Varicose Veins:​Diagnosis and Treatment

Jaqueline Raetz, MD;​Megan Wilson, MD;​and Kimberly Collins, MD

University of Washington Family Medicine Residency, Seattle, Washington

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, preg-
nancy, 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. Con-
servative treatment options include external compression;​lifestyle modifications, such as avoidance
of prolonged standing and straining, exercise, wearing nonrestrictive clothing, modification of car-
diovascular 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 stock-
ings 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, endo-
venous 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 Although surgery was once the standard of care, it largely has been
replaced by endovenous thermal ablation, which can be performed under local anesthesia and may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 endove-
nous thermal ablation, although it may be necessary for insurance coverage. (Am Fam Physician. 2019;​
99(11):​682-688. Copyright © 2019 American Academy of Family Physicians.)

Varicose veins are subcutaneous veins dilated

to at least 3 mm in diameter when measured FIGURE 1
with the patient in an upright position. They are
part of a continuum of chronic venous disorders
ranging from fine telangiectasias, also called spi-
der veins, (less than 1 mm;​Figure 1) and reticu-
lar veins (1 to 3 mm;​Figure 1) to chronic venous
insufficiency, which may include edema, hyper-
pigmentation, and venous ulcers. Chronic venous
disease is most commonly described using the
CEAP (clinical, etiologic, anatomic, pathophysi-
ologic) classification system (Table 1).1

CME This clinical content conforms to AAFP criteria for

continuing medical education (CME). See CME Quiz on
page 673. Telangiectasia, or spider veins, (black arrow) are small
Author disclosure:​ No relevant financial affiliations. dilated superficial veins less than 1 mm in diameter.
Patient information:​ A handout on this topic is available at They are present in 43% of men and 55% of women. 3
https://​family​doctor.org/condition/varicose-veins. Reticular veins (white arrow) are 1 to 3 mm in diameter.

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 VARICOSE VEINS
SORT:​KEY RECOMMENDATIONS FOR PRACTICE

Evidence
Clinical recommendation rating References Comments

There is not enough evidence to determine if compression B 7, 15, 19-21 Based on a Cochrane review and clinical
stockings are effective in the treatment of varicose veins in guidelines based on systematic reviews;​
the absence of active or healed venous ulcers. consensus guidelines and expert opinion

Horse chestnut seed extract (Aesculus hippocastanum) B 23-25 Based on systematic reviews/Cochrane
and other phlebotonics may ease the symptoms of review of lower-quality RCTs
varicose veins, but long-term studies of the safety and
effectiveness of phlebotonics are lacking.

Referral for interventional treatment of symptomatic vari- C 7, 15 Clinical guidelines based on systematic
cose veins in nonpregnant patients should not be delayed reviews;​consensus guidelines and expert
for a trial of external compression. Interventional treat- opinion
ment should be offered if valvular reflux is documented.

Endovascular laser ablation may be better tolerated than B 30, 31 Based on a Cochrane review of lower-
sclerotherapy and surgery, with fewer adverse effects and quality RCTs and an RCT on quality-of-life
equal effectiveness. 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://​w ww.aafp.
org/afpsort.

