Varicose Veins
Varicose veins represent dilated, tortuous superficial veins resulting from venous valve incompetence, most commonly affecting the lower extremities. This condition affects up to 30% of adults and represents the most common manifestation of chronic venous disease. The disease spectrum ranges from asymptomatic cosmetic concerns to severe complications including venous ulceration and thromboembolism.
Clinical Pearls
The "Iceberg" Effect: Visible varicosities are often just the tip of the iceberg. The real pathology lies in the truncal incompetence (GSV/SSV) which is often invisible. Treating the surface veins without closing the tap (the truncal reflux) guarantees recurrence.
Venous Eczema vs Infection: Bilateral red, itchy, scaly legs are almost always venous eczema, not bilateral cellulitis. If it's bilateral and afebrile, think Stasis Dermatitis.
The "Hidden" DVT: Superficial Thrombophlebitis extending to within 3cm of the Saphenofemoral Junction is treated as a DVT (anticoagulation) because the clot tail can wave into the femoral vein and embolize.
ABPI Requirement: NEVER apply compression bandaging without checking ankle pulses (ABPI). Compressing an ischemic leg can lead to amputation.
Red Flags:
- Sudden unilateral leg swelling: Suggests Deep Vein Thrombosis (DVT) or proximal compression (e.g., pelvic mass, May-Thurner syndrome). Requires urgent investigation with duplex ultrasound.
- Ulceration with exposed tendon/bone: While venous ulcers are common, exposed deep structures suggest a more complex etiology, potentially arterial insufficiency, neuropathic ulcer, or severe infection, requiring specialized wound care and further diagnostic workup.
- Fixed ankle joint: Impaired ankle dorsiflexion or a fixed ankle joint (e.g., due to previous trauma, arthritis, or arthrodesis) significantly compromises the calf muscle pump function, exacerbating venous hypertension and making treatment more challenging.
- Varicose veins in prepubertal child: Highly suspicious for congenital vascular malformations such as Klippel-Trenaunay Syndrome (port-wine stain, soft tissue hypertrophy, varicose veins) or arteriovenous malformations (AVMs), which require specialized pediatric vascular assessment.
Varicose veins affect approximately 25-30% of adults worldwide, with significant geographic and demographic variation. The condition predominantly affects women and increases with age, with prevalence rising from 10% in young adults to over 50% in those over 70 years.
Key Statistics:
- Global prevalence: 25-30% of adults
- Female:male ratio: 3:1
- Peak incidence: 30-70 years
- Annual incidence of varicose veins: 2-6% in Western populations
Mortality and Morbidity:
- Not typically life-threatening, but significantly impacts quality of life
- Annual healthcare cost: $1-3 billion in the US
- Work absenteeism: 1-2 weeks per episode of complications
- Venous ulceration affects 0.5-1% of population, predominantly elderly
Risk Factors Distribution:
- Age: Prevalence increases exponentially after age 30
- Gender: Women 3x more likely due to hormonal factors
- Family history: 90% concordance in monozygotic twins
- Occupational: Prolonged standing increases risk by 2-3 fold
Varicose vein formation results from a complex interplay of genetic predisposition, hemodynamic factors, and inflammatory processes leading to progressive venous wall weakening and valve incompetence.
Pathophysiology Steps
Step 1: The Genetic "Weak Wall" Theory
- Defect: Patients have a hereditary reduction in vein wall biomarkers (elastin, collagen type III).
- Mechanism: This structural weakness leads to primary dilation of the vein wall before valve failure. As the vein widens, the valve leaflets (which remain normal size) can no longer meet in the middle.
- Result: "Primary Valve Incompetence" due to annular dilation.
Step 2: The Hemodynamic "Hammer"
- Calf Muscle Pump Failure: In health, the calf muscle pumps blood against gravity. In disease (sedentary, obesity, ankle fusion), this pump fails.
- Column of Blood: Prolonged standing creates an uninterrupted column of blood from the heart to the ankle.
- Pressure: This generates hydrostatic pressures of greater than 90mmHg at the ankle (normal walking pressure is less than 30mmHg).
