AKT · Cardiovascular/Vessels, aorta & venouslow yield

Varicose veins & chronic venous insufficiency

Venous valve incompetence → venous hypertension in the lower limb

Overview

Incompetent venous valves cause reflux and venous hypertension, producing dilated tortuous superficial veins (varicose veins) and, over time, the skin changes of chronic venous insufficiency that culminate in venous (gravitational) ulceration. Compression is the mainstay; endovenous/surgical treatment is for symptomatic or complicated disease.

Recognise

Visible dilated tortuous superficial leg veins; aching, heaviness, itching, swelling, worse on standing/end of day
Chronic venous insufficiency: haemosiderin pigmentation, venous eczema, lipodermatosclerosis ('inverted champagne bottle' leg), atrophie blanche, oedema
Venous ulcer: shallow, exudative, irregular, over the medial malleolus (gaiter area), relatively painless

Red flags

Bleeding varicosity → elevate and apply direct pressure (can be torrential)
Active or healed venous ulcer, thrombophlebitis, or skin changes → refer to vascular services

Differentials & how to tell them apart

Deep vein thrombosisacute unilateral swelling/pain — exclude before attributing to varicose veins

Arterial ulcerpunched-out, painful, on pressure points/toes, absent pulses

Lymphoedemanon-pitting, involves the foot/toes, no venous skin changes

Cellulitisacute hot erythema with systemic features

Varicose veins with chronic venous skin changes of the lower leg
S A Sewell, Wellcome Collection / CC BY 4.0 — Wikimedia Commons

Investigations

Clinical diagnosis; venous duplex ultrasound to map reflux and exclude deep venous obstruction before intervention; ABPI BEFORE compression (to exclude significant arterial disease — compression can cause harm if ABPI low).

Management

Compression (after checking ABPI) + leg care; endovenous ablation/sclerotherapy for symptomatic veins

1Confirm clinically and map with venous duplex; check ABPI before any compression. Conservative care = compression hosiery, elevation, weight loss and exercise.Gate: Check ABPI before applying compression — significant arterial disease (low ABPI) makes compression harmful; a bleeding varicosity → elevate and apply direct pressure.
2Symptomatic, bleeding, ulcerating or skin-changing disease → refer for endovenous ablation/foam sclerotherapy (or surgery); venous ulcers heal with compression bandaging and wound care.

Compression (check ABPI ≥0.8 first) + leg elevation + weight loss/exercise — mainstay; ACTIVE/non-healing venous ulcer → compression BANDAGING (4-layer); once HEALED/healing → maintenance compression STOCKINGS to prevent recurrence

Endovenous ablation (radiofrequency/laser) or foam sclerotherapy — first-line interventional treatments for symptomatic varicose veins

Surgery (ligation/stripping) — if endovenous options unsuitable

Wound care for venous ulcers — compression + dressings; treat infection if present

Key points

Dilated tortuous leg veins with aching, haemosiderin staining and a shallow ulcer over the medial malleolus = varicose veins / chronic venous insufficiency → compression is the mainstay, but ALWAYS check ABPI first (compression harms an ischaemic leg). Endovenous ablation for symptomatic veins.

Monitor & prognosis

Skin changes, ulcer healing, symptom relief; recurrence after intervention.

Chronic; compression controls symptoms and heals most venous ulcers; recurrence is common.

Source: NICE CG168 (varicose veins)