Editing Varicose veins

{{Short description|Medical condition in which superficial veins become large and twisted}}
{{Infobox medical condition (new)
| name          = Varicose veins
| synonyms      = 
| image         = Leg Before 1.jpg
| width         = 
| alt           = 
| caption       = Left leg of a male affected by varicose veins
| pronounce     = {{IPAc-en|ˈ|v|æɹ|ɪ|k|oʊ|s}}
| field         = [[Vascular surgery]], [[dermatology]]<ref name="NIH2019" />
| symptoms      = None, fullness, pain in the area<ref name="Mer2019Pro" />
| complications = Bleeding, [[superficial thrombophlebitis]]<ref name="Mer2019Pro" /><ref name="NIH2019" />
| onset         = 
| duration      = 
| types         = 
| causes        = 
| risks         = [[Obesity]], not enough exercise, leg trauma, [[family history]], [[pregnancy]]<ref name="MLP2019" />
| diagnosis     = Based on examination<ref name="Mer2019Pro" />
| differential  = [[Arterial insufficiency]], [[peripheral neuritis]]<ref>{{cite book | vauthors = Buttaro TM, Trybulski JA, Polgar-Bailey P, Sandberg-Cook J |title=BOPOD – Primary Care: A Collaborative Practice |date=2016 |publisher=Elsevier Health Sciences |isbn=9780323355216 |page=609 |url=https://books.google.com/books?id=avnwCwAAQBAJ&pg=PA609 |language=en}}</ref>
| prevention    = 
| treatment     = [[Compression stockings]], exercise, [[sclerotherapy]], surgery<ref name="Mer2019Pro" /><ref name="MLP2019" />
| medication    = 
| prognosis     = Commonly reoccur<ref name="Mer2019Pro" />
| frequency     = Very common<ref name="MLP2019" />
| deaths        = 
}}
<!-- Definition and symptoms -->'''Varicose veins''', also known as '''varicoses''', are a medical condition in which [[superficial vein]]s become enlarged and twisted. Although usually just a cosmetic ailment, in some cases they cause fatigue, pain, [[itch|itching]], and [[cramp|nighttime leg cramps]].<ref name="NIH2019" /><ref name="Mer2019Pro" /><ref>{{cite web |url=https://www.mayoclinic.org/diseases-conditions/varicose-veins/symptoms-causes/syc-20350643 |title=Varicose veins |website=Mayo Clinic |access-date=19 June 2024}}</ref> These [[vein]]s typically develop in the legs, just under the skin.<ref name="MLP2019" /> Their complications can include bleeding, [[ulcer (dermatology)|skin ulcers]], and [[superficial thrombophlebitis]].<ref name="NIH2019" /><ref name="Mer2019Pro" /> [[Varices]] in the [[scrotum]] are known as [[varicocele]], while those around the [[Human anus|anus]] are known as [[hemorrhoids]].<ref name="NIH2019">{{cite web |title=Varicose Veins |url=https://www.nhlbi.nih.gov/health-topics/varicose-veins |website=National Heart, Lung, and Blood Institute (NHLBI) |access-date=20 January 2019}}</ref> The physical, social, and psychological effects of varicose veins can lower their bearers' [[quality of life]].<ref>{{cite journal | vauthors = Lumley E, Phillips P, Aber A, Buckley-Woods H, Jones GL, Michaels JA | title = Experiences of living with varicose veins: A systematic review of qualitative research | journal = Journal of Clinical Nursing | volume = 28 | issue = 7–8 | pages = 1085–1099 | date = April 2019 | pmid = 30461103 | doi = 10.1111/jocn.14720 | url = https://eprints.whiterose.ac.uk/139160/3/Lumley_et_al-2018-Journal_of_Clinical_Nursing.pdf }}</ref>

<!-- Cause and diagnosis -->
Varicose veins have no specific cause.<ref name="Mer2019Pro" /> Risk factors include [[obesity]], lack of exercise, leg trauma, and [[family history]] of the condition.<ref name="MLP2019" /> They also develop more commonly during [[pregnancy]].<ref name="MLP2019" /> Occasionally they result from [[chronic venous insufficiency]].<ref name="Mer2019Pro" /> Underlying causes include weak or damaged valves in the veins.<ref name="NIH2019" /> They are typically diagnosed by examination, including observation by [[ultrasound]].<ref name="Mer2019Pro" />