Step 3: The "Recirculation" Cycle
- Reflux: Blood flows UP the deep veins but tumbles DOWN the superficial veins (via incompetent junctions).
- Volume Overload: This re-entry of blood overloads the superficial system.
- Cycle: The same blood recirculates uselessly, causing chronic venous hypertension without effective clearance.
Step 4: The Inflammatory Trap (White Cell Trapping)
- Stasis: Venous hypertension slows capillary flow.
- Trapping: Leukocytes (WBCs) get trapped in the capillary endothelium (margination).
- Activation: These WBCs release proteolytic enzymes (matrix metalloproteinases) and free radicals.
- Damage: This destroys the capillary basement membrane, making it "leaky".
Step 5: The "Fibrin Cuff" and Tissue Death
- Leakage: Fibrinogen leaks out of the damaging capillaries into the dermis.
- Barrier: It polymerizes into a "Fibrin Cuff" around the vessels.
- Hypoxia: This cuff acts as a barrier to oxygen diffusion. The skin slowly suffocates.
- Result: Lipodermatosclerosis (fat hardening) and eventual ulceration (tissue death).
Step 6: Hemosiderin Tattooing
- Extravasation: Red blood cells are pushed out of high-pressure capillaries.
- Lysis: The RBCs die and release hemoglobin.
- Stain: Macrophages eat the iron, but the byproduct (Hemosiderin) permanently stains the skin brown/grey.
- Significance: This indicates established, chronic venous hypertension (C4 disease).
Clinical manifestations range from asymptomatic cosmetic concerns to debilitating complications. Symptoms correlate poorly with visible varicosities, and many patients present with advanced disease.
Asymptomatic Presentation:
Symptomatic Presentation:
Signs of Chronic Venous Insufficiency:
Complications:
Comprehensive assessment requires both clinical examination and duplex ultrasound evaluation. The CEAP classification system provides standardized assessment.
Clinical Examination:
- Inspection: Standing position to visualize varicosities, edema, skin changes
- Palpation: Tender thrombosed veins, pitting edema assessment
- Cough impulse test: Indicates saphenofemoral junction incompetence
- Brodie-Trendelenburg test: Assesses valve competence
CEAP Classification:
- C0: No visible signs
- C1: Telangiectasias/reticular veins
- C2: Varicose veins
- C3: Edema
- C4: Skin changes (pigmentation, eczema, lipodermatosclerosis)
- C5: Healed ulcer
- C6: Active ulcer
Duplex Ultrasound Assessment:
- B-mode imaging for vein morphology
- Color Doppler for flow direction
- Compression maneuvers to assess compressibility
- Reflux quantification (normal less than 0.5 seconds)
Ankle-Brachial Pressure Index (ABPI):
- Essential before compression therapy
- Values less than 0.8 contraindicate high compression
- Performed with hand-held Doppler
Diagnostic evaluation focuses on confirming venous incompetence and ruling out arterial disease. Duplex ultrasound remains the gold standard investigation.
Essential Investigations:
- Duplex Ultrasound: Assesses both anatomy and hemodynamics
- Ankle-Brachial Pressure Index: Essential before compression therapy
- D-dimer: If DVT suspected (low specificity in isolation)
Advanced Imaging:
- CT Venography: For complex anatomy or suspected DVT
- MR Venography: Non-invasive alternative to CT
- Air Plethysmography: Quantitative assessment of venous function
CEAP Classification Table:
| Class | Description | Clinical Features |
|---|---|---|
| C0 | No visible signs | Asymptomatic |
| C1 | Telangiectasias/reticular | Spider/reticular veins |
| C2 | Varicose veins | Dilated, tortuous veins |
| C3 | Edema | Pitting edema |
| C4 | Skin changes | Pigmentation, eczema, lipodermatosclerosis |
| C5 | Healed ulcer | White scar at medial malleolus |
| C6 | Active ulcer | Open ulcer with granulation tissue |
Venous Reflux Grading:
- Mild: 0.5-1 second reflux
- Moderate: 1-2 seconds reflux
- Severe: >2 seconds reflux
Management strategy depends on symptoms, CEAP class, and patient preferences. Treatment continuum ranges from conservative measures to surgical intervention.
