Varicose veins

Last reviewed: 22 Feb 2023

Last updated: 06 Mar 2020

Very common condition that affects up to 40% of the population, but not all varicose veins are symptomatic.

Clinical presentation includes lower extremity pain, fatigue, itching and/or heaviness, which often worsen with prolonged standing, associated with dilated tortuous veins.

Varicose veins can lead to significant quality of life impairment in affected individuals.

Underlying venous insufficiency can be documented by duplex ultrasound.

Treatment options for symptomatic varicose veins include endovenous thermal ablation, foam sclerotherapy, and open surgery.

Compression hosiery should be reserved for those unsuitable for intervention, those who are unfit, and as long-term management for those with chronic venous diseases or healed ulceration.

Chronic venous skin changes, superficial venous thrombosis, venous ulceration, and bleeding are recognised complications.

Definition

Varicose veins are subcutaneous, permanently dilated veins 3 mm or more in diameter when measured in a standing position; however, they may not be visible.[1]

History and exam

Key diagnostic factors

presence of risk factors
dilated tortuous veins

More key diagnostic factors

Other diagnostic factors

leg fatigue or aching with prolonged standing
leg cramps
restless legs
haemosiderin deposition
corona phlebectatica
itching
lipodermatosclerosis
ankle swelling
ulceration
bleeding from varices

Other diagnostic factors

Risk factors

increasing age
family history
female sex
increasing numbers of births
deep vein thrombosis
occupation with prolonged standing
obesity

More risk factors

Diagnostic investigations

1st investigations to order

duplex ultrasound

More 1st investigations to order

Treatment algorithm

ONGOING

symptomatic superficial vein insufficiency, no evidence of peripheral vascular disease or superficial axial truncal insufficiency: tributary insufficiency only

symptomatic superficial vein insufficiency, no evidence of peripheral vascular disease or superficial tributary insufficiency: truncal axial insufficiency only

symptomatic superficial vein insufficiency, no evidence of peripheral vascular disease: truncal axial and tributary insufficiency

symptomatic superficial vein insufficiency, no evidence of peripheral vascular disease: perforator veins with reflux located near healed or active venous ulcers

deep vein insufficiency without superficial truncal vein insufficiency but with superficial tributary insufficiency

deep vein insufficiency with superficial truncal vein insufficiency

deep vein insufficiency without superficial vein insufficiency

deep vein obstruction

Contributors

Authors

Alun H Davies, MA, DM, DSc, FRCS, FHEA, FEBVS, FACPh

Professor of Vascular Surgery and Honorary Consultant Vascular Surgeon

Department of Surgery and Cancer

Imperial College London

Imperial Vascular Unit

Imperial College Healthcare NHS Trust

London

Disclosures

AHD declares that he has no competing interests.

Tristan RA Lane, MBBS, BSc, PhD, FRCS

Clinical Lecturer and Post CCT Fellow in Vascular Surgery

Department of Surgery and Cancer

Imperial College London

Imperial Vascular Unit

Imperial College Healthcare NHS Trust

London

Disclosures

TRAL declares that he has no competing interests.

Acknowledgements

Professor Alun Davies and Mr Tristan Lane would like to gratefully acknowledge Dr Luis R. Leon Jr, Dr Maureen K. Sheehan, and Dr Boulos Toursarkissian, previous contributors to this topic.

Disclosures

LRL, MKS and BT declare that they have no competing interests.

Peer reviewers

Paul Tisi, MBBS, MS, FRCSEd

Medical Director/Consultant Vascular Surgeon

Bedford Hospital

Bedford

Disclosures

PT declares that he has no competing interests.

Nick Morrison, MD, FACS, FACPh

Director

Morrison Vein Institute

Scottsdale

Disclosures

NM declares that he has no competing interests.

Differentials
- Telangiectasias
- Reticular veins
More Differentials
Guidelines
- Management of venous leg ulcers
- The care of patients with varicose veins and associated chronic venous diseases
More Guidelines
Patient leaflets
Varicose veins: what are they?
Varicose veins: surgery to remove varicose veins
More Patient leaflets
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Varicose veins

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic investigations

1st investigations to order

Treatment algorithm

symptomatic superficial vein insufficiency, no evidence of peripheral vascular disease or superficial axial truncal insufficiency: tributary insufficiency only

symptomatic superficial vein insufficiency, no evidence of peripheral vascular disease or superficial tributary insufficiency: truncal axial insufficiency only

symptomatic superficial vein insufficiency, no evidence of peripheral vascular disease: truncal axial and tributary insufficiency

symptomatic superficial vein insufficiency, no evidence of peripheral vascular disease: perforator veins with reflux located near healed or active venous ulcers

deep vein insufficiency without superficial truncal vein insufficiency but with superficial tributary insufficiency

deep vein insufficiency with superficial truncal vein insufficiency

deep vein insufficiency without superficial vein insufficiency

deep vein obstruction

Contributors

Authors

Alun H Davies, MA, DM, DSc, FRCS, FHEA, FEBVS, FACPh

Disclosures

Tristan RA Lane, MBBS, BSc, PhD, FRCS

Disclosures

Acknowledgements

Disclosures

Peer reviewers

Paul Tisi, MBBS, MS, FRCSEd

Disclosures

Nick Morrison, MD, FACS, FACPh

Disclosures

Differentials

Guidelines

Patient leaflets

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

Log in to access all of BMJ Best Practice