BMJ Learning

Varicose veins: an update on management

د. حسين محمد جمعة
اختصاصي الامراض الباطنة
البورد العربي
كلية طب الموصل
2010

Learning outcomes

On completion of this module you should understand:
The symptoms varicose veins may cause
How to examine someone with varicose veins
When to refer someone with varicose veins
What treatments are available and their advantages and disadvantages.

Why we wrote this module

"Varicose veins are common and can occasionally cause serious morbidity as a result of skin damage and ulceration. Most people with varicose veins suffer little or no harm from them but there are uncertainties about when referral for specialist advice is necessary. In addition, a number of new treatments have recently become available, which can have different advantages and disadvantages.”


Key points
Varicose veins seldom cause complications but are often of considerable concern to patients
Doctors should base their decisions about referral for treatment on symptoms and skin changes.

Identification of venous problems of the skin is one of the most important aspects of the clinical assessment: damage of the skin or ulceration are indications for referral for possible treatment of varicose veins.

There are a number of new treatments for varicose veins but there is limited comparative evidence on their clinical or cost effectiveness
Thrombophlebitis should be treated with NSAIDs, not antibiotics.
A hard, inflamed area above the ankle in the presence of varicose veins may well be inflammatory liposclerosis - not thrombophlebitis
Bleeding from varicose veins is rare but requires referral for treatment.

Clinical tips

Varicose veins and associated skin changes may be appreciated as much by palpation as by inspection
Minimally invasive treatments are available as an alternative to surgery and are usually performed under local anaesthesia
Frail patients with venous ulcers or bleeding from varicose veins may still be suitable for definitive treatment of venous reflux.

What are varicose veins?

Varicose veins are enlarged tortuous veins associated with reflux of blood due to incompetent valves. They are conventionally defined as being more than 4 mm in diameter.
Patients may also be concerned about other visible veins on their legs which are not varicose veins. These include normal subcutaneous veins which are easily visible in some people, particularly if they have pale skin.

Reticular veins are defined as dilated non-palpable subdermal veins smaller than 4 mm in diameter (see figure 1).
Telangiectasies (usually called thread veins or spider veins): these are dilated intradermal venules less than 1 mm in diameter which may be isolated or occur in patches or blushes.


• Figure 1: Reticular veins
• in popliteal fossa
•



The American and European nomenclature regarding varicose veins has recently been standardised. While the terms long saphenous vein and short saphenous vein are still widely used and understood, the official terminology now refers to great saphenous (previously long saphenous) and small saphenous (previously short saphenous) veins. The terms great saphenous vein and small saphenous vein will therefore be used throughout this module.

How common are varicose veins?

Are common and their prevalence increases with age By the sixth decade they are found in about one person in two. Traditionally they were considered to occur more often in women: this was based on anecdote and on studies using self administered questionnaires. But in the Edinburgh Vein Study, a large well conducted cross sectional population study of 1566 subjects, 40% of men and 32% of women had varicose veins.

It is possible that the impression of a higher prevalence in women was related to the fact that more women present for advice and treatment.
Reticular veins and thread veins were observed in over 80% of the population in the Edinburgh Vein Study.

What causes varicose veins?

It is usually difficult to attribute a single cause to any patient's varicose veins. They can occur as a result of obstruction to deep veins (for example after deep vein thrombosis) but this is a rare reason for varicose veins. Most varicose veins are primary - they have no identifiable cause. Women often first notice varicose veins in pregnancy and pregnancy can cause them to worsen.

A family history is common and people with varicose veins are often worried that their veins will become huge and extensive or that they will develop ulcers because a family member has had these problems. There is nothing predictable about varicosities enlarging or causing ulcers on the basis of a family history..

Occupation

Associations have been described between occupations involving prolonged standing and the development of varicose veins.


Diagnosis
The relationship between varicose veins and symptoms is unpredictable.
The Edinburgh Vein Study used a self assessment questionnaire to assess symptoms.
In men, the only symptom importantly associated with varicose veins was itching.
In women there was an important association between varicose veins and heaviness, tension, aching, and itching.

Regardless of whether they had varicose veins, more than half of all women complained of aching legs and the authors concluded most lower limb symptoms probably had a non-venous cause.