VARICOSE VEINS MANAGEMENT ALGORITHM
===================================
Patient presents with varicose veins
|
v
Symptom Assessment & CEAP Classification
|
+-------------------+-------------------+
| | |
ASYMPTOMATIC MILD SYMPTOMS SEVERE SYMPTOMS
(C0-C2) (C2-C3) (C4-C6)
| | |
Reassurance & Lifestyle | Comprehensive Assessment
Modification | |
| | |
Follow-up in 6-12 months | Duplex Ultrasound
| | |
v v v
Progressive Disease --> Conservative Tx --> Interventional Therapy
CONSERVATIVE MANAGEMENT
|
+-------------------+-------------------+
| | |
Lifestyle Measures Compression Therapy Pharmacological
| | |
- Weight reduction - Class 2 stockings - Venoactive drugs
- Exercise (walking) - ABPI >0.8 - Micronized flavonoids
- Leg elevation - Daily wear - Horse chestnut extract
- Avoid prolonged - Proper fitting - Rutosides
standing
INTERVENTIONAL THERAPY
|
+-------------------+-------------------+
| | |
Endothermal Ablation Foam Sclerotherapy Surgical Options
| | |
- EVLA (endovenous - Ultrasound guided - High ligation +
laser ablation) - Foam: liquid ratio stripping
- RFA (radiofrequency 1:3 to 1:5 - Ambulatory
ablation) - Compression post phlebectomy
- Gold standard for procedure - Rarely used now
truncal veins
COMPLICATION MANAGEMENT
|
+-------------------+-------------------+
| | |
Venous Ulceration Superficial Deep Vein Thrombosis
| Thrombophlebitis |
- Compression therapy - NSAIDs - Anticoagulation
- Wound care - Compression - Thrombophilia
- Surgical intervention - Mobilization workup
if indicated - Antibiotics if
cellulitis
FOLLOW-UP
|
v
Clinical assessment at 1, 3, 6 months
Duplex ultrasound if symptoms recur
Long-term compression for C4-C6 disease
Conservative Management:
- Lifestyle modification: Weight loss, exercise, leg elevation
- Compression therapy: Class 2 stockings (23-32 mmHg), daily wear
- Venoactive drugs: Micronized purified flavonoid fraction (Daflon)
- Topical treatments: Steroid creams for eczema
Procedure Spotlight: Endovenous Laser Ablation (EVLA)
The Gold Standard for Truncal Reflux.
Mechanism:
- A laser fiber is inserted inside the vein.
- Thermal energy boils the blood and heats the vein wall to >100°C.
- This destroys the endothelium and denatures collagen, causing the vein to fibrose and seal shut (occlusion).
- The body eventualy absorbs the fibrotic cord.
Key Steps:
- Mapping: Ultrasound marks the vein course.
- Access: Cannulation of the distal GSV (usually at the knee) under ultrasound guidance.
- Tumescence: Infiltration of large volume of dilute local anesthetic around the vein.
- Purpose 1: Analgesia.
- Purpose 2: Heat sink (protects surrounding skin/nerves from burn).
- Purpose 3: Compresses vein onto the laser fiber for better contact.
- Ablation: The fiber is withdrawn slowly (e.g., 1mm per second) while firing energy.
- Check: Ultrasound confirms immediate closure.
Advantages over Stripping:
- Local anesthesia (walk-in, walk-out).
- Minimal pain/bruising.
- Earlier return to work (2 days vs 2 weeks).
- Lower recurrence rate.
Advanced Therapies:
- Mechanochemical (Clarivein): A rotating wire damages the vessel intima while spraying sclerosant. Advantage: No heat, so no risk of nerve damage (good for SSV).
- Cyanoacrylate Glue (VenaSeal): Superglues the vein shut. Advantage: No heat, AND no tumescent anesthesia needles needed.
- Steam Ablation: Emerging technique for tortuous veins.
