Varicose Veins

Cardiovascular

Description

Varicose veins are dilated, tortuous superficial veins—most commonly of the great or small saphenous systems—that become visible and palpable under the skin of the lower extremities because chronically elevated venous pressure causes valvular incompetence, venous reflux, and progressive venous wall remodeling. They constitute CEAP class C2 chronic venous disease and affect up to one-third of adults, with prevalence increasing steeply after the fourth decade and a female-to-male ratio of roughly 2 : 1.

Symptoms

Patients typically report dull ache, heaviness, throbbing, pruritus, burning, or restless legs that worsen with prolonged standing and improve with leg elevation or ambulation. Visible bluish, serpiginous bulges over the calf or medial thigh are hallmark; dependent ankle edema, nocturnal calf cramps, and telangiectatic spider veins often coexist. Skin hyperpigmentation, induration, or eczematous changes herald chronic venous insufficiency, while sudden pain and a tender cord suggest superficial thrombophlebitis.

Risk Factors

Advancing age, female sex, multiparity, positive family history, obesity, taller stature, prolonged occupational standing, sedentary lifestyle, chronic constipation or heavy lifting that raises intra-abdominal pressure, previous deep-vein thrombosis, estrogen or progesterone therapy, and conditions causing pelvic venous reflux such as ovarian-vein insufficiency markedly raise susceptibility. Genetic studies suggest heritability of 17–20 %, and smoking further accelerates disease progression.

Diagnosis

The diagnosis is clinical, confirmed and mapped with duplex ultrasonography that measures venous diameter, valve competence, and reflux time (> 0.5 s in superficial veins) in the upright position. CEAP classification and Venous Clinical Severity Score document anatomic extent and clinical impact, guiding therapy. Additional imaging such as CT or MR venography is reserved for suspected pelvic or deep-vein obstruction. Routine D-dimer, coagulation panels, or thrombophilia screens are unnecessary unless thrombosis is suspected.

Treatment

First-line management for symptomatic but uncomplicated disease combines graduated compression stockings (20–30 mm Hg), daily calf-muscle exercise, leg elevation, and weight reduction. Persistent symptoms, cosmetically distressing veins, or skin complications warrant endovenous or surgical intervention. Endovenous thermal ablation—radiofrequency or 1470-nm laser delivered under tumescent anesthesia—achieves > 90 % long-term occlusion with faster recovery and less neuropathy than high-ligature/stripping surgery; mechanochemical ablation and cyanoacrylate closure offer tumescent-free alternatives. Foam sclerotherapy with polidocanol micro-foam treats refluxing tributaries or perforators, often as an adjunct to truncal ablation. For extensive reflux, high-saphenous ligation with segmental stripping remains effective and cost-efficient. Compression alone is inadequate for ulcer healing, but early endovenous ablation accelerates ulcer closure and halves recurrence. Low-dose rivaroxaban or fondaparinux is given when thrombophlebitis extends toward the saphenofemoral junction.

Outlook

Lifestyle measures relieve minor symptoms in most patients, while modern minimally invasive ablation yields durable freedom from reflux in 70–95 % at five years, improves quality-of-life scores, and lowers ulcer recurrence compared with compression alone. Nevertheless, new reflux can develop in untreated tributaries or contralateral limbs, so long-term surveillance and weight control are key to sustained benefit. Life-threatening complications are rare; five-year mortality parallels the general population unless deep-vein thrombosis or severe chronic venous insufficiency supervenes.

Complications

Untreated varicosities may progress to chronic venous insufficiency with edema, lipodermatosclerosis, atrophie blanche, eczema, and venous leg ulcers; superficial thrombophlebitis occasionally propagates into the deep system, causing pulmonary embolism. Rarely, ruptured varices lead to exsanguinating hemorrhage, and long-standing ulcers can transform into Marjolin-type squamous-cell carcinoma.

Prevention

Maintaining normal body mass index, regular aerobic exercise, periodic ambulation during long flights or seated work, and compression hosiery during pregnancy or jobs demanding prolonged standing mitigate venous hypertension and delay varicosity development. Early treatment of refluxing saphenous trunks decreases the likelihood of secondary tributary dilatation and skin changes.

Support

Daily use of graduated compression stockings from waking until bedtime, intermittent calf raises during prolonged standing, twice-daily limb elevation above heart level for fifteen minutes, avoidance of tight girdles or high-heel shoes that hamper venous return, meticulous skin moisturization to prevent stasis dermatitis, and prompt treatment of minor leg abrasions reduce symptom burden and progression. Caregivers can assist by reminding patients to don stockings correctly and scheduling follow-up duplex scans six to twelve weeks after ablation.