Conventionally varicose veins are thought to be more symptomatic when the leg is dependent. A detailed questionnaire study of patients attending outpatient clinics with varicose veins found that many complained their symptoms were worse during or after standing; symptoms were also more common in hot weather or during menstruation.

Skin problems

The venous hypertension caused by reflux of blood in varicose veins can lead to skin problems at the ankle, with the risk of ulceration if this is allowed to progress. Skin damage may present in different ways:

Eczema

This usually presents as eczematous patches on the lower leg and sometimes elsewhere on the body. These can be itchy. Steroid cream (without antibiotics) settles the acute problem. Advise your patient not to use steroid cream for more than about 10 days at a time. Recurrent eczema should prompt regular application of moisturiser and wearing of compression hosiery and/or referral for treatment of the varicose veins.

Skin pigmentation

If this remains light brown, with normal subcutaneous tissues, then it is a warning sign but poses little threat. Application of moisturiser may help to prevent progression. You should manage worsening (dark brown or spreading) pigmentation like lipodermatosclerosis (below).

Lipodermatosclerosis

Lipodermatosclerosis (figure 2) means pigmentation of the skin, together with sclerosis (scarring and hardening) of the subcutaneous tissues on the lower leg. The affected area may become visibly depressed. White, pearly areas of atrophie blanche may appear.


These changes all indicate a risk of ulceration and should prompt advice for the use of well fitted, below knee, graduated compression hosiery (normally Class 2) and a moisturiser (once or twice a day) and/or referral for treatment of varicose veins.

Sometimes an area of subcutaneous tissue may become red, inflamed, hard, and painful. This inflammatory liposclerosis is commonly confused with phlebitis, but it is a more common reason for hard, painful inflammation near the ankle. Analgesic and anti-inflammatory medication may help the symptoms. Antibiotic treatment is unnecessary. Early referral to a vascular specialist is indicated to consider treatment for the underlying venous hypertension.

• Figure 2: Lipodermatosclerosis

•

Why do patients with varicose veins present to their doctor?

Cosmetic concern
Symptoms of discomfort (which may or may not be related to the varicose veins)
Complications of varicose veins (such as ulceration, bleeding, or thrombophlebitis).
Concerns about what might happen in the future

It is important to clarify the reason for presentation as this can help you decide if the patient needs referral for treatment. Many patients simply need reassurance that their varicose veins are causing no harm and are unlikely to do so in the future.

What else is relevant in the history?

It is important to determine whether the patient has had any complications related to their varicose veins, such as:
Bleeding
Thrombophlebitis
Changes of the skin
Ulceration.
These will affect the urgency of the referral.


In addition, it is worth considering comorbidity, including obesity, since this may affect management. You should encourage an obese patient without complications of varicose veins to lose weight prior to referral to reduce the risks of treatment.
You may want to advise an unfit patient with uncomplicated varicose veins against intervention.

Young women may wish to complete their family planning prior to treatment.

It is useful to find out whether there has been any history of deep vein thrombosis, bearing in mind that if the patient has had a leg fracture or prolonged period of immobilisation they may have had an undetected deep vein thrombosis. Patients often confuse superficial thrombophlebitis with deep vein thrombosis but a careful history will usually resolve the issue.

How should I examine patients with varicose veins?

For the examination, the patient should be standing with their legs exposed up to the groins. Good light is helpful - daylight is ideal. During examination ask yourself the three following questions:

Are varicose veins present and how big are they? Varicose veins are usually visible, but may only be obvious on palpation, particularly in people with adipose legs. You should not confuse them with easily visible subcutaneous veins or with thread or reticular veins (but these may occur together with varicose veins).

What is the extent and distribution of the varicose veins? You should record whether varicosities are extensive or localised and if one or both legs are affected.
Then check and record whether varicose veins are mainly in the great saphenous territory (medially above and/or below the knee) or
in the small saphenous territory in the posterior calf.

Is venous hypertension damaging the skin? This is the most important aspect of examination. Is there any sign of eczema or lipodermatosclerosis on the lower leg? Skin pigmentation is obvious but you may only appreciate liposclerosis (scarring and contraction of the subcutaneous fat) by gentle palpation, and perhaps by comparison with the consistency of the subcutaneous fat of the other leg.

