Management of Varicose Veins RICHARD h. JONES, MD, MSPH, Naval Health Clinic, Quantico, Virginia PETER J. cAREK, MD, MS, Medical University of South Carolina, Charleston, South Carolina Varicose veins are twisted, dilated veins most commonly located on the lower extremities. Risk factors include chronic cough, constipation, family history of venous disease, female sex, obesity, older age, pregnancy, and prolonged stand- ing. The exact pathophysiology is debated, but it involves a genetic predisposition, incompetent valves, weakened vascular walls, and increased intravenous pressure. A heavy, achy feeling; itching or burning; and worsening with prolonged standing are all symptoms of varicose veins. Potential complications include infection, leg ulcers, stasis changes, and thrombosis. Some conservative treatment options are avoidance of prolonged standing and straining, elevation of the affected leg, exercise, external compression, loosening of restrictive clothing, medical therapy, modi- fication of cardiovascular risk factors, reduction of peripheral edema, and weight loss. More aggressive treatments include external laser treatment, injection sclerotherapy, endovenous interventions, and surgery. Comparative treat- ment outcome data are limited. There is little evidence to preferentially support any single treatment modality. Choice of therapy is affected by symptoms, patient preference, cost, potential for iatrogenic complications, available medical resources, insurance reimbursement, and physician training. (Am Fam Physician. 2008;78(11):1289-1294. Copyright © 2008 American Academy of Family Physicians.) aricose veins are generally iden- With increased pressure on the local venous tified by their twisted, bulging, system, the larger affected veins may become superficial appearance on the elongated and tortuous. Although no specific lower extremities. They also can etiology is noted, in most cases the valvular beV found in the vulva, spermatic cords (vari- dysfunction is presumed to be caused by a coceles), rectum (hemorrhoids), and esoph- loss of elasticity in the vein wall, with failure agus (esophageal varices).1 Varicose veins of the valve leaflets to fit together.6 are a common problem, with widely varying estimates of prevalence. In general, they are Diagnosis found in 10 to 20 percent of men and 25 to CLINICAL PRESENTATION 33 percent of women.2,3 The clinical presentation of varicose veins varies among patients.7 Some patients are Etiology asymptomatic. Symptoms, if present, are The etiology of varicose veins is multifactorial usually localized over the area with varicose and may include: increased intravenous pres- veins; however, they may be generalized to sure caused by prolonged standing; increased include diffuse lower extremity conditions. intra-abdominal pressure arising from tumor, Localized symptoms include pain, burning, pregnancy, obesity, or chronic constipation; or itching. Generalized symptoms consist of familial and congenital factors; second- leg aching, fatigue, or swelling. Symptoms are ary vascularization caused by deep venous often worse at the end of the day, especially thrombosis; or less commonly, arteriovenous after periods of prolonged standing, and shunting.4 Shear forces and inflammation usually disappear when patients sit and ele- have recently been recognized as important vate their legs. Women are significantly more etiologic factors for venous disease.5 likely than men to report lower limb symp- Venous disease resulting in valve reflux toms, such as heaviness or tension, swelling, appears to be the underlying pathophysi- aching, restless legs, cramps, or itching.8 ology for the formation of varicose veins. No correlation between the severity of the Rather than blood flowing from distal to varicose veins and the severity of symptoms proximal and superficial to deep, failed or has been noted. Established risk factors for incompetent valves in the venous system varicose veins include chronic cough, con- allow blood to flow in the reverse direction. stipation, family history of venous disease, Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright © 2008 American Academy of Family Physicians. For the private, noncommercial use of one individual user of the Web site. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright © 2008 American Academy of Family Physicians. For the private, noncommercial use of one individual user of the Web site. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. SORT: KEY Recommendations For Practice Evidence Clinical recommendation rating References Conservative therapy (e.g., elevation, external compression devices, C 13-16 butcher’s broom, horse chestnut seed extract, weight loss) for varicose veins may be helpful, but there are few clinical trials. There is insufficient evidence to preferentially recommend any specific B 12, 13, 15, treatment or combination of treatments for varicose veins. 22, 29 Sclerotherapy may be used to improve the symptoms and cosmetic B 29 appearance of varicose veins. 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 http://www.aafp.org/afpsort.xml. female sex, obesity, occupations associated saphenofemoral and saphenopopliteal junc- with orthostasis, older age, pregnancy, and tions. It can also assess the competence and prolonged standing.9 diameter of the greater and lesser saphenous Although varicose veins may cause vary- veins and the vascular architecture of the ing degrees of discomfort or cosmetic tributary and deeper perforating veins. Other concern, they are rarely associated with sig- less commonly used studies that may be help- nificant medical complications. Skin pigmen- ful in select patients include venography, light tation changes, eczema, infection, superficial reflex rheography, ambulatory venous pres- thrombophlebitis, venous ulceration, loss of sure measurements, photoplethysmography, subcutaneous tissue, and a decrease in lower air plethysmography, and foot volumetry. leg circumference (lipodermatosclerosis) are possible complications. Although rare, exter- Treatment nal hemorrhage resulting from the perfora- Treatment options for varicose veins include tion of a varicose vein has been reported.10 conservative management, external laser Evaluation of patient risk factors, symp- treatment, injection sclerotherapy, endove- toms, and typical physical examination find- nous interventions, and surgery (Table 2).12 ings help determine a diagnosis. Although a The indications for treatment are largely detailed physical examination is sufficient to based on patient preference. Choice of treat- diagnose most patients with primary varicose ment is also affected by symptoms, cost, veins, it does not provide information about potential for iatrogenic complications, avail- the presence of deep venous insufficiency. able medical resources, insurance reim- Clinical tests used to detect the site of reflux are bursement, and physician training, as well of limited value (Table 1).11 A positive tap test as the presence or absence of deep venous and negative Perthes test are most helpful.11 insufficiency and the characteristics of the affected veins. Vascular surgical intervention IMAGING STUDIES for venous insufficiency may be indicated in Imaging studies are generally not necessary for patients with aching pain and leg fatigue, diagnosis, but they may be useful in patients ankle edema, chronic venous insufficiency, with severe symptoms or in patients who are cosmetic concerns, early hyperpigmenta- obese. They also may be helpful for planning tion, external bleeding, progressive or pain- procedures, documenting the extent of vas- ful ulcer, or superficial thrombophlebitis. cular pathology, or identifying the source of venous reflux. Duplex Doppler ultraso- CONSERVATIVE MANAGEMENT nography is a simple, noninvasive, painless, Conservative treatment options include readily available modality that can assess the avoidance of prolonged standing and anatomy and physiology of the lower extrem- straining, elevation of the affected leg, ity venous system. It can evaluate for acute exercise, external compression, loosening and occult deep venous thrombosis, super- of restrictive clothing, medical therapy, ficial thrombophlebitis, and reflux at the modification of cardiovascular risk factors, 1290 American Family Physician www.aafp.org/afp Volume 78, Number 11 ◆ December 1, 2008 Table 1. Clinical Tests Used to Detect Venous Reflux in Patients with Varicose Veins Positive Negative Sensitivity Specificity predictive predictive Test Description Finding (%) (%) value (%) value (%) Tap test With the patient A palpable transmitted 18 92 70 47 standing, a hand impulse denotes that the is placed over the LSV is distended with blood. SFJ, and the LSV is The SFJ is then tapped tapped at the level and the presence of a of the knee with the retrograde, palpably other hand. transmitted impulse at the knee indicates incompetence of valves between the SFJ and the LSV, with reflux in the proximal LSV. Cough test With the patient A palpable thrill or impulse on 59 67 64 38 standing, a finger is coughing is indicative