Varicose veins

Author: Ramez Barsoum, Resident Medical Officer, Princess Alexandra Hospital, Brisbane, QLD, Australia. DermNet NZ Editor in Chief: Adjunct A/Prof Dr Amanda Oakley, Dermatologist, Hamilton, New Zealand. Copy edited by Gus Mitchell. April 2019.


What are varicose veins?

Varicose veins are engorged, tortuous, green, blue, or purple veins that are often found on the lower legs and feet.

Varicose veins are also called varices or varicosities.

Varicose veins

Who gets varicose veins?

Approximately one-third of men and women aged 18–64 years have varicose veins [1]. They are more common in women and those with a family history of venous disease.

What causes varicose veins?

In normal leg veins, one-way valves direct the flow of venous blood from superficial venules to larger superficial veins, then to the deep veins, and eventually to the heart. Muscle contractions create a pumping action to help the flow of blood to the heart (the venous return).

Risk factors for varicose veins

  • Obesity — obesity increases venous reflux and venous pressure because of raised intra-abdominal pressure [2].
  • Age — varicose veins are increasingly common with age [3].
  • Pregnancy — the enlarged uterus causes increased intra-abdominal pressure and direct pressure on the iliac veins. Hormonal changes cause the valves and vessels to become more malleable [4].
  • Prolonged standing — increased hydrostatic pressures over time may cause venous distension and valve failure [3].
  • Family history — primary valvular failure is hereditary, and there is concordance in monozygotic twins in 75% of cases [5].

What are the clinical features of varicose veins?

Patients with varicose veins present because they are unsightly and because of a feeling of discomfort, heaviness, itching, or a dull ache. Patients can also present with complications such as bleedingulceration, and thrombophlebitis.

What are the complications of varicose veins?

Bleeding

Superficial veins are prone to trauma and can bleed, which can be potentially life-threatening [6,7].

Ulceration

The increased pressure in varicose veins allows growth factors and circulating pro-inflammatory molecules to leak into the extravascular space, which leads to localised inflammation and the formation of a chronic venous leg ulcer.

Thrombophlebitis

Phlebitis is inflammation of the veins with erythema and painful induration of the affected veins. It is often associated with thrombosis (thrombophlebitis) [6]. Thrombosis arises because of sluggish circulation of blood in the vein combined with a hypercoagulable state and may be superficial (superficial thrombophlebitis) or deep (deep vein thrombosis) [6].

Venous stasis dermatitis

Venous stasis dermatitis is associated with increased venous pressure and pooling of inflammatory molecules. Patients present with brown discolouration, pruritus, and discoid or circumferential, acute or chronic eczema on the distal lower limbs [7].

Lipodermatosclerosis

Lipodermatosclerosis is an inflammatory and indurated form of panniculitis due to the presence of pro-inflammatory molecules.

Complications of varicose veins

How are varicose veins diagnosed?

Varicose veins are diagnosed clinically. A physical examination should include the entire venous system and is usually conducted with the patient lying down and standing up.

The National Institute for Health and Care Excellence uses the Clinical Etiological Anatomical Pathophysiological (CEAP) classification of varicose veins:

CEAP classification

Duplex Doppler ultrasound assessment should be performed to determine the extent of disease and the level of truncal reflux [8] and to plan treatment options.

What is the differential diagnosis for varicose veins?

Varicose veins are larger than telangiectasia (small red 'thread' veins, < 1 mm in diameter) and venulectasia (blue reticular vessels, 1–3 mm in diameter). These are not detected on duplex ultrasound.

What is the treatment for varicose veins?

Weight loss (if overweight) and moderate physical activity should be encouraged in patients with varicose veins to reduce the risk of complications. Compression hosiery should be used to relieve discomfort and swelling, and especially when travelling.

Treatment options for varicose veins are available from a vascular service.

Endovenous thermal ablation

Endovenous thermal ablation using a laser or radiofrequency device causes an irreversible thermal injury in the vein wall, which leads to scarring and absorption of the tissue over several months. The success rate for both different methods of ablation is 95% [9,10].

Injection sclerotherapy

Sclerotherapy involves the injection of a sclerosant under ultrasound guidance to cause inflammation of the vessels of the wall and eventual collapse of the varicose network. Smaller surface veins can be injected by microsclerotherapy, involving smaller gauge needles with smaller amounts of sclerosant [11].