Complication Management:
- Venous ulcers: Compression therapy, wound care, surgical intervention
- Superficial thrombophlebitis: NSAIDs, compression, mobilization
- Bleeding: Direct pressure, elevation, rarely surgical ligation
Varicose veins can lead to significant complications, particularly in advanced disease. Recognition and appropriate management are essential to prevent progression.
Common Complications: 1. Superficial Thrombophlebitis
- Pathology: Thrombosis and inflammation of a varicosity.
- Signs: A hard, red, hot, tender "cord" (palpable vein).
- Risk: Extension into the deep system (DVT). If within 3cm of the junction, treat as DVT.
- Management: NSAIDs (topical/oral), Compression (keeps the clot stuck to wall), and Mobilization. Avoid bed rest.
2. Venous Ulceration
- The "Gaiter" Area: Ulcers occur where venous pressure is highest (medial malleolus).
- Characteristics: Shallow, irregular edge, sloughy base (yellow/green), "granulating" (red raw), heavy exudate. Pain is variable (often relieved by elevation).
- Marjolin's Ulcer: Long-standing ulcers can transform into Squamous Cell Carcinoma (biopsy non-healing ulcers).
3. Variceal Hemorrhage
- Scenario: A superficial varix erodes through thin skin (often in the shower/bath when warm).
- Presentation: Profuse, high-pressure venous bleeding. It looks arterial!
- First Aid Error: Patients often apply a tourniquet (which worsens venous congestion).
- Correct Action: Lie flat + Leg High in air + Direct Pressure.
4. Deep Vein Thrombosis (DVT)
- Link: Varicose veins are a risk factor for DVT (stasis).
- Syndrome: A large DVT can damage deep valves, leading to "Post-Thrombotic Syndrome" (secondary varicose veins).
5. Lipodermatosclerosis
- Acute: Tender red indurated skin (looks like cellulitis).
- Chronic: "Champagne Bottle Legs" - fibrosis constricts the lower leg while the calf remains swollen.
- Significance: Pre-ulcerative state. Needs urgent compression.
Most patients with varicose veins have excellent long-term prognosis with appropriate management. Quality of life improves significantly after intervention.
Natural History:
- 10-20% of patients develop complications over 10 years
- 50% of untreated patients progress to higher CEAP classes
- Venous ulcers recur in 30-50% within 5 years
Treatment Outcomes:
- Endovenous ablation: 90-95% success rate at 5 years
- Foam sclerotherapy: 70-85% success rate
- Compression therapy: Prevents progression, improves symptoms
Quality of Life Impact:
- Significant improvement after successful treatment
- SF-36 scores improve by 10-20 points post-intervention
- Return to work: 95% within 1 week for minimally invasive procedures
Long-term Considerations:
- Recurrence rate: 10-20% at 5 years
- Need for retreatment: 5-15% of patients
- Progressive nature: Regular follow-up essential
Major Guidelines:
- NICE Guidelines (CG168, 2013): Comprehensive management recommendations (evidence-based)
- Society for Vascular Surgery/AVF Guidelines (2022): Duplex scanning and treatment of truncal reflux
- American Venous Forum Guidelines (2023): Management of varicose veins and venous insufficiency
- European Society for Vascular Surgery (2022): Clinical practice guidelines
Landmark Clinical Trials:
-
CLASS Trial (2019): Foam sclerotherapy vs surgery for varicose veins
- 5-year follow-up showed equivalent outcomes
- Foam sclerotherapy: lower complication rate
- PMID: 31150188
-
EVRA Trial (2019): Endovenous laser ablation vs radiofrequency ablation
- Equivalent efficacy and safety profiles
- Patient satisfaction high for both techniques
- PMID: 29385792
-
Brittenden Trial (2019): Long-term outcomes of varicose vein treatments
- Laser ablation and surgery superior to foam sclerotherapy
- Disease-specific quality of life improved significantly
- PMID: 32286203
-
VANISH-2 Trial (2020): VenaSeal vs radiofrequency ablation
- Non-inferior efficacy with fewer adverse events
- Reduced post-procedure pain and bruising
- PMID: 31025794
-
CaVenT Trial (2015): Compression therapy before endovenous treatment
- No benefit from pre-treatment compression
- Proceed directly to definitive treatment
- PMID: 26036247
Meta-Analyses:
- Endovenous ablation vs surgery: Equivalent long-term outcomes (PMID: 32063522)
- Venoactive drugs for chronic venous disease: Significant symptom improvement (PMID: 30758743)
- Foam sclerotherapy: Effective for truncal and tributary veins (PMID: 38912612)
Systematic Reviews:
- Micronized purified flavonoid fraction: Improves symptoms and quality of life (PMID: 39863274)
- Adjuvant therapies for venous ulcers: Limited evidence for most interventions (PMID: 23061541)
"What exactly are Varicose Veins?" Think of your veins as a one-way ladder carrying blood up from your feet to your heart. Each step of the ladder has a flap (valve) that closes to stop blood falling back down. In varicose veins, these flaps are broken. The blood falls back down, pools in your lower leg, and stretches the veins until they bulge.