By contrast, [[telangiectasia|spider veins]] affect the [[capillaries]] and are smaller.<ref name="NIH2019" /><ref name="WOMEN2016">{{cite web |title=Varicose veins and spider veins |url=https://www.womenshealth.gov/a-z-topics/varicose-veins-and-spider-veins |website=womenshealth.gov |access-date=21 January 2019 |language=en |date=15 December 2016}}</ref>

<!-- Treatment -->
Treatment may involve lifestyle changes or medical procedures with the goal of improving symptoms and appearance.<ref name="NIH2019" /> Lifestyle changes may include wearing [[compression stockings]], exercising, elevating the legs, and weight loss.<ref name="NIH2019" /> Possible medical procedures include [[sclerotherapy]], [[laser surgery]], and [[vein stripping]].<ref name="Mer2019Pro">{{cite web |title=Varicose Veins – Cardiovascular Disorders |url=https://www.merckmanuals.com/en-ca/professional/cardiovascular-disorders/peripheral-venous-disorders/varicose-veins |website=Merck Manuals Professional Edition |access-date=20 January 2019 |language=en-CA}}</ref><ref name="NIH2019" /> However, recurrence is common following treatment.<ref name="Mer2019Pro" />

<!-- Epidemiology and culture -->
Varicose veins are very common, affecting about 30% of people at some point in their lives.<ref name="Baram_2022">{{Cite journal | vauthors = Baram A, Rashid DF, Saqat BH |date = August 2022 |title=Non-randomized comparative study of three methods for great saphenous vein ablation associated with mini-phlebectomy; 48 months clinical and sonographic outcome |journal=Annals of Medicine and Surgery |volume=80 |pages=104036 |doi=10.1016/j.amsu.2022.104036 |pmid = 35846854 |pmc = 9283499 }}</ref><ref name="MLP2019">{{cite web |title=Varicose Veins |url=https://medlineplus.gov/varicoseveins.html |website=medlineplus.gov |access-date=20 January 2019}}</ref><ref name="NHS2007">{{cite web |title=Varicose veins Introduction – Health encyclopaedia |url=http://www.nhsdirect.nhs.uk/articles/article.aspx?ArticleID=387 |archive-url=https://web.archive.org/web/20071109064548/http://www.nhsdirect.nhs.uk/articles/article.aspx?ArticleID=387 |url-status=dead |archive-date=9 November 2007 |publisher=NHS Direct |access-date=20 January 2019 |date=8 November 2007}}</ref> They become more common with age.<ref name="MLP2019" /> Women develop varicose veins about twice as often as men.<ref name="WOMEN2016" /> Varicose veins have been described throughout history and have been treated with surgery since at least the second century BC, when Plutarch tells of such treatment performed on the Roman leader Gaius Marius.{{cn|date=June 2024}}

== Signs and symptoms ==
{{More citations needed section|date=January 2016}}
{{Proseline section|date=August 2024}}
* Aching, [[heavy legs]]<ref name=":0">{{cite journal | vauthors = Tisi PV | title = Varicose veins | journal = BMJ Clinical Evidence | volume = 2011 | date = January 2011 | pmid = 21477400 | pmc = 3217733 }}</ref><ref name=":1">{{Cite web|date=2017-10-23|title=Varicose veins|url=https://www.nhs.uk/conditions/varicose-veins/|access-date=2020-12-29|website=nhs.uk|language=en}}</ref>
* Appearance of spider veins ([[telangiectasia]]) in the affected leg
* Ankle swelling<ref name=":0" /><ref name=":1" />
* A brownish-yellow shiny skin discoloration near the affected veins
* Redness, dryness, and itchiness of areas of skin, termed [[stasis dermatitis]] or venous [[eczema]]<ref name=":1" />
* Muscle cramps when making sudden movements, such as standing<ref name=":1" /><ref>{{cite journal | vauthors = Chandra A |title= Clinical review of varicose veins: epidemiology, diagnosis and management | journal = GPonline |url=https://www.gponline.com/clinical-review-varicose-veins-epidemiology-diagnosis-management/cv-thromboembolic-disorders/article/1291408}}</ref>
* Abnormal bleeding or healing time for injuries in the affected area
* [[Lipodermatosclerosis]] or shrinking skin near the ankles
* [[Restless legs syndrome]] appears to be a common overlapping clinical syndrome in people with varicose veins and other [[chronic venous insufficiency]]<ref>{{cite web |url=https://www.lecturio.com/concepts/chronic-venous-insufficiency/| title=Chronic Venous Insufficiency
|website=The Lecturio Medical Concept Library |access-date= 9 July 2021}}</ref>
* [[Livedoid vasculitis|Atrophie blanche]], or white, scar-like formations
* Burning or throbbing sensation in the legs<ref name=":1" />
People with varicose veins might have a positive [[D-dimer]] blood test result due to chronic low-level thrombosis within dilated veins ([[varices]]).<ref>{{Cite web |title=Varicose Vein Surgery Workup: Approach Considerations, Tests for Ruling Out Deep Venous Thrombosis As Cause, Tests for Demonstrating Reflux |url=https://emedicine.medscape.com/article/462579-workup |access-date=2022-04-12 |website=emedicine.medscape.com}}</ref>

=== Complications ===
Most varicose veins are reasonably benign, but severe varicosities can lead to major complications, due to the poor circulation through the affected limb.
* Pain, tenderness, heaviness, inability to walk or stand for long hours
* Skin conditions / [[dermatitis]] which could predispose skin loss
* Skin ulcers especially near the ankle, usually referred to as [[venous ulcer]]s
* Development of [[carcinoma]] or [[sarcoma]] in longstanding venous ulcers. Over 100 reported cases of malignant transformation have been reported at a rate reported as 0.4% to 1%<ref name="Goldman">Goldman M. (1995) ''Sclerotherapy, Treatment of Varicose and Telangiectatic Leg Veins''. Hardcover Text, 2nd Ed.</ref>{{dubious|date=June 2024}}
* Severe bleeding from minor trauma, of particular concern in the elderly<ref name=":1" />
* [[Coagulation|Blood clotting]] within affected veins, termed [[superficial thrombophlebitis]].<ref name=":1" /> These are frequently isolated to the superficial veins, but can extend into deep veins, becoming a more serious problem.<ref name=":1" />
* Acute fat necrosis can occur, especially at the ankle of overweight people with varicose veins. Females have a higher tendency of being affected than males

== Causes ==
[[File:Varicose veins-en.svg|thumb|upright=1.3|How a varicose vein forms in a leg. Figure A shows a normal vein with a working valve and normal blood flow. Figure B shows a varicose vein with a deformed valve, abnormal blood flow, and thin, stretched walls. The middle image shows where varicose veins might appear in a leg.]]
[[File:Blausen 0891 VaricoseVein.png|thumb|Comparison of healthy and varicose veins]]

Varicose veins are more common in women than in men and are linked with [[heredity]].<ref>{{cite journal | vauthors = Ng MY, Andrew T, Spector TD, Jeffery S | title = Linkage to the FOXC2 region of chromosome 16 for varicose veins in otherwise healthy, unselected sibling pairs | journal = Journal of Medical Genetics | volume = 42 | issue = 3 | pages = 235–239 | date = March 2005 | pmid = 15744037 | pmc = 1736007 | doi = 10.1136/jmg.2004.024075 }}</ref> Other related factors are [[pregnancy]], [[obesity]], [[menopause]], [[Senescence|aging]], prolonged standing, leg injury and abdominal straining. Varicose veins are unlikely to be caused by crossing the legs or ankles.<ref>{{cite web|url=http://www.dukehealth.org/health_library/health_articles/myth-or-fact-crossing-your-legs-causes-varicose-veins|title=Myth or Fact: Crossing Your Legs Causes Varicose Veins| vauthors = Griesmann K |publisher=Duke University Health System|date=March 16, 2011|access-date=March 1, 2014|archive-url=https://web.archive.org/web/20140305174414/http://www.dukehealth.org/health_library/health_articles/myth-or-fact-crossing-your-legs-causes-varicose-veins|archive-date=2014-03-05|url-status=dead}}</ref> Less commonly, but not exceptionally, varicose veins can be due to other causes, such as [[Post-thrombotic syndrome|post-phlebitic obstruction]] or incontinence, venous and arteriovenous malformations.<ref>{{cite book | vauthors = Franceschi C | date = 1996 | chapter = Physiopathologie Hémodynamique de l'Insuffisance veineuse |page = 49 | title = Chirurgie des veines des Membres Inférieurs | series = AERCV editions 23 | location = Paris }}</ref>

[[Chronic venous insufficiency|Venous reflux]] is a significant cause. Research has also shown the importance of pelvic vein reflux (PVR) in the development of varicose veins. Varicose veins in the legs could be due to ovarian vein reflux.<ref>{{cite journal |last1=Hobbs |first1=J. T. |title=Varicose veins arising from the pelvis due to ovarian vein incompetence |journal=International Journal of Clinical Practice |date=14 September 2005 |volume=59 |issue=10 |pages=1195–1203 |doi=10.1111/j.1368-5031.2005.00631.x |pmid=16178988 |doi-access=free }}</ref><ref>{{cite journal | vauthors = Giannoukas AD, Dacie JE, Lumley JS | title = Recurrent varicose veins of both lower limbs due to bilateral ovarian vein incompetence | journal = Annals of Vascular Surgery | volume = 14 | issue = 4 | pages = 397–400 | date = July 2000 | pmid = 10943794 | doi = 10.1007/s100169910075 }}</ref> Both ovarian and internal [[iliac vein]] reflux causes leg varicose veins. This condition affects 14% of women with varicose veins or 20% of women who have had vaginal delivery and have leg varicose veins.<ref>{{cite journal | vauthors = Marsh P, Holdstock J, Harrison C, Smith C, Price BA, Whiteley MS | title = Pelvic vein reflux in female patients with varicose veins: comparison of incidence between a specialist private vein clinic and the vascular department of a National Health Service District General Hospital | journal = Phlebology | volume = 24 | issue = 3 | pages = 108–113 | date = June 2009 | pmid = 19470861 | doi = 10.1258/phleb.2008.008041 }}</ref> In addition, evidence suggests that failing to look for and treat pelvic vein reflux can be a cause of recurrent varicose veins.<ref>{{cite journal | vauthors = Ostler AE, Holdstock JM, Harrison CC, Fernandez-Hart TJ, Whiteley MS | title = Primary avalvular varicose anomalies are a naturally occurring phenomenon that might be misdiagnosed as neovascular tissue in recurrent varicose veins | journal = Journal of Vascular Surgery. Venous and Lymphatic Disorders | volume = 2 | issue = 4 | pages = 390–396 | date = October 2014 | pmid = 26993544 | doi = 10.1016/j.jvsv.2014.05.003 | doi-access = free }}</ref>

There is increasing evidence for the role of incompetent [[perforator vein]]s (or "perforators") in the formation of varicose veins.<ref>{{cite journal | vauthors = Whiteley MS | title = Part one: for the motion. Venous perforator surgery is proven and does reduce recurrences | journal = European Journal of Vascular and Endovascular Surgery | volume = 48 | issue = 3 | pages = 239–242 | date = September 2014 | pmid = 25132056 | doi = 10.1016/j.ejvs.2014.06.044 | doi-access = free }}</ref> and recurrent varicose veins.<ref>{{cite journal | vauthors = Rutherford EE, Kianifard B, Cook SJ, Holdstock JM, Whiteley MS | title = Incompetent perforating veins are associated with recurrent varicose veins | journal = European Journal of Vascular and Endovascular Surgery | volume = 21 | issue = 5 | pages = 458–460 | date = May 2001 | pmid = 11352523 | doi = 10.1053/ejvs.2001.1347 | doi-access = free }}</ref>

Varicose veins could also be caused by [[Hyperhomocysteinemia#Causes|hyperhomocysteinemia]] in the body, which can degrade and inhibit the formation of the three main structural components of the artery: [[collagen]], [[elastin]] and the [[proteoglycans]]. [[Homocysteine]] permanently degrades [[cysteine]] [[disulfide]] bridges and [[lysine]] [[amino acid]] residues in [[proteins]], gradually affecting function and structure. Simply put, homocysteine is a 'corrosive' of long-living proteins, i.e. [[collagen]] or [[elastin]], or lifelong proteins, i.e. [[fibrillin]]. These long-term effects are difficult to establish in clinical trials focusing on groups with existing artery decline. [[Klippel–Trenaunay syndrome]] and [[Parkes Weber syndrome]] are relevant for [[differential diagnosis]].{{citation needed|date=February 2021}}

Another cause is chronic alcohol consumption due to the vasodilatation side effect in relation to gravity and blood viscosity.<ref>{{cite book | veditors = Ayala C, Spellberg B | title = Pathophysiology for the Boards and Wards | edition = 4th| publisher = Lippincott Williams & Wilkins | date = 2009 | isbn = 978-0-7817-8743-7 }}</ref>

== Diagnosis ==

=== Clinical test ===
Clinical tests that may be used include:{{citation needed|date=February 2021}}
* [[Trendelenburg test]] – to determine the site of venous reflux and the nature of the saphenofemoral junction

=== Investigations ===
{{See|Ultrasonography of chronic insufficiency of the legs}}
Traditionally, varicose veins were investigated using imaging techniques only if there was a suspicion of deep venous insufficiency, if they were recurrent, or if they involved the saphenopopliteal junction. This practice is now less widely accepted. People with varicose veins should now be investigated using [[Ultrasonography of chronic insufficiency of the legs|lower limbs venous ultrasonography]]. The results from a [[randomised controlled trial]] on patients with and without routine ultrasound have shown a significant difference in recurrence rate and reoperation rate at 2 and 7 years of follow-up.<ref>{{cite journal | vauthors = Blomgren L, Johansson G, Emanuelsson L, Dahlberg-Åkerman A, Thermaenius P, Bergqvist D | title = Late follow-up of a randomized trial of routine duplex imaging before varicose vein surgery | journal = The British Journal of Surgery | volume = 98 | issue = 8 | pages = 1112–1116 | date = August 2011 | pmid = 21618499 | doi = 10.1002/bjs.7579 | doi-access = free }}</ref>

=== Stages ===
The CEAP (Clinical, Etiological, Anatomical, and Pathophysiological) Classification, developed in 1994 by an international ad hoc committee of the [[American Venous Forum (AVF)|American Venous Forum]], outlines these stages<ref name="pmid24868066">{{cite journal | vauthors = O'Flynn N, Vaughan M, Kelley K | title = Diagnosis and management of varicose veins in the legs: NICE guideline | journal = The British Journal of General Practice | volume = 64 | issue = 623 | pages = 314–315 | date = June 2014 | pmid = 24868066 | pmc = 4032011 | doi = 10.3399/bjgp14X680329 }}</ref><ref name="pmid15622385">{{cite journal | vauthors = Eklöf B, Rutherford RB, Bergan JJ, Carpentier PH, Gloviczki P, Kistner RL, Meissner MH, Moneta GL, Myers K, Padberg FT, Perrin M, Ruckley CV, Smith PC, Wakefield TW | display-authors = 6 | title = Revision of the CEAP classification for chronic venous disorders: consensus statement | journal = Journal of Vascular Surgery | volume = 40 | issue = 6 | pages = 1248–1252 | date = December 2004 | pmid = 15622385 | doi = 10.1016/j.jvs.2004.09.027 | doi-access = free }}</ref>

* C0 – [[Perthes test]] – no visible or palpable signs of venous disease
* C1 – [[telangectasia]] or reticular veins
* C2 – varicose veins
* C2r – recurrent varicose veins
* C3 – edema
* C4 – changes in skin and subcutaneous tissue due to Chronic Venous Disease
* C4a – pigmentation or eczema
* C4b – [[lipodermatosclerosis]] or atrophie blanche
* C4c – Corona phlebectatica
* C5 – healed venous ulcer
* C6 – active venous ulcer
* C6r – recurrent active ulcer

Each clinical class is further characterized by a subscript depending upon whether the patient is symptomatic (S) or asymptomatic (A), e.g. C2S.<ref name="Bailey&Love">{{Cite book | veditors = Williams NS, Bulstrode CJ, O'Connell PR, Bailey H, McNeill Love RJ |title=Bailey & Love's Short Practice of Surgery |edition=26th | date = 2013 | location = London | publisher = Hodder Arnold | isbn = 978-1-4441-2127-8 }}</ref>

== Treatment ==
Treatment can be either active or conservative.

=== Active ===
Treatment options include surgery, [[Laser ablation|laser]] and [[radiofrequency ablation]], and ultrasound-guided foam [[sclerotherapy]].<ref name="Baram_2022" /><ref>{{cite journal | vauthors = Kheirelseid EA, Crowe G, Sehgal R, Liakopoulos D, Bela H, Mulkern E, McDonnell C, O'Donohoe M | display-authors = 6 | title = Systematic review and meta-analysis of randomized controlled trials evaluating long-term outcomes of endovenous management of lower extremity varicose veins | journal = Journal of Vascular Surgery. Venous and Lymphatic Disorders | volume = 6 | issue = 2 | pages = 256–270 | date = March 2018 | pmid = 29292115 | doi = 10.1016/j.jvsv.2017.10.012 }}</ref><ref>{{cite journal | vauthors = Hamann SA, Timmer-de Mik L, Fritschy WM, Kuiters GR, Nijsten TE, van den Bos RR | title = Randomized clinical trial of endovenous laser ablation versus direct and indirect radiofrequency ablation for the treatment of great saphenous varicose veins | journal = The British Journal of Surgery | volume = 106 | issue = 8 | pages = 998–1004 | date = July 2019 | pmid = 31095724 | pmc = 6618092 | doi = 10.1002/bjs.11187 }}</ref> Newer treatments include [[cyanoacrylate]] glue, mechanochemical ablation, and endovenous steam ablation. No real difference could be found between the treatments, except that radiofrequency ablation could have a better long-term benefit.<ref>{{cite journal | vauthors = Whing J, Nandhra S, Nesbitt C, Stansby G | title = Interventions for great saphenous vein incompetence | journal = The Cochrane Database of Systematic Reviews | volume = 2021 | issue = 8 | pages = CD005624 | date = August 2021 | pmid = 34378180 | pmc = 8407488 | doi = 10.1002/14651858.CD005624.pub4 }}</ref>

=== Conservative ===
The [[National Institute for Health and Clinical Excellence]] (NICE) produced clinical guidelines in July 2013 recommending that all people with symptomatic varicose veins (C2S) and worse should be referred to a vascular service for treatment.<ref>{{cite web |url=http://www.nice.org.uk/guidance/cg168/chapter/1-Recommendations |title=Varicose veins in the legs: The diagnosis and management of varicose veins. 1.2 Referral to a vascular service |author=NICE |access-date=August 25, 2014 |date=July 23, 2013 |publisher=[[National Institute for Health and Care Excellence]]}}</ref> Conservative treatments such as support stockings should not be used unless treatment was not possible.

The symptoms of varicose veins can be controlled to an extent with the following:
* Elevating the legs often provides temporary symptomatic relief.
* Advice about regular exercise sounds sensible but is not supported by any evidence.<ref>{{cite journal | vauthors = Campbell B | title = Varicose veins and their management | journal = BMJ | volume = 333 | issue = 7562 | pages = 287–292 | date = August 2006 | pmid = 16888305 | pmc = 1526945 | doi = 10.1136/bmj.333.7562.287 }}</ref>
* The wearing of graduated [[compression stockings]] with variable pressure gradients (Class II or III) has been shown to correct the swelling, increase nutritional exchange, and improve the microcirculation in legs affected by varicose veins.<ref>{{cite conference |vauthors=Curri SB, Annoni F, Pabisch S, et al |title=Changes of cutaneous microcirculation from elasto-compression in chronic venous insufficiency |pages=852–854 |editor1-last=Davy |editor1-first=André |editor2-last=Stemmer |editor2-first=Robert |conference=Phlébologie 89 : actes du 10e Congrès mondial, Union internationale de phlébologie, Strasbourg, 25-29 septembre 1989 |date=1989 |publisher=Libbey Eurotext |isbn=978-0-86196-216-7 |oclc=22812590 }}</ref> They also often provide relief from the discomfort associated with this disease. Caution should be exercised in their use in patients with concurrent [[peripheral arterial disease]].
* The wearing of [[intermittent pneumatic compression]] devices has been shown to reduce swelling and pain.<ref name="Yamany Hamdy 2021 p.">{{cite journal | vauthors = Yamany A, Hamdy B | title = Effect of sequential pneumatic compression therapy on venous blood velocity, refilling time, pain and quality of life in women with varicose veins: a randomized control study | journal = Journal of Physical Therapy Science | volume = 28 | issue = 7 | pages = 1981–1987 | date = July 2016 | pmid = 27512247 | pmc = 4968489 | doi = 10.1589/jpts.28.1981 }}</ref>
* [[Diosmin]]/[[hesperidin]] and other [[flavonoid]]s.
* Anti-inflammatory medication such as [[ibuprofen]] or [[aspirin]] can be used as part of treatment for superficial thrombophlebitis along with graduated compression hosiery – but there is a risk of intestinal bleeding. In extensive superficial thrombophlebitis, consideration should be given to anti-coagulation, thrombectomy, or sclerotherapy of the involved vein.{{medical citation needed|date=May 2013}}
* [[Topical gels|Topical gel]] application{{vague|date=November 2017}} helps in managing symptoms related to varicose veins such as inflammation, pain, swelling, itching, and dryness.

=== Procedures ===
==== Stripping ====
Stripping consists of removal of all or part the saphenous vein ([[Great saphenous vein|great/long]] or [[Small saphenous vein|lesser/short]]) main trunk. The complications include [[deep vein thrombosis]] (5.3%),<ref>{{cite journal | vauthors = van Rij AM, Chai J, Hill GB, Christie RA | title = Incidence of deep vein thrombosis after varicose vein surgery | journal = The British Journal of Surgery | volume = 91 | issue = 12 | pages = 1582–1585 | date = December 2004 | pmid = 15386324 | doi = 10.1002/bjs.4701 | doi-access = free }}</ref> [[pulmonary embolism]] (0.06%), and wound complications including infection (2.2%). There is evidence for the [[great saphenous vein]] regrowing after stripping.<ref>{{cite journal | vauthors = Munasinghe A, Smith C, Kianifard B, Price BA, Holdstock JM, Whiteley MS | title = Strip-track revascularization after stripping of the great saphenous vein | journal = The British Journal of Surgery | volume = 94 | issue = 7 | pages = 840–843 | date = July 2007 | pmid = 17410557 | doi = 10.1002/bjs.5598 | doi-access = free }}</ref> For traditional surgery, reported recurrence rates, which have been tracked for 10 years, range from 5% to 60%. In addition, since stripping removes the saphenous main trunks, they are no longer available for use as venous bypass grafts in the future (coronary or leg artery vital disease).<ref>{{cite journal | vauthors = Hammarsten J, Pedersen P, Cederlund CG, Campanello M | title = Long saphenous vein saving surgery for varicose veins. A long-term follow-up | journal = European Journal of Vascular Surgery | volume = 4 | issue = 4 | pages = 361–364 | date = August 1990 | pmid = 2204548 | doi = 10.1016/S0950-821X(05)80867-9 }}</ref>

==== Other ====
Other surgical treatments are:
* [[CHIVA method]] (ambulatory conservative haemodynamic correction of venous insufficiency) is a relatively low-invasive surgical technique that incorporates venous hemodynamics and preserves the superficial venous system.<ref name=":2">{{cite journal | vauthors = Bellmunt-Montoya S, Escribano JM, Pantoja Bustillos PE, Tello-Díaz C, Martinez-Zapata MJ | title = CHIVA method for the treatment of chronic venous insufficiency | journal = The Cochrane Database of Systematic Reviews | volume = 2021 | issue = 9 | pages = CD009648 | date = September 2021 | pmid = 34590305 | pmc = 8481765 | doi = 10.1002/14651858.CD009648.pub4 }}</ref> The overall effectiveness compared to stripping, radiofrequency ablation treatment, or endovenous laser therapy is not clear and there is no strong evidence to suggest that CHIVA is superior to stripping, radiofrequency ablation, or endovenous laser therapy for recurrence of varicose veins.<ref name=":2" /> There is some low-certainty evidence that CHIVA may result in more bruising compared to radiofrequency ablation treatment.<ref name=":2" />
* Vein ligation is done at the saphenofemoral junction after ligating the tributaries at the saphenofemoral junction without stripping the long saphenous vein, provided the perforator veins are competent and DVT is absent in the deep veins. With this method, the long saphenous vein is preserved.
* [[Cryosurