Summary

Varicose Veins are dilated, tortuous superficial veins caused by Valvular Incompetence (Reflux). They are exceedingly common, affecting 30% of adults. The primary pathology is failure of the valves at the Sapheno-Femoral Junction (SFJ) or Sapheno-Popliteal Junction (SPJ), allowing blood to flow backwards (reflux) from the high-pressure deep system to the low-pressure superficial system. This venous hypertension leads to symptoms (aching, heaviness, itch) and skin changes (eczema, haemosiderin, lipodermatosclerosis), culminating in Venous Leg Ulcers. Management follows a hierarchy: Endothermal Ablation (Laser/Radiofrequency) is first-line, followed by Foam Sclerotherapy, with Open Surgery (Stripping) now reserved for complex recurrences. Compression hosiery is the mainstay of conservative care.

Key Facts

• Prevalence: 30% of adults. Female > Male.
• Primary Cause: SFJ Incompetence (Great Saphenous Vein Reflux).
• CEAP Classification: The standard for grading severity (C0-C6).
• NICE Guideline: Refer if: Bleeding, Symptomatic (Pain/Ache), Skin Changes, Ulceration, or Thrombophlebitis. Do NOT refer for cosmetic reasons alone on the NHS.
• Gold Standard Tx: Endovenous Ablation (EVLT / RFA).

Clinical Pearls

"The Champagne Bottle Leg": In chronic venous insufficiency, fat necrosis and fibrosis (Lipodermatosclerosis) constrict the lower calf ("gaiter area"), while the upper calf remains normal. The leg looks like an inverted champagne bottle.

"Bleeding? Elevate!": A burst varicose vein bleeds torrentially (high pressure). The instant solution is to LIFT THE LEG (above heart level). The bleeding stops instantly. Do not apply tourniquets.

"Tap Test is Useless": The Trendelenburg test (tourniquets) and Tap test are historic. Duplex Ultrasound is the only way to accurately map reflux.

"Hidden Varicose Veins": A patient with an ulcer may have no visible varicosities, but severe underlying reflux. Always scan a venous ulcer.

Used globally to describe clinical severity.

          PATIENT WITH VARICOSE VEINS
                     ↓
        ASSESS FOR "RED FLAG" SYMPTOMS
   (Bleeding, Ulcer, Phlebitis, Pain, Skin Change)
                     ↓
      ┌──────────────┼───────────────┐
     NO             YES             PREGNANT
  (Cosmetic)      (Referral)       (Wait)
      ↓              ↓               ↓
  REASSURE       DUPLEX SCAN      STOCKINGS
  Or Private         ↓            (Resolves
  Referral       CONFIRM REFLUX    post-partum)
                     ↓
         TREATMENT HIERARCHY (NICE)
     ┌───────────────┴────────────────┐
  1. ENDOTHERMAL ABLATION           2. FOAM SCLEROTHERAPY
     (RFA / EVLT) - Gold Std           (If unsuited for thermal)
             │                                │
             └──────────────┬─────────────────┘
                            ↓
                    3. OPEN SURGERY
                    (Stripping - Last resort)
                            ↓
                    4. COMPRESSION HOSIERY
                    (If intervention declined/unsuitable)

1. Conservative

• Compression Stockings: Class 2 (Below knee).
  • Mechanism: Squeezes superficial veins, aids muscle pump.
  • Check: Must have normal ABPI (>0.8) before prescribing.
• Lifestyle: Weight loss, Elevation, Avoid standing.

2. Endovenous Thermal Ablation (EVLT / RFA)

• Laser (EVLT) or Radiofrequency (RFA).
• Procedure:
  • Catheter inserted into GSV under ultrasound guidance.
  • Tumescent anaesthesia (fluid sheath) injected around vein.
  • Catheter pulled back while heating the vein wall (120°C).
  • Vein occludes and fibroses (turns into a string).
• Pros: Local anaesthetic, walk in/walk out, 95% success.

3. Ultrasound-Guided Foam Sclerotherapy

• Procedure: Polidocanol (sclerosant) mixed with air to make foam. Injected into vein. Causes chemical burn -> Fibrosis.
• Pros: Quick, cheap.
• Cons: Higher recurrence (30%), skin staining (brown marks).

4. Open Surgery (High Tie and Strip)

• Procedure: Incision in groin. Ligate SFJ tributaries. Insert stripper. Rip the vein out.
• Cons: General Anaesthetic, bruising, nerve injury, neovascularisation (recurrence at groin). Now rare.

• DVT: Rare (<1%).
• Nerve Injury:
  • Saphenous Nerve: EVLT of GSV below mid-calf. Numb medial ankle.
  • Sural Nerve: EVLT of SSV. Numb lateral foot.
• Skin Burns: If tumescence not done properly.
• Pigmentation: Brown staining over treated vein.

Radiofrequency Ablation (RFA)

1. Access: Cannulate GSV at knee level (Seldinger technique).
2. Position: Tip of catheter 2cm below SFJ (Deep Epigastric Vein is the landmark).
3. Tumescence: Inject large volume of dilute LA/Saline around vein. Acts as heat sink (protects tissues) and compresses vein onto catheter.
4. Ablate: 7cm segments treated at 120°C for 20 seconds.

Open High Tie

1. Incision: Groin crease.
2. Dissection: Identify SFJ.
3. The "Flush" Tie: Ligate GSV flush with Femoral Vein.
4. Tributaries: Ligate all 5 tributaries (Superficial Epigastric, Circumflex Iliac, External Pudendal, etc) to prevent recurrence.

Superficial Thrombophlebitis (SVT)

• Topical NSAIDs (Hirudoid cream).
• If <3cm from SFJ: Treat as DVT (Anticoagulate).
• If >5cm long: Prophylactic Fondaparinux (2.5mg OD for 45 days) reduces DVT risk (CALISTO trial).

Landmark Trials

1. EVOLVES Trial: Proved Endovenous (RFA/EVLT) superior to Surgery for recovery/pain/QoL.
2. CLASS Study: Compared EVLT, Foam, and Surgery. EVLT and Surgery durable. Foam higher recurrence. All cost-effective.

NICE CG168

• Do not refer uncomplicated asymptomatic varicosities.
• Refer skin changes, ulcers, bleeding, or symptomatic.
• Order: Thermal -> Foam -> Surgery -> Compression.

What are Varicose Veins?

Veins have one-way valves to help blood flow up the leg against gravity. If these valves break, blood falls back down and pools in the leg, causing the veins to stretch and bulge.

Are they dangerous?

Usually they are just annoying (aching/ugly). However, over many years, the high pressure can damage the skin at the ankle, leading to eczema or ulcers (sores that won't heal).

Can they be fixed?

Yes. We used to "strip" them out surgically. Now, we use a laser or heat probe. We put a tiny tube inside the vein (under local anaesthetic) and seal it shut from the inside. The body then absorbs the dead vein. You can walk out the same day.

Will they come back?

The treated vein is gone forever. However, you can develop new varicose veins in other places, as your genetic tendency to weak valves remains.