Varicose veins are common on the lower extrem- venous disease;​female sex;​older age;​chronically
ities, with widely varying estimates of prevalence.2 increased intra-abdominal pressure due to obe-
A recent study found that telangiectasias occur in sity, pregnancy, chronic constipation, or a tumor;​
43% of men and 55% of women, and varicose veins prolonged standing;​deep venous thrombosis
occur in 16% of men and 29% of women.3 In a pop- causing damage to valves and secondary revas-
ulation with a mean age of 60 years, the prevalence cularization;​and arteriovenous shunting.8,9
of CEAP classification C0 to C6 is 29%, 29%, 23%,
10%, 9%, 1.5%, and 0.5%, respectively.4 Diagnosis
CLINICAL PRESENTATION
Etiology The clinical presentation of varicose veins varies,
Venous disease resulting in valvular reflux and some patients may be asymptomatic.10 Local-
appears to be the underlying cause of varicose ized symptoms may be unilateral or bilateral and
veins.5 The exact pathophysiology is debated, but include pain, burning, itching, and tingling at the
it involves a genetic predisposition, incompetent site of the varicose veins. Generalized symptoms
valves, weakened vascular walls, and increased consist of aching, heaviness, cramping, throb-
intravenous pressure. In most cases, the valvular bing, restlessness, and swelling in the legs.7,11
dysfunction is presumed to be caused by a loss of Symptoms are often worse at the end of the day,
elasticity in the vein wall, with failure of the valve especially after prolonged standing, and usually
leaflets to fit together. Rather than blood flowing resolve when patients sit and elevate their legs.
from distal to proximal and superficial to deep, Women are significantly more likely than men to
failed or incompetent valves allow blood to flow report lower limb symptoms.12 Patients are more
in the reverse direction. With increased pressure likely to have symptoms and increasing severity
on the affected venous system, the larger veins of symptoms with increasing CEAP clinical class
may become elongated and tortuous. Shear stress (C 0 to C6).6
on venous endothelial cells due to reversed or Although varicose veins may cause varying
turbulent blood flow and inflammation are also degrees of discomfort or cosmetic concern, they
important etiologic factors for venous disease.6 are rarely associated with significant complica-
Varicose veins in the legs may involve the tions. Signs of a more serious underlying vascular
main axial superficial veins (the great saphe- insufficiency may include changes in skin pigmen-
nous vein and the small saphenous vein or their tation, eczema, infection, superficial thrombo-
superficial tributaries).7 Established risk fac- phlebitis, venous ulceration, loss of subcutaneous
tors for varicose veins include family history of tissue, and lipodermatosclerosis (a decrease in

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 TABLE 1 FIGURE 2

The Basic CEAP Classification System

for Chronic Venous Disease
Classification Description

Clinical*
C0 No visible or palpable signs of
venous disease
C1 Telangiectasias or reticular veins
C2 Varicose veins
C3 Edema
C 4a Pigmentation or eczema
C 4b Lipodermatosclerosis or atrophie
blanche
C5 Healed venous ulcer
C6 Active venous ulcer

Etiologic
Ec Congenital
Corona phlebectatica with edema. Corona phlebec-
tatica can include blue veins, blue telangiectasia, red
Ep Primary
telangiectasia, and darker stasis spots. It is consid-
Es Secondary (postthrombotic) ered an early sign of advanced venous disease. Using
En No venous cause identified the CEAP classification system (Table 1), this patient
would be classified as having C3 vascular disease.
Anatomic
As Superficial veins
Ap Perforating veins
Ad Deep veins Evaluation of patient risk factors, symptoms,
An No venous location identified and typical physical examination findings helps
determine a diagnosis. Through inspection and
Pathophysiologic palpation, the examiner should note the size and
Pr Reflux distribution of varicose veins, the presence and
Po Obstruction
type of edema, and the presence of skin discol-
Pr,o Reflux and obstruction
oration, excoriation, or ulceration. Fan-shaped
Pn No venous pathophysiology
identifiable
varicose veins in the ankle (corona phlebectatica;​
Figure 2) are considered an early sign of advanced
Note:​ The CEAP classification system provides a framework to venous disease. Decreased ankle mobility, atro-
characterize venous disease, including varicose veins. The first por-
tion of the CEAP classification system can be used alone in practice.
phie blanche (a circular whitish area of scar tissue
For example, a patient presenting to the office with varicose veins surrounded by dilated capillaries), and lipoder-
with mild edema and aching but no hemosiderin staining of the matosclerosis are also signs of advanced venous
lower extremities could be documented as having C3S venous dis-
ease. Venous studies would be needed to further classify the patient
disease.1 Noting locations of other varicosities
using the remainder of the CEAP system. is important. Perineal, vulvar, or groin varicosi-
*—The presence or absence of symptoms is noted with a subscript ties may be a sign of pelvic vein incompetence or
“S” or “A,” for example C1A (asymptomatic telangiectasias) or C5S obstruction, which may include abdominal, pel-
(symptomatic healed venous ulcer). Symptoms include aching,
vic, or renal masses.7 Bedside clinical tests used
pain, tightness, skin irritation, heaviness, muscle cramps, and other
symptoms attributable to venous dysfunction. to detect the site of reflux, such as palpation for a
Adapted with permission from Eklöf B, Rutherford RB, Bergan JJ, et retrograde transmitted impulse from the saphe-
al.;​American Venous Forum International Ad Hoc Committee for nofemoral junction through the long saphenous
Revision of the CEAP Classification. Revision of the CEAP classifi- vein (tap test) or for transmission of a thrill or
cation for chronic venous disorders:​consensus statement. J Vasc
Surg. 2004;​40(6):​1 251-1252. impulse with coughing at the saphenofemoral
junction (cough test), are of limited value because
of their poor sensitivity or specificity.14
lower leg circumference due to chronic inflam-
mation, fibrosis, and contraction of the skin and IMAGING STUDIES
subcutaneous tissues). Although rare, hemo- When venous disease is severe or interventional
dynamically significant external hemorrhage therapy is being considered, venous duplex ultra-
resulting from the perforation of a varicose vein sonography is the modality of choice.7,15 Duplex
has been reported.13 ultrasonography is a simple, noninvasive,

684  American Family Physician www.aafp.org/afp Volume 99, Number 11 ◆ June 1, 2019
 VARICOSE VEINS
TABLE 2

Treatment Options for Varicose Veins

Treatment Comments

Conservative measures
Compression (e.g., bandages, Compression stockings can provide relief from discomfort, although
support stockings, intermittent evidence is lacking;​external compression is first-line treatment only in
pneumatic compression devices) pregnant women
Elevation of the affected leg May improve symptoms in some patients
Lifestyle modifications Examples include avoidance of prolonged standing and straining, exer-
cise, wearing nonrestrictive clothing, modification of cardiovascular risk
factors, and interventions to reduce peripheral edema
Weight loss Weight loss may improve symptoms in patients who are obese
Phlebotonics Most are available as dietary supplements (often with multiple agents in
one supplement) and are sold over the counter in the United States;​horse
chestnut seed extract (Aesculus hippocastanum) may provide symptom-
atic relief, but long-term studies are lacking

Interventional
Thermal ablation
External laser thermal ablation Works best for telangiectasias
Endovenous thermal ablation Used for larger vessels, including the greater saphenous vein
(using a laser or radio waves)
Endovenous sclerotherapy A variety of agents may be used, including hypertonic saline, sodium
tetradecyl (Sotradecol), and polidocanol (Varithena)
Surgery (ligation and stripping or Although surgery has historically been the most widely recommended
phlebectomy with multiple small treatment option, a growing body of literature does not consistently sup-
incisions) port surgery as the best interventional treatment option;​updated surgical
techniques use small incisions to reduce scarring, blood loss, and com-
plications and limit removal of the superficial axial veins from the groin to
knee, and may be performed under local or regional anesthesia

Adapted with permission from Jones RH, Carek PJ. Management of varicose veins. Am Fam Physician. 2008;​78(11):​1 292,
with additional information from references 7 and 15.

painless, and readily available modality that can for treatment decisions. Treatment options for
assess the anatomy and physiology of the lower varicose veins include conservative management
extremity venous system. It can help determine and interventional therapies such as thermal
which saphenous junctions are incompetent, the ablation, endovenous sclerotherapy, and surgery
diameter of the junctions, the extent of reflux, (Table 2).7,15,18 The decision to proceed with treat-
and the location and size of other incompetent ment and the choice of treatment are based on
perforating veins. It can also assess for acute symptoms and patient preferences. Other consid-
and occult deep venous thrombosis and super- erations include cost, potential for complications,
ficial thrombophlebitis. Reflux is defined as a availability of resources, insurance reimburse-
retrograde flow duration of more than 350 milli­ ment, and physician training. The presence or
seconds in the perforating veins, more than 500 absence of deep venous insufficiency and the
milliseconds in the superficial and deep calf characteristics of the affected veins can also help
veins, and more than 1,000 milliseconds in the guide treatment.17
femoropopliteal veins.16,17 Other imaging modal- Over the past 10 years, there has been a signif-
ities, such as computed tomography, magnetic icant change in the recommendations for treat-
resonance imaging, venography, and plethys- ment of symptomatic varicose veins. This is in
mography, are used only if venous ultrasonogra- large part because of the lack of evidence support-
phy is inconclusive or for more complex surgical ing the use of compression stockings and the rise
situations.7 of minimally invasive endovascular techniques.

