treatment options include phlebectomy, sclerotherapy, and compression therapy, which may be used alone or in combination with endovenous thermal ablation 2, 3, 4.
• The choice of treatment depends on the severity of the varicose veins, the presence of symptoms, and the patient's overall health status 5, 6.
• It is essential to monitor and report outcomes to ensure the best possible results for patients with varicose veins 2.

Diagnostic Tests

• Duplex ultrasound scanning is the recommended diagnostic test for varicose veins, as it provides accurate information about the location and severity of vein incompetence 3, 4.
• Other diagnostic tests, such as transvaginal duplex ultrasound and venography, may be used in certain cases, such as pelvic vein reflux 2.

Treatment Options

• Endovenous thermal ablation is a minimally invasive procedure that uses heat to close off the incompetent vein, and is recommended as the primary treatment for truncal vein incompetence 2, 4.
• Phlebectomy and sclerotherapy are other treatment options that may be used to remove or close off varicose veins 2, 3, 4.
• Compression therapy may be used to alleviate symptoms and prevent complications, but is not recommended as the primary treatment for varicose veins 4.

Special Considerations

• Patients with varicose veins and symptoms or signs have a significant advantage in having treatment over conservative treatment with compression stockings or venotropic drugs 2.
• Small varicose veins or telangiectasia without symptoms or signs can be treated for cosmetic reasons, but investigation with venous duplex should be mandatory before treatment 2.
• Pelvic vein reflux is best investigated with transvaginal duplex ultrasound, and treatment options include coil embolization, plugs, or transcatheter sclerotherapy 2, 4.