Venous insufficiency (including varicose veins)

Overview

•Visible dilated veins - tortuous superficial veins along medial thigh/calf (great saphenous) or posterolateral calf (small saphenous)

•Heaviness/aching - worse after prolonged standing, improves with leg elevation

•Ankle oedema - pitting, worse at end of day, relieved overnight

•Skin changes of CVI - haemosiderin pigmentation (brown, gaiter area), venous eczema, lipodermatosclerosis (firm woody induration, inverted-champagne-bottle deformity)

•Venous ulceration - shallow, irregular margins, sloughy base, medial gaiter area above medial malleolus; usually painless unless infected

•Superficial thrombophlebitis - tender, erythematous, indurated segment along a varicosity

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Lipodermatosclerosis vs cellulitis: lipodermatosclerosis is bilateral, chronic, non-tender, firm and woody; cellulitis is unilateral, acute, warm, tender, with systemic features (fever, raised WBC/CRP).

Investigations

🏆 Gold standard

•duplex ultrasound (B-mode + colour Doppler) - maps venous anatomy, identifies reflux at SFJ/SPJ (>0.5 s significant), excludes DVT; required before ANY intervention (NICE CG168)

•First-line bedside: handheld Doppler - rapid assessment of reflux at SFJ/SPJ; does not replace duplex before intervention

•ABPI - mandatory before compression therapy; ABPI <0.8 contraindicates full compression

🎯

Duplex ultrasound is required before ANY intervention for varicose veins per NICE CG168. Old clinical tests (Trendelenburg, tap test, cough test) are historical only.

Management

•Conservative (mild/asymptomatic or awaiting referral):

•Compression hosiery (class 2 or 3 graduated stockings) - first-line for patients not suitable for intervention; requires ABPI ≥0.8 first

•Leg elevation, weight loss, regular exercise

•Emollients and topical steroids for venous eczema

•Interventional (when duplex confirms truncal reflux - NICE CG168 hierarchy):

•First-line: endothermal ablation - radiofrequency ablation (RFA) or endovenous laser ablation (EVLA); preferred over surgery - lower complication rates, faster recovery

•Second-line: ultrasound-guided foam sclerotherapy (UGFS) - polidocanol or sodium tetradecyl sulphate; when endothermal ablation unsuitable (tortuous anatomy, small calibre veins)

•Third-line: surgical ligation and stripping (high tie and strip) - reserved for unsuitable anatomy or failed above

•Venous ulcer: high-compression bandaging (four-layer) is cornerstone; correct underlying reflux once healed

Complications

•Venous ulceration - most significant; medial gaiter area; prone to recurrence without correcting reflux

•Superficial thrombophlebitis - risk of propagation to deep system if near SFJ

•Haemorrhage - spontaneous or post-traumatic from varicosity; first aid: elevation and direct pressure

•DVT - varicose veins are an independent risk factor for VTE