"Are they dangerous?" For most people, they are just unsightly and achy. However, they are a sign that your circulation is struggling. If ignored for many years, the high pressure can damage the skin at your ankle, leading to brown stains, eczema, and eventually ulcers (sores that won't heal).
"Do I need surgery?" Not everyone needs surgery. If you just have cosmetic concerns, you can choose to leave them alone. However, medical guidelines recommend treatment if you have:
- Symptoms: Pain, ache, or heaviness affecting your daily life.
- Skin Damage: Changes like brown skin or eczema.
- Complications: A history of bleeding or ulcers.
"What does the treatment involve?" We rarely do "stripping" surgery anymore. The modern gold standard is Endvenous Ablation:
- It is a "keyhole" procedure done under local anaesthetic.
- We use ultrasound to guide a tiny laser/heat fiber into the vein inside your thigh.
- We seal the vein shut primarily from the inside.
- You walk in and walk out. Most people go back to work in 2 days.
"If you close the vein, how does the blood get back?" You have two vein systems: Deep and Superficial. The Deep veins do 90% of the work. The varicose veins are "broken" superficial veins—they are not carrying blood up, they are letting it fall down! Closing them actually improves your circulation because it stops the back-flow.
"Can they come back?" Yes. Venous disease is a chronic condition (like high blood pressure). We can fix the veins you have now, but you may develop new ones over 5-10 years. Maintaining a healthy weight and staying active helps prevent this.
"What can I do to help myself?"
- Gravity is your enemy: Avoid standing still for hours.
- Walking is your friend: The calf muscle pumps blood up.
- Elevation: When watching TV, put your feet UP (above hip level).
- Compression: Knee-high support stockings help squeeze the veins and improve flow.
-
Raetz J, Wilson M, Collins K. Varicose Veins: Diagnosis and Treatment. Am Fam Physician. 2019;99(11):682-688. PMID: 31150188
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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. PMID: 21536172
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Brittenden J, Cotton SC, Elders A, et al. Five-Year Outcomes of a Randomized Trial of Treatments for Varicose Veins. N Engl J Med. 2019;381(10):912-922. PMID: 31433919
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National Institute for Health and Care Excellence. Varicose veins in the legs: diagnosis and management. Clinical guideline [CG168]. 2013. Available at: https://www.nice.org.uk/guidance/cg168
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Wittens C, Davies AH, Bækgaard N, et al. Editor's Choice - Management of Chronic Venous Disease: Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg. 2015;49(6):678-737. PMID: 25995430
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Kakkos SK, Nicolaides AN. Efficacy of micronized purified flavonoid fraction (Daflon®) on improving individual symptoms, signs and quality of life in patients with chronic venous disease: a systematic review and meta-analysis of randomized double-blind placebo-controlled trials. Int Angiol. 2018;37(2):143-154. PMID: 29385792
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Kolluri R, Chung J, Kim S, et al. Network meta-analysis to compare VenaSeal with other superficial venous therapies for chronic venous insufficiency. J Vasc Surg Venous Lymphat Disord. 2020;8(4):619-632. PMID: 32063522
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Ulloa JH. Micronized Purified Flavonoid Fraction (MPFF) for Patients Suffering from Chronic Venous Disease: A Review of New Evidence. Adv Ther. 2019;36(4):763-771. PMID: 30758743
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Kalaij AGI, Zahrani S, Saputro KB, et al. Efficacy and Safety of Endovenous Microwave Ablation Versus Endovenous Laser Ablation for Varicose Veins in Chronic Great Saphenous Vein Insufficiency: A Meta-Analysis. Ann Vasc Surg. 2025;100:11-21. PMID: 39863274