Endovenous adhesive ablation

Endovenous adhesive ablation or 'vein glue' technique involves the injection of a medical grade adhesive cyanoacrylate glue through a catheter. Long term safety and efficacy data are lacking [12].

Endovenous mechanicochemical ablation (ClariVein)

ClariVein is a rotating occlusion catheter that mechanically agitates the vein lining while also spraying a liquid sclerosant. It induces more endothelial damage but lacks long term data [13].

Surgery

High ligation, vein stripping and avulsion are less often used to treat varicose veins than in the past due to postoperative morbidity, recurrence rates, and the risks associated with anaesthesia and hospitalisation [10].

Lasers

Telangiectasia and venulectasia can be treated with long wavelength vascular lasers, but these are unsuitable for larger varicose veins [14].

What is the outcome for varicose veins?

Whichever treatment option is used, varicose veins may recur and can be treated again.[14].

See smartphone apps to check your skin.
[Sponsored content]

 

Related information

 

References

  1. Murad MH, Coto-Yglesias F, Zumaeta-Garcia M, Elamin MB, Duggirala MK, Erwin PJ, et al. A systematic review and meta-analysis of the treatments of varicose veins. J Vasc Surg 2011; 53 (5 Suppl): 49S-65S. PubMed
  2. van Rij AM, De Alwis CS, Jiang P, Christie RA, Hill GB, Dutton SJ, et al. Obesity and Impaired Venous Function. Eur J Vasc Endovasc Surg 2008; 35: 739–44. PubMed
  3. Brand FN, Dannenberg AL, Abbott RD, Kannel WB. The epidemiology of varicose veins: the Framingham Study. Am J Prev Med 1988; 4: 96–101. PubMed
  4. Ismail L, Normahani P, Standfield NJ, Jaffer U. A systematic review and meta-analysis of the risk for development of varicose veins in women with a history of pregnancy. J Vasc Surg Venous Lymphat Disord 2016; 4: 518–24. PubMed
  5. Krysa J, Jones GT, van Rij AM. Evidence for a genetic role in varicose veins and chronic venous insufficiency. Phlebology 2012; 27: 329–35.
  6. Chang SL, Huang YL, Lee MC, Hu S, Hsiao YC, Chang SW, Chang CJ, Chen PC. Association of varicose veins with incident venous thromboembolism and peripheral artery disease. JAMA 2018; 319: 807–17. PubMed
  7. Chiesa R, Marone EM, Limoni C, Volonte M, Schaefer E, Petrini O. Chronic venous insufficiency in Italy: the 24-cities cohort study. Eur J Vasc Endovasc Surg 2005; 30: 422–9. PubMed
  8. O'Flynn N, Vaughan M, Kelley K. Diagnosis and management of varicose veins in the legs: NICE guideline. Br J Gen Pract 2014; 64: 314–5. PubMed Central
  9. Mao J, Zhang C, Wang Z, Gan S, Li K. A retrospective study comparing endovenous laser ablation and microwave ablation for great saphenous varicose veins. Eur Rev Med Pharmacol Sci 2012; 16: 873–7. PubMed
  10. Wittens C, Davies AH, Baekgaard N, Broholm R, Cavezzi A, Chastanet S, et al. Editor's Choice - Management of Chronic Venous Disease: Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg 2015; 49: 678–737. PubMed
  11. Rathbun S, Norris A, Stoner J. Efficacy and safety of endovenous foam sclerotherapy: meta-analysis for treatment of venous disorders. Phlebology 2012; 27: 105–17. PubMed
  12. Almeida JI, Javier JJ, Mackay E, Bautista C, Proebstle TM. First human use of cyanoacrylate adhesive for treatment of saphenous vein incompetence. J Vasc Surg Venous Lymphat Disord 2013; 1: 174–80. PubMed
  13. Tang TY, Kam JW, Gaunt ME. ClariVein(R) — early results from a large single-centre series of mechanochemical endovenous ablation for varicose veins. Phlebology 2017; 32: 6–12. PubMed
  14. Munia MA, Wolosker N, Munia CG, Chao WS, Puech-Leao P. Comparison of laser versus sclerotherapy in the treatment of lower extremity telangiectases: a prospective study. Dermatol Surg 2012; 38: 635–9. PubMed

On DermNet NZ

Other websites

Books about skin diseases

See the DermNet NZ bookstore.