Check if there is any sign of ulceration such as:

An open ulcer
Fragile skin at imminent risk of breakdown
Scarring from previous ulcers.


Other considerations
Leg swelling may be due to varicose veins, but on their own varicose veins rarely cause leg swelling. There are many other causes, including deep venous incompetence or lymphoedema. A cause other than varicose veins is likely if the swelling affects both legs as a manifestation of generalised oedema (eg due to right ventricular failure, nephrotic syndrome, hypoalbuminaemia) or as a result of immobility or prolonged dependency of the legs.
Hard, tender varicose veins indicate thrombophlebitis.
Scars from previous varicose veins surgery may be visible.

Referral

When should I refer people with varicose veins to a specialist?
The following is a good guide:
Immediate: Bleeding from a varicosity that has eroded the skin
Urgent: Has bled from a varicosity and at risk of bleeding again
Soon: Ulcer which is progressive or painful despite treatment.

Routine:

Active or healed ulcer and/or progressive skin changes that may benefit from surgery
Recurrent superficial thrombophlebitis
Troublesome symptoms attributable to varicose veins
The extent, site, and size of the varicosities are having a severe impact on the patient's quality of life.

How do vascular specialists assess people with varicose veins?

Determine the sites of venous incompetence:
Hand held Doppler is performed in clinic as the first line investigation to identify the source of reflux (figure 3): it is operator dependent and more accurate for the great saphenous system than for the small saphenous system. Specialists no longer use tourniquet tests (the Trendelenberg test).


Duplex ultrasound scanning is now the gold standard investigation for varicose veins, but there has been much debate about when it is indicated. Some specialists recommend duplex assessment for all patients ,while others request duplex selectively for patients with reflux in the popliteal fossa, recurrences, or atypical varicose veins.

Venograms are almost never used to assess varicose veins nowadays, although MR and CT venography is sometimes required for complex venous disease.

• Figure 3: Examination of the saphenofemoral junction using handheld Doppler

•

Treatments

Compression hosiery
improves both venous haemodynamics and symptoms in patients with varicose
The disadvantages are:
That the benefit is restricted to the period during which the stocking is worn
That many patients find compression difficult to tolerate, particularly in hot weather (when symptoms from their veins are often most troublesome).

In addition:

There is no advantage to above knee stockings over below knee stockings if symptoms are mostly below the knee or if skin problems are the indication.
Pharmacies and other outlets often stock just one type and patients should be aware there are several different makes, some of which may suit them better than others.

When prescribing stockings it is important to be aware that there are two different standards.
In the European standard (used by hospitals)
Class 1 provides light compression (18.4-21.1 mm Hg at the ankle).
Class 2 provides 25.2-32.3 mm Hg,
Class 3 provides 36.5-46.6 mm Hg, and
Class 4 provides >59 mm Hg.


In the British standard (used in primary care)
Class 1 provides 14-17 mm Hg.
Class 2 provides 18-25 mm Hg, and
Class 3 provides 25-35 mm Hg. For uncomplicated varicose veins Class 2 (British) should be sufficient, for patients with skin changes Class 3 (British) is preferable. However some compression is better than none and compliance may be less with heavier stockings.

Medication

A variety of medical treatments have been promoted for symptomatic varicose veins.
A recent Cochrane review concluded horse chestnut seed extract relieved symptoms of chronic venous insufficiency. There is insufficient evidence to recommend the use of phlebotonics (topical or oral drugs purported to improve venous tone).

Surgery

Conventional treatment for varicose veins consists of surgical abolition of the source of reflux and removal of the varicosities, most often by:
Saphenofemoral ligation
Stripping of the great saphenous vein
Phlebectomies (sometimes called avulsions).

Surgery of the great saphenous vein has been shown to improve the quality of life for patients with varicose veins and it is a clinically and cost effective treatment.
Conventional surgery needs a general anaesthetic but most patients are treated and discharged the same day. The return to normal activity has been reported as 2-3 weeks but patients will do no harm by returning to full activity as soon as they are able.

Surgery can cause considerable short term bruising of the legs in some patients - especially those whose varicose veins were big and extensive. Cutaneous nerves run close to the veins and patients may experience temporary or even permanent numb areas on their legs following surgery: this rarely causes important disability.

