Varicose Veins: Diagnosis and Treatment

 

Am Fam Physician. 2019 Jun 1;99(11):682-688.

  Patient information: A handout on this topic is available at https://familydoctor.org/condition/varicose-veins.

Author disclosure: No relevant financial affiliations.

Varicose veins are twisted, dilated veins most commonly located on the lower extremities. The exact pathophysiology is debated, but it involves a genetic predisposition, incompetent valves, weakened vascular walls, and increased intravenous pressure. Risk factors include family history of venous disease; female sex; older age; chronically increased intra-abdominal pressure due to obesity, pregnancy, chronic constipation, or a tumor; and prolonged standing. Symptoms of varicose veins include a heavy, achy feeling and an itching or burning sensation; these symptoms worsen with prolonged standing. Potential complications include infection, leg ulcers, stasis changes, and thrombosis. Conservative treatment options include external compression; lifestyle modifications, such as avoidance of prolonged standing and straining, exercise, wearing nonrestrictive clothing, modification of cardiovascular risk factors, and interventions to reduce peripheral edema; elevation of the affected leg; weight loss; and medical therapy. There is not enough evidence to determine if compression stockings are effective in the treatment of varicose veins in the absence of active or healed venous ulcers. Interventional treatments include external laser thermal ablation, endovenous thermal ablation, endovenous sclerotherapy, and surgery. Although surgery was once the standard of care, it largely has been replaced by endovenous thermal ablation, which can be performed under local anesthesia and may have better outcomes and fewer complications than other treatments. Existing evidence and clinical guidelines suggest that a trial of compression therapy is not warranted before referral for endovenous thermal ablation, although it may be necessary for insurance coverage.

Varicose veins are subcutaneous veins dilated to at least 3 mm in diameter when measured with the patient in an upright position. They are part of a continuum of chronic venous disorders ranging from fine telangiectasias, also called spider veins, (less than 1 mm; Figure 1) and reticular veins (1 to 3 mm; Figure 1) to chronic venous insufficiency, which may include edema, hyperpigmentation, and venous ulcers. Chronic venous disease is most commonly described using the CEAP (clinical, etiologic, anatomic, pathophysiologic) classification system (Table 1).1

 Enlarge     Print

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferencesComments

There is not enough evidence to determine if compression stockings are effective in the treatment of varicose veins in the absence of active or healed venous ulcers.

B

7, 15, 1921

Based on a Cochrane review and clinical guidelines based on systematic reviews; consensus guidelines and expert opinion

Horse chestnut seed extract (Aesculus hippocastanum) and other phlebotonics may ease the symptoms of varicose veins, but long-term studies of the safety and effectiveness of phlebotonics are lacking.

B

2325

Based on systematic reviews/Cochrane review of lower-quality RCTs

Referral for interventional treatment of symptomatic varicose veins in nonpregnant patients should not be delayed for a trial of external compression. Interventional treatment should be offered if valvular reflux is documented.

C

7, 15

Clinical guidelines based on systematic reviews; consensus guidelines and expert opinion

Endovascular laser ablation may be better tolerated than sclerotherapy and surgery, with fewer adverse effects and equal effectiveness.

B

30, 31

Based on a Cochrane review of lower-quality RCTs and an RCT on quality-of-life outcomes


RCT = randomized controlled trial.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferencesComments

There is not enough evidence to determine if compression stockings are effective in the treatment of varicose veins in the absence of active or healed venous ulcers.

B

7, 15, 1921

Based on a Cochrane review and clinical guidelines based on systematic reviews; consensus guidelines and expert opinion

Horse chestnut seed extract (Aesculus hippocastanum) and other phlebotonics may ease the symptoms of varicose veins, but long-term studies of the safety and effectiveness of phlebotonics are lacking.

B

2325

Based on systematic reviews/Cochrane review of lower-quality RCTs

Referral for interventional treatment of symptomatic varicose veins in nonpregnant patients should not be delayed for a trial of external compression. Interventional treatment should be offered if valvular reflux is documented.

C

7, 15

Clinical guidelines based on systematic reviews; consensus guidelines and expert opinion

Endovascular laser ablation may

The Authors

show all author info

JAQUELINE RAETZ, MD, is an associate professor in the University of Washington Family Medicine Residency program, Seattle....

MEGAN WILSON, MD, is an assistant professor in the University of Washington Family Medicine Residency program.

KIMBERLY COLLINS, MD, is an assistant professor in the University of Washington Family Medicine Residency program.

Address correspondence to Jaqueline Raetz, MD, 331 NE Thornton Place, Seattle, WA 98125 (e-mail: jraetz@uw.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

show all references

1. Eklöf B, Rutherford RB, Bergan JJ, et al.; American Venous Forum International Ad Hoc Committee for Revision of the CEAP Classification. Revision of the CEAP classification for chronic venous disorders: consensus statement. J Vasc Surg. 2004;40(6):1248–1252....

2. Eberhardt RT, Raffetto JD. Chronic venous insufficiency. Circulation. 2014;130(4):333–346.

3. Kaplan RM, Criqui MH, Denenberg JO, Bergan J, Fronek A. Quality of life in patients with chronic venous disease: San Diego population study. J Vasc Surg. 2003;37(5):1047–1053.

4. McLafferty RB, Passman MA, Caprini JA, et al. Increasing awareness about venous disease: The American Venous Forum expands the National Venous Screening Program. J Vasc Surg. 2008;48(2):394–399.