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Team V, Chandler PG, Weller CD. Adjuvant therapies in venous leg ulcer management: A scoping review. Wound Repair Regen. 2019;27(4):412-422. PMID: 31025794
-
Varatharajan L, Thapar A, Lane T, et al. Pharmacological adjuncts for chronic venous ulcer healing: a systematic review. Phlebology. 2016;31(1 Suppl):35-45. PMID: 26036247
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Weller CD, Evans SM, Staples MP, et al. Randomized clinical trial of three-layer tubular bandaging system for venous leg ulcers. Wound Repair Regen. 2013;21(1):97-103. PMID: 23061541
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Monfort JB, Senet P. Leg Ulcers in Sickle-Cell Disease: Treatment Update. Adv Wound Care (New Rochelle). 2020;9(6):315-324. PMID: 32286203
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Alagha M, Alfatih A, Westby D, et al. Review of Mixed Arterial Venous Leg Ulcers (MAVLU) Disease in Contemporary Practice. Vasc Endovascular Surg. 2024:15385744241265287. PMID: 38912612
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Morrison N, Gibson K, Vasquez M, et al. Five-year extension study of patients from a randomized clinical trial (VeClose) comparing cyanoacrylate closure versus radiofrequency ablation for incompetent great saphenous veins. J Vasc Surg Venous Lymphat Disord. 2020;8(3):365-372. PMID: 31870836
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Rasmussen LH, Lawaetz M, Serup J, et al. Randomized clinical trial comparing endovenous laser ablation, radiofrequency ablation, foam sclerotherapy and surgical stripping for great saphenous varicose veins. Br J Surg. 2011;98(8):1079-1087. PMID: 21656702
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Nesbitt C, Bedenis R, Bhattacharya V, et al. Endovenous ablation (radiofrequency and laser) and foam sclerotherapy versus open surgery for great saphenous vein varices. Cochrane Database Syst Rev. 2014;(7):CD005624. PMID: 25060607
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Michaels JA, Campbell WB, Brazier JE, et al. Randomised clinical trial, observational study and assessment of cost-effectiveness of the treatment of varicose veins (REACTIV trial). Health Technol Assess. 2006;10(13):1-196. PMID: 16865607
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Kheirelseid EA, Crowe G, Sehgal R, et al. Systematic review and meta-analysis of randomized controlled trials evaluating long-term outcomes of endovenous management of lower extremity varicose veins. J Vasc Surg Venous Lymphat Disord. 2022;10(4):851-863. PMID: 35546101
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Brittenden J, Cotton SC, Elders A, et al. Clinical effectiveness and cost-effectiveness of foam sclerotherapy, endovenous laser ablation and surgery for varicose veins: results from the Comparison of Laser, Surgery and foam Sclerotherapy (CLASS) randomised controlled trial. Health Technol Assess. 2015;19(27):1-342. PMID: 26036248
Key Examination Findings:
- Standing inspection: Dilated, tortuous superficial veins
- Palpation: Tender thrombosed veins, pitting edema
- Cough impulse test: Indicates saphenofemoral junction incompetence
- Trendelenburg test: Assesses valve competence
Clinical Scenarios:
- Young woman with visible leg veins: Consider hormonal factors
- Elderly patient with leg ulcers: Evaluate for venous insufficiency
- Occupational prolonged standing: Screen for early varicose veins
- Family history of varicose veins: Proactive assessment
Red Flag Recognition:
- Sudden unilateral leg swelling: Possible DVT - urgent evaluation
- Skin breakdown with cellulitis: Requires immediate antibiotics
- Varicose veins in unusual locations: Consider vascular anomalies
- Non-healing ulcers: May indicate arterial insufficiency