Surgery as a comparator with the newer treatments

The aim of the newer treatments, described in the following sections, is to reduce the morbidity associated with surgery and allow quicker return to normal activity. Surgery is still regarded as the gold standard with regard to abolition of reflux and varicosities, and needs to be a comparator in studies on the effectiveness of the newer techniques.


Radiofrequency and endovenous laser ablation.
Radiofrequency ablation and endovenous laser ablation are both new techniques which seal off the great saphenous vein (or the small saphenous) using heat, rather than stripping it surgically. This may result in regression of varicose veins but additional treatment is often necessary (phlebectomies or sclerotherapy). Both techniques:

Are endovenous, involving introduction of a catheter into the great saphenous vein through a tiny incision near the knee and advancing it up to the saphenofemoral junction under ultrasound guidance. No groin incision is needed.

The radiofrequency ablation or laser fibre is withdrawn at a controlled rate, heating and ablating the vein
Can be done under local anaesthesia (wide infiltration of the subcutaneous tissues of the thigh) although general anaesthesia may be preferable if a large number of phlebectomies are to be done concurrently

Need to be followed by a period of compression - usually with bandages and a stocking. One to two weeks is typical advice, but some specialists recommend a stocking for longer than this
Rely on the presence of a fairly straight great saphenous vein or small saphenous vein - they are not suitable for patients who have recurrent varicose veins without a residual incompetent great or small saphenous vein or for patients with tortuous great or small saphenous veins.

Radiofrequency ablation

Abolition of reflux is reported in 84-96% patients following radiofrequency ablation with associated improvement in symptoms. Paraesthesia may occur but is usually temporary, deep vein thrombosis is generally reported in <1% patients although some series have reported a higher incidence Skin burns have been reported occasionally.Tenderness over the treated vein is common following treatment

Randomised controlled trials suggest a similar clinical result to surgery with a shorter recovery period and less post-treatment pain.
There are little follow up data published beyond two to three years.

Endovenous laser ablation

Abolition of reflux is reported in 80-99% of patients following endovenous laser ablation with similar improvements in symptoms to surgery.
Thrombophlebitis occurs in about 10% of patients. Paraesthesia and deep vein thrombosis are uncommon51 53 54 and skin burns are rare.


Three randomised controlled trials have shown similar outcomes to surgery but with less post-operative pain, and conflicting results regarding the recovery period.
There are little published follow up data beyond one to two years.

Foam sclerotherapy

This is different to conventional sclerotherapy because the sclerosant is forcibly mixed with a gas (commonly air) to form a foam. When injected, the foam spreads widely through the veins, displacing the blood and causing venous spasm. It is usually done with the help of duplex ultrasound imaging. Foam may be used to treat the great or small saphenous vein in addition to varicosities themselves.

After the injections compression is applied: advice varies about how long all this compression is left in place, but seven to 14 days is typical.
Varicosities are often tender and hard following treatment, shrivelling over a period of weeks or months, and brown skin discoloration is common, although usually temporary.

Deep vein thrombosis is rare (incidence <1%),58 as are visual disturbances (about 1%); these are thought to be due to vasospasm induced by the foam and are more common in patients with a history of migraine.

Stroke has been reported following injection of a large volume of foam which passed through a patent foramen ovale and two more neurological defects occurred recently despite only 4 ml of foam being used in one of the patients.
Recovery after foam sclerotherapy may be quicker than after conventional surgery but results (up to three to five years) are somewhat less good than surgery. Longer term outcomes have not yet been reported.

Conventional sclerotherapy

Conventional compression sclerotherapy, using liquid sclerosant, still has a place in the treatment of varicose veins, so long as they are limited in extent and so long as there is no important proximal incompetence. The poor reputation of sclerotherapy in the past was due largely to the fact that it was often used in the presence of upstream reflux, so recurrence was common. Used appropriately, it can produce entirely satisfactory results.

Choice of treatment

There is insufficient comparative evidence as yet to draw firm conclusions about the best treatment for varicose veins, but the table offers some suggestions as to which treatments may be more appropriate for different clinical scenarios. Availability of the newer treatments varies between hospitals with few centres offering all options.

