Varicose veins

Definition
Varicose veins are dilated, elongated, and tortuous superficial veins that result from venous valve incompetence, leading to retrograde blood flow and venous hypertension. They most commonly occur in the legs, affecting the great or small saphenous veins and their tributaries.

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Causes and Pathophysiology

• Primary varicose veins – caused by intrinsic weakness of vein wall or congenital absence of valves

• Secondary varicose veins – develop due to obstruction or damage to deep veins/valves (e.g., after deep vein thrombosis)

• Pathophysiology:

  • Valve failure → reflux of blood → increased venous pressure → venous dilation and tortuosity

  • Chronic venous hypertension damages capillaries, leading to skin changes and ulceration in severe cases

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Risk Factors

• Female sex (hormonal influence)

• Pregnancy (increased blood volume, progesterone-induced vessel relaxation)

• Ageing

• Family history of varicose veins

• Prolonged standing occupations

• Obesity

• Previous leg injury or DVT

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Clinical Features

• Visible, dilated, tortuous veins on the legs

• Leg heaviness, aching, throbbing (worse with prolonged standing, relieved by elevation)

• Swelling (oedema) in ankles or lower legs

• Nocturnal leg cramps

• Skin changes in chronic venous insufficiency:

  • Hyperpigmentation (haemosiderin deposition)

  • Eczema (varicose eczema)

  • Lipodermatosclerosis

  • Atrophie blanche

• In severe cases: venous leg ulcers near the medial malleolus

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Complications

• Superficial thrombophlebitis

• Bleeding from traumatised veins

• Chronic venous insufficiency with skin changes and ulceration

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Diagnosis

• Clinical examination: standing inspection and palpation to assess distribution, skin changes, and complications

• Duplex ultrasound: gold standard for assessing venous reflux, valve function, and anatomy

• Assessment for underlying DVT in suspected secondary varicose veins

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Treatment

1. Conservative measures

• Avoid prolonged standing and sitting with legs down

• Elevate legs when resting

• Regular exercise to improve calf muscle pump

• Weight reduction if overweight

• Graduated compression stockings (knee or thigh length) – especially for symptom relief or if surgery not suitable (ABPI must be checked if arterial disease suspected)

2. Interventional treatments (for symptomatic, complicated, or cosmetically concerning varicose veins)

• Endothermal ablation:

  • Endovenous laser ablation (EVLA)

  • Radiofrequency ablation (RFA)

• Ultrasound-guided foam sclerotherapy – for smaller varicose veins or as an alternative to ablation

• Surgical ligation and stripping – less common now, reserved for when minimally invasive methods are unsuitable

• Ambulatory phlebectomy – for superficial tributary veins

3. Management of complications

• Varicose eczema: emollients, topical corticosteroids

• Ulcers: compression therapy, wound care

• Thrombophlebitis: NSAIDs, compression, mobilization; anticoagulation if extension to deep veins suspected

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Prognosis

• Not life-threatening but may cause chronic discomfort and skin complications if untreated

• Minimally invasive procedures have high success rates (>90% vein closure) and low recurrence when performed with proper technique