Varicose Veins: Diagnosis and Treatment

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, pregnancy, 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. Conservative treatment options include external compression; lifestyle modifications, such as avoidance of prolonged standing and straining, exercise, wearing nonrestrictive clothing, modification of cardiovascular 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 stockings 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, endovenous 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 Although surgery was once the standard of care, it largely has been replaced by endovenous thermal ablation, which can be performed under local anesthesia and may have better outcomes and fewer complications than other treatments.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 endovenous thermal ablation, although it may be necessary for insurance coverage.