Table: Suggested roles of treatments for varicose veins

Treatment
Best for
Avoid in
Compression
Patients not suitable for definitive treatment, particularly if skin changes
Patients with coexisting peripheral arterial disease
Medical (HSCE)
Not known
Pregnancy or breastfeeding
Surgery
Large extensive varicositiesFit patientsMay provide best cosmetic result
Recurrent varicose veinsPatients at high risk from general anaesthesia
Endovenous laser or radiofrequency ablation
Below knee varicositiesPatients not suitable for general anaesthesia or who prefer local anaesthesia
Patients with no great and small saphenous vein (for example due to previous surgery) or large varicosities in anterior thigh
Foam sclerotherapy
Patients not fit for for general anaesthesia or who prefer local anaesthesiaRecurrent varicose veins
Patients with needle phobiaPatients with extensive large varicosities or thin skinPatients who would consider skin staining (brown) to be cosmetically unacceptable
Liquid sclerotherapy
Isolated varicosities without reflux in the great and small saphenous veins
Significant reflux in the great and small saphenous veins


What is the risk of recurrence after treating varicose veins?
Any kind of treatment for varicose veins may be followed by recurrence despite thorough treatment. You should warn your patients of this. This may be due to varicose veins developing in a different part of the leg to that previously treated or due to true recurrence in an area already treated.

The chance of troublesome recurrence is about one in three at 10 years following surgery. The risk of recurrence beyond about five years following the newer treatments is not yet known.

Complications

How should you manage thrombophlebitis in varicose veins?
Superficial thrombophlebitis (phlebitis) of the lower limbs occurs most commonly in association with varicose veins. NSAIDs reduce the extension of phlebitis in the superficial veins and are as effective as low molecular weight heparin.

Topical treatments with anti-inflammatory preparations improve local symptoms.

Thrombophlebitis is not an infective condition and antibiotics have no place in its management.

Deep vein thrombosis has been reported on duplex ultrasound scanning in about 10-20% of patients with superficial thrombophlebitis and is more common when thrombophlebitis affects veins above the knee. These deep vein thromboses are usually asymptomatic, minor, and are seldom associated with clinical sequelae.

Many of the patients reported in the studies had additional risk factors; the risk of deep vein thrombosis in fit people with varicose veins is likely to be much lower but good data are not available.

Based on our interpretation of the evidence, we offer the following practical advice:

All patients with phlebitis should be advised to take NSAIDs (unless contraindicated) and to keep mobile. Wearing of a below knee graduated compression stocking may be helpful (especially for extensive phlebitis and high risk patients). Topical NSAIDs or heparinoids may give additional symptom relief.

Phlebitis in varicose veins above the knee, especially if progressing rapidly and/or extensive. Refer to secondary care for a duplex scan and further advice
Patients with other risk factors for thromboembolism (including those who are immobile) or if there is a high level of concern for any other reason.


Refer to secondary care for scan and/or treat with low molecular weight heparin for at least 10 days
Phlebitis in the absence of varicose veins. Investigate for an underlying cause (for example hypercoagulable state, malignancy).

What about bleeding from varicose veins?

Many people are worried that their varicose veins may bleed, but this fear is seldom justified unless the skin over a vein is compromised. The usual situation is an area of dark, thin skin overlying a varicosity, which bleeds after being rubbed (commonly by a towel when drying after showering). Once this has happened the risk of further bleeds is real.

The most serious risk is of a persistent bleed during sleep, when it is possible for a large volume of blood to be lost.

The emergency treatment of bleeding from a varicose vein is to elevate the limb and to apply local pressure. This should always control venous bleeding effectively. A pad and firm bandage can then be applied and left in place for at least 48 hours, then being removed under supervision to check that the area has settled.

It is sensible to continue with a protective dressing and/or compression until the patient is seen by a specialist, via an urgent referral.
A major bleed in a frail patient may be appropriately dealt with by emergency referral to hospital.
A history of a bleed is an indication for early treatment of varicose veins.

What about venous ulcers?

Venous ulcers occur due to venous hypertension which can impair perfusion of the skin and subcutaneous tissues (figure 4). Chronic venous ulceration affects 1-2% of the population.

Venous ulcers were initially thought to occur only with deep venous incompetence but there is now good evidence that superficial venous incompetence alone can cause ulcers and is probably responsible for up to half of all venous ulcers.