Treatment CONSERVATIVE MANAGEMENT

Use of the CEAP classification system is import- Conservative treatment options include exter-
ant for diagnosis but does not provide guidance nal compression;​lifestyle modifications, such as

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 VARICOSE VEINS

avoidance of prolonged standing and straining, possibly decrease symptoms such as cramps, rest-
exercise, wearing nonrestrictive clothing, modi- less legs, and paresthesia.25
fication of cardiovascular risk factors, and inter- Most phlebotonics are available as dietary sup-
ventions to reduce peripheral edema;​elevation plements in the United States, and many formu-
of the affected leg;​weight loss;​and phlebotonics. lations contain multiple phlebotonics in a single
These measures are recommended for patients supplement. Long-term studies of the safety and
who are not candidates for endovenous or surgi- effectiveness of phlebotonics for the treatment of
cal management, do not desire intervention, or varicose veins are lacking.25
are pregnant.7,15
Compression has long been recommended INTERVENTIONAL TREATMENTS
as initial therapy for varicose veins. However, Thermal Ablation. Thermal ablation destroys
there is not enough evidence to determine if damaged veins using an external laser or via
compression stockings are effective in the treat- endovenous catheter using a laser (endovenous
ment of varicose veins in the absence of active laser ablation) or radio waves (radiofrequency
or healed venous ulcers.7,19-21 The 2013 National ablation). External laser thermal ablation works
Institute for Health and Care Excellence clinical best for telangiectasias. In this therapy, hemoglo-
guidelines recommend offering external com- bin absorbs the laser light leading to thermoco-
pression only if interventional treatment is inef- agulation.26 Endovenous thermal ablation can be
fective and as first-line therapy only in pregnant used for larger vessels, including the great saphe-
women.15 nous vein. Under ultrasound guidance, a laser
In some cases, a trial of external compression optical fiber or radiofrequency catheter electrode
may be required by insurance companies before is inserted into the vein in a distal to proximal
approval of interventional treatments. Although direction. Heat from the laser or radio waves
the optimal length and pressure for effective coagulates the blood in the vein, resulting in clo-
treatment has not been determined, typical rec- sure of the vein and redirection of blood flow to
ommendations include wearing 20 to 30 mm Hg functional veins.26,27
elastic compression stockings with a gradient of Endovenous thermal ablation is performed
decreasing pressure from the distal to proximal after a local anesthetic is injected around the
extremity.22 vein. Patients can walk after the procedure and
Phlebotonics are oral and topical therapies may be discharged home the same day. Patients
that may increase venous tone, improve capillary may return quickly to work and other activities.
hyperpermeability, and decrease blood viscosity There is a risk (approximately 7%) of surround-
with the goal of decreasing symptoms of chronic ing nerve damage attributed to thermal injury;​
venous insufficiency.23 They include flavonoids or however, most nerve damage is temporary.27
other compounds often extracted from plants, Endovenous thermal ablation is recommended as
such as rutin (also called rutoside), diosmin, first-line treatment for nonpregnant patients with
hidrosmin, disodium flavodate, French mari- symptomatic varicose veins and documented val-
time pine bark extract (Pycnogenol), grape seed vular reflux, and need not be delayed for a trial of
extract, and horse chestnut seed extract (Aesculus external compression.7,15
hippocastanum). Diosmiplex (Vasculera) is the Endovenous Sclerotherapy. Endovenous sclero-
only prescription formulation available in the therapy involves using ultrasound guidance to
United States.23 Diosmiplex is derived from inject superficial veins with an agent that causes
orange rinds and is categorized as a medical food, inflammation of the endothelium, resulting in
not a drug. The usual dosage is 630 mg daily. fibrosis and occlusion in the vein.27 Sclerother-
Horse chestnut seed extract appears to be safe apy is typically used for small (1 to 3 mm) and
and effective in reducing pain, edema, and pru- medium (3 to 5 mm) veins or to treat recurrent
ritus from chronic venous insufficiency when varicose veins after surgery;​however, there is
used for two to 16 weeks. The common dosage is not a precise diameter used to make treatment
300 mg twice daily or 50 mg of escin, the active decisions.28
compound.24 There is moderate-quality evidence A needle is inserted into the vein lumen and
that other phlebotonics may improve edema and the sclerosing agent is injected, often with air to

