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Varicose Veins

Clinical Subject Page

Varicose Veins

ICD-10

Q25.0

Specialty

Cardiology

Onset

Chronic

Reviewed

July 2026

On This Page

Overview

Varicose veins are dilated, tortuous superficial veins caused by venous valve incompetence, leading to venous reflux and chronic venous hypertension, most commonly affecting the lower limbs.

Etiology & Risk Factors

  • Etiology

    • Primary venous valve incompetence (most common)
    • Chronic venous insufficiency
    • Previous deep vein thrombosis (post-thrombotic syndrome)
    • Congenital venous valve abnormalities
    • Venous obstruction

    Risk Factors

    • Increasing age
    • Female sex
    • Family history
    • Pregnancy
    • Obesity
    • Prolonged standing
    • Sedentary lifestyle
    • Previous DVT

Pathophysiology

  • – During fetal development:
    – Anterior and superior deviation of the infundibular septum causes:
  • Malaligned VSD
  • Overriding aorta
  • Right ventricular outflow tract obstruction
  • Blood flow depends on the severity of RVOTO:
  • Large VSD causes equal right and left ventricular pressures.
  • Mild RVOTO → predominantly left-to-right shunt → minimal cyanosis.
  • Severe RVOTO → right-to-left shunt → deoxygenated blood enters systemic circulation.
  • Persistent right-to-left shunting eventually results in right ventricular hypertrophy

Clinical Presentation

  • Symptoms

    • Visible enlarged veins
    • Leg heaviness
    • Aching pain
    • Leg fatigue
    • Swelling
    • Itching
    • Night cramps

    Signs

    • Dilated tortuous superficial veins
    • Ankle edema
    • Hyperpigmentation
    • Lipodermatosclerosis
    • Venous eczema
    • Venous ulcers (advanced disease)

History Taking

Key Questions

  • When did the veins first appear?
  • Leg pain or heaviness?
  • Symptoms worse after standing?
  • Swelling?
  • Skin discoloration?
  • Previous DVT?
  • Pregnancy history?
  • Family history?
  • Occupation requiring prolonged standing?

Red Flags

  • Sudden unilateral swelling
  • Severe pain
  • Bleeding from varicose veins
  • Non-healing ulcer
  • Suspected DVT

Physical Examination

Inspection

  • Dilated, tortuous superficial veins (>3 mm in diameter)
  • Leg swelling (edema), usually starting at the ankle
  • Telangiectasias (spider veins)
  • Yellow-brown or red-brown skin pigmentation around the medial ankle (hemosiderin deposition)
  • Stasis dermatitis (scaly, itchy rash)
  • Lipodermatosclerosis (hard, indurated skin of the lower leg)
  • Venous ulcers (typically around the medial malleolus in advanced disease)

Palpation

  • Assess for:
    • Tenderness
    • Warmth
    • Extent of edema
    • Induration from lipodermatosclerosis

Vascular Examination

  • Check pedal pulses to exclude coexisting peripheral arterial disease.
  • Compare both legs for swelling and skin changes.

Bedside Clinical Tests

  • Trendelenburg test: Assesses superficial and perforating vein valve competence.
  • Perthes test: Assesses deep venous patency (deep vein function).

Note: These bedside tests may help identify venous insufficiency, but venous duplex ultrasound is required for diagnostic confirmation.

Investigations

  • Laboratory

    • Usually not required
    • D-dimer (if DVT suspected)

    Imaging

    • Duplex venous ultrasound (gold standard)
      • Venous reflux
      • Valve incompetence
      • Excludes DVT

    Additional Tests

    • CEAP classification
    • Venous Clinical Severity Score (VCSS)

Diagnosis

  • Diagnosis is based on:

    • Clinical examination
    • Duplex venous ultrasound confirming venous reflux and valve incompetence
    • CEAP classification to determine disease severity
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Management

  • Conservative Management

    • Compression stockings
    • Leg elevation
    • Regular exercise
    • Weight reduction
    • Avoid prolonged standing

    Procedures

    • Endovenous thermal ablation (laser or radiofrequency)
    • Ultrasound-guided foam sclerotherapy
    • Ambulatory phlebectomy
    • Surgical vein stripping (selected patients)

Complications

  • Chronic venous insufficiency
  • Venous ulcers
  • Superficial thrombophlebitis
  • Bleeding
  • Skin pigmentation
  • Lipodermatosclerosis
  • Recurrent varicosities

Prognosis

  • Generally excellent with appropriate treatment.
  • Symptoms improve significantly after endovenous therapy.
  • Recurrence may occur, especially if risk factors persist.
  • Untreated disease may progress to chronic venous insufficiency and venous ulceration.

Key Points / Clinical Pearls

  • Venous valve incompetence is the primary cause of varicose veins.
  • Duplex venous ultrasound is the diagnostic test of choice.
  • Compression therapy is the first-line conservative treatment.
  • Endovenous thermal ablation is the preferred minimally invasive intervention.
  • Symptoms worsen with prolonged standing and improve with leg elevation.
  • Venous ulcers are the most significant long-term complication.