In patients who have a combination of deep and superficial venous incompetence, treating the superficial incompetence may improve venous haemodynamics and therefore be beneficial. All this emphasises the importance of recognising varicose veins as an underlying cause of skin problems near the ankle.


Compression is the mainstay of treatment for healing venous ulcers, with studies showing healing rates after 24 weeks of 64-83%. The ESCHAR study showed that surgery of varicose veins importantly reduced the risk of recurrence (28% at one year for compression alone versus 12% for compression plus surgery).

Patients with mixed arterial and venous disease are more difficult to treat. Referral to a vascular specialist may be helpful for advice about:
Whether compression bandaging is appropriate.
Whether treatment of the arterial insufficiency is desirable.
Whether there is an advantage to treating superficial venous insufficiency.
Aggressive treatment may be justified even in frail patients if an ulcer is causing pain.

• Figure 4: Typical venous ulcer over medial malleolus with associated lipodermatosclerosis and varicose veins.
•

What are the treatments of thread veins (telangiectases, spider veins)?

Treatment of thread veins is almost always done for cosmetic reasons only, although rarely an area of thread veins may throb or feel hot, in the presence of demonstrable venous reflux. Two forms of treatment are commonly used.

Microsclerotherapy

This means injection of sclerosant with a fine needle. You can treat many areas of thread veins at a single session. It is usual to apply compression (padding, bandage, stocking) for a few days after treatment.

If sclerosant extravasates during injection it can cause an area of ulceration (which gradually heals, leaving a scar). This should be rare in experienced hands. Brown staining may persist for several months and occasionally for the long term.


Laser ablation
This works particularly well for birthmarks and blemishes comprising miniscule veins, which are too small to be accessed by a needle for microsclerotherapy.
A small randomised study reported better results after treatment of telangiectases on the legs after microsclerotherapy than after laser treatment, with equal numbers of adverse sequelae.

What about varicose veins and pregnancy?

Women presenting with varicose veins often say that they first noticed them in pregnancy and there is some evidence for an association between varicose veins and parity.3 Small studies on pregnant women have stimulated some controversy about whether pregnancy really is a cause of varicose veins.

Women with varicose veins do tend to experience worse symptoms when they are pregnant. Compression hosiery can provide symptom relief82 and there is some evidence that rutosides (oxerutins) can also provide symptom relief.

Traditionally, there was a tendency for specialists to advise against treatment of varicose veins until women had finished having children, because of concern about recurrence with further pregnancies. It is reasonable to warn women of this possibility but if they have troublesome symptoms there is no compelling contraindication to treating women who may become pregnant thereafter.

Vulval varicosities may occur in 4% of women, usually during pregnancy. They may be symptomatic but usually regress following delivery. Persistent vulval varicosities in non-pregnant women may be associated with ovarian vein reflux, which can be diagnosed by ovarian venography and treated at the same time by embolising the refluxing ovarian veins with special coils. Diagnosis can also be made using magnetic resonance venography or transvaginal ultrasound, prior to ovarian venography.

Ovarian vein reflux may be the underlying cause of troublesome menstrual symptoms from varicose veins, varicose veins of atypical distribution (for example over the buttocks and backs of the upper thighs), and recurrence of varicose veins after apparently definitive treatment.

Varicose veins and deep vein thrombosis and risk of air travel.

Many people with varicose veins are worried about deep vein thrombosis since varicose veins feature in lists of risk factors for deep vein thrombosis. Evidence for an association is all derived from studies on patients having major abdominal and pelvic surgery in the era before regular use of prophylaxis.

There is no good evidence that varicose veins confer a risk of deep vein thrombosis in otherwise healthy people during their normal daily lives, and strong reassurance is appropriate.

The risk of clinically important deep vein thrombosis following a long haul flight is low (0.05%). The risk is higher in people with risk factors for venous thromboembolism but it remains uncertain as to whether varicose veins are an important risk factor.


Compression stockings reduce the incidence of asymptomatic deep vein thrombosis and avoiding dehydration and immobility seems logical; with these precautions people with varicose veins should be reassured about flying.




علمني المطركيف اغسل همومي واحزانيوكيف اجدد حياتي كما تغسل قطرات المطراوراق الشجروتعيد لها الحياة