686  American Family Physician www.aafp.org/afp Volume 99, Number 11 ◆ June 1, 2019
 VARICOSE VEINS

create a foam. The foam displaces the blood and Maintaining saphenous vein occlusion at six
reacts with the vascular endothelium, sealing months is less likely with sclerotherapy than with
and scarring the vein. A variety of agents may be endovenous laser ablation or surgery (43% vs.
used, including hypertonic saline, sodium tetra- 80%).31 Endothermal ablation resulted in less
decyl (Sotradecol), and polidocanol (Varithena). recurrence of reflux at one year compared with
There is no evidence that any of these agents is surgery when treating varicose veins of the small
superior to the others in terms of effectiveness or saphenous vein resulting from incompetence of
patient satisfaction.29 the saphenous-popliteal junction.27
Surgery. Historically, surgery with ligation and Nonsurgical therapies may have faster return-
stripping of the great or small saphenous vein to-work and recovery times than surgery. Endo-
has been the standard of care for the treatment venous laser ablation may be better tolerated than
of varicose veins after the failure of conservative sclerotherapy and surgery, with fewer adverse
therapy. However, a growing body of literature effects and equal effectiveness.30,31 For all three
does not consistently support surgery as the best therapies, rates of minor and major complica-
interventional treatment option, and the 2013 tions, including numbness, persistent bruising
National Institute for Health and Care Excellence or tenderness, skin ulceration, skin staining, and
clinical guidelines recommend surgery as third- lumpiness, are relatively low (1% to 7%).31 Hema-
line therapy after endovenous thermal ablation tomas occur more often with surgical treatment
and sclerotherapy.15,30,31 than with foam sclerotherapy or radiofrequency
Updated surgical techniques use small inci- ablation. Endovenous laser ablation appears to be
sions to reduce scarring, blood loss, and compli- superior to surgery in terms of technical failure
cations and limit removal of the superficial axial and neovascularization. Although all interven-
veins from the groin to knee. Some of these pro- tional treatment leads to symptomatic improve-
cedures can be performed under regional or local ment, the improvement at six months may be
anesthesia.7 Ligation and stripping of the great more significant with endovenous laser ablation
and small saphenous vein are probably the best- and surgery than with foam sclerotherapy.31
known procedures. Typically, the vein is divided This article updates a previous article on this topic by
proximally, a vein stripper is passed distally to an Jones and Carek.18
incision made near the knee to access the tip of
Data Sources:​ A search was performed in Essen-
the stripper. The proximal end of the stripper is tial Evidence Plus. Additionally, PubMed and the
secured to the vein and the vein is then removed Cochrane database were searched using the key
as the stripper is pulled distally. Nonsaphenous term varicose veins. The PubMed search was limited
and smaller veins can be removed via phlebec- to English language, humans, 10 years, and system-
tomy, during which a scalpel or large-gauge nee- atic reviews. Search dates:​March 15, 2018; June 6,
2018; and February 21, 2019.
dle is used to create punctures every 2 to 3 cm
along a varicose vein. Segments of the damaged
vein are removed using forceps or small hooks. The Authors
JAQUELINE RAETZ, MD, is an associate professor
OUTCOME DATA in the University of Washington Family Medicine
A 2014 Cochrane review concluded that endo- Residency program, Seattle.
venous laser ablation, radiofrequency ablation, MEGAN WILSON, MD, is an assistant professor
and foam sclerotherapy are as effective as sur- in the University of Washington Family Medicine
gery for great saphenous vein varices.30 Prior Residency program.
literature suggested that traditional surgical
KIMBERLY COLLINS, MD, is an assistant professor
treatment of varicose veins with great saphenous
in the University of Washington Family Medicine
vein ligation at the saphenofemoral junction and Residency program.
stripping has a five-year recurrence rate of 20%
to 28%.30 Clinical recurrence of varicose veins Address correspondence to Jaqueline Raetz, MD,
at five years was measured in only one study in 331 NE Thornton Place, Seattle, WA 98125 (e-mail:​
jraetz@​uw.edu). Reprints are not available from
the Cochrane review and suggested no difference the authors.
between endovenous laser ablation and surgery.30

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 VARICOSE VEINS

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