5. Clarke GH, Vasdekis SN, Hobbs JT, Nicolaides AN. Venous wall function in the pathogenesis of varicose veins. Surgery. 1992;111(4):402–408.

6. Bergan JJ, Schmid-Schönbein GW, Smith PD, Nicolaides AN, Boisseau MR, Eklof B. Chronic venous disease. N Engl J Med. 2006;355(5):488–498.

7. Gloviczki P, Comerota AJ, Dalsing MC, et al. The care of patients with varicose veins and associated chronic venous diseases: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg. 2011;53(5 suppl):2S–48S.

8. Beebe-Dimmer JL, Pfeifer JR, Engle JS, Schottenfeld D. The epidemiology of chronic venous insufficiency and varicose veins. Ann Epidemiol. 2005;15(3):175–184.

9. Sadick NS. Advances in the treatment of varicose veins: ambulatory phlebectomy, foam sclerotherapy, endovascular laser, and radiofrequency closure. Dermatol Clin. 2005;23(3):443–455, vi.

10. Teruya TH, Ballard JL. New approaches for the treatment of varicose veins. Surg Clin North Am. 2004;84(5):1397–1417, viii–ix.

11. Langer RD, Ho E, Denenberg JO, Fronek A, Allison M, Criqui MH. Relationships between symptoms and venous disease: the San Diego population study. Arch Intern Med. 2005;165(12):1420–1424.

12. Bradbury A, Evans C, Allan P, Lee A, Ruckley CV, Fowkes FG. What are the symptoms of varicose veins? Edinburgh vein study cross sectional population survey. BMJ. 1999;318(7180):353–356.

13. Racette S, Sauvageau A. Unusual sudden death: two case reports of hemorrhage by rupture of varicose veins. Am J Forensic Med Pathol. 2005;26(3):294–296.

14. Kim J, Richards S, Kent PJ. Clinical examination of varicose veins—a validation study. Ann R Coll Surg Engl. 2000;82(3):171–175.

15. National Institute for Health and Care Excellence. Varicose veins: diagnosis and management. Clinical guideline 168. July 2013. https://www.nice.org.uk/guidance/cg168. Accessed May 21, 2018.

16. Labropoulos N, Tiongson J, Pryor L, et al. Definition of venous reflux in lower-extremity veins. J Vasc Surg. 2003;38(4):793–798.

17. Coleridge-Smith P, Labropoulos N, Partsch H, Myers K, Nicolaides A, Cavezzi A. Duplex ultrasound investigation of the veins in chronic venous disease of the lower limbs—UIP consensus document. Part I. Basic principles. Eur J Vasc Endovasc Surg. 2006;31(1):83–92.

18. Jones RH, Carek PJ. Management of varicose veins. Am Fam Physician. 2008;78(11):1289–1294.

19. Shingler S, Robertson L, Boghossian S, Stewart M. Compression stockings for the initial treatment of varicose veins in patients without venous ulceration. Cochrane Database Syst Rev. 2013;(12):CD008819.

20. O'Meara S, Cullum N, Nelson EA, Dumville JC. Compression for venous leg ulcers. Cochrane Database Syst Rev. 2012;(11):CD000265.

21. Nelson EA, Bell-Syer SE. Compression for preventing recurrence of venous ulcers. Cochrane Database Syst Rev. 2014;(9):CD002303.

22. Lam Ey, Giswold ME, Moneta GL. Venous and lymphatic disease. In: Dries DJ, ed. Schwartz's Principles of Surgery. 8th ed. New York, NY: McGraw-Hill; 2005:823–825.

23. Bush R, Comerota A, Meissner M, Raffetto JD, Hahn SR, Freeman K. Recommendations for the medical management of chronic venous disease: the role of micronized purified flavonoid fraction (MPFF) [published correction appears in Phlebology. 2017;32(10):NP36]. Phlebology. 2017;32(1 suppl):3–19.

24. Pittler MH, Ernst E. Horse chestnut seed extract for chronic venous insufficiency. Cochrane Database Syst Rev. 2012;(11):CD003230.

25. Martinez-Zapata MJ, Vernooij RW, Uriona Tuma SM, et al. Phlebotonics for venous insufficiency. Cochrane Database Syst Rev. 2016;(4):CD003229.

26. Reichert D. Evaluation of the long-pulse dye laser for the treatment of leg telangiectasias. Dermatol Surg. 1998;24(7):737–740.

27. Paravastu SC, Horne M, Dodd PD. Endovenous ablation therapy (laser or radiofrequency) or foam sclerotherapy versus conventional surgical repair for short saphenous varicose veins. Cochrane Database Syst Rev. 2016;(11):CD010878.

28. Tisi PV, Beverley C, Rees A. Injection sclerotherapy for varicose veins. Cochrane Database Syst Rev. 2006;(4):CD001732.

29. Schwartz L, Maxwell H. Sclerotherapy for lower limb telangiectasias. Cochrane Database Syst Rev. 2011;(12):CD008826.

30. Nesbitt C, Bedenis R, Bhattacharya V, Stansby G. Endovenous ablation (radiofrequency and laser) and foam sclerotherapy versus open surgery for great saphenous vein varices. Cochrane Database Syst Rev. 2014;(7):CD005624.

31. Brittenden J, Cotton SC, Elders A, et al. A randomized trial comparing treatments for varicose veins. N Engl J Med. 2014;371(13):1218–1227.

 

 

Copyright © 2019 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions

CME Quiz

More in AFP


Related Content


More in Pubmed

MOST RECENT ISSUE


Oct 15, 2019

Access the latest issue of American Family Physician

Read the Issue


Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article