Varicose veins

Overview

•Visible tortuous dilated veins - medial leg/thigh (GSV reflux) or posterolateral calf (SSV reflux)

•Dull aching/heaviness - worse after prolonged standing, better with leg elevation

•Ankle oedema, itching, night cramps

•Skin changes (advanced disease) - haemosiderin pigmentation, venous eczema, lipodermatosclerosis, venous ulceration at medial gaiter area

Risk factors

Female sex

Pregnancy

Obesity

Prolonged standing

Increasing age

Previous DVT

Pelvic mass/malignancy

Family history

🚨

Always consider secondary cause (pelvic malignancy compressing iliac veins) when varicose veins present alongside red flags: unexplained weight loss, rectal/vaginal bleeding, change in bowel habit, pelvic pain, or urinary symptoms.

Investigations

•First-line / gold standard: duplex Doppler ultrasound - maps superficial and deep venous anatomy, identifies sites of reflux (SFJ, SPJ, perforators), confirms deep vein patency, guides treatment planning

•ABPI - must be performed before compression therapy; compression contraindicated if ABPI <0.8

⚠️

Trendelenburg test and hand-held Doppler have been superseded by duplex ultrasound in modern practice - do not recommend as primary investigation.

Management

•Conservative (all patients): weight loss, regular walking (activates calf pump), leg elevation, avoid prolonged standing

•First-line symptom relief: compression hosiery (class 2, 23-32 mmHg) - requires ABPI >0.8 before application

•First-line interventional (NICE CG168): endothermal ablation - radiofrequency ablation (RFA) or endovenous laser ablation (EVLA); day-case, local anaesthesia, lower recurrence than surgery

•Second-line interventional: foam sclerotherapy (e.g. sodium tetradecyl sulphate) - if endothermal ablation unsuitable; suitable for smaller veins and recurrences

🥉 Third-line

•surgical ligation and stripping - high ligation of SFJ + GSV stripping; reserved when endothermal and sclerotherapy unsuitable; higher recurrence rate

🎯

NICE CG168 referral indications: active or healed venous ulceration, bleeding from varicose veins, symptomatic superficial vein thrombosis, or symptoms significantly affecting quality of life. Cosmetic concerns alone do not meet NHS referral criteria.

•Acute haemorrhage: direct pressure and leg elevation; admit to vascular service; definitive treatment of offending vein arranged electively

Complications

•Superficial vein thrombosis (thrombophlebitis) - painful indurated cord; risk of DVT extension

•Deep vein thrombosis and pulmonary embolism - independently elevated risk

•Venous eczema, lipodermatosclerosis ('champagne bottle' leg), haemosiderin pigmentation

•Venous ulceration - shallow, irregular ulcer at medial gaiter area; end-stage chronic venous insufficiency (CEAP C6)

•Haemorrhage - spontaneous or minor-trauma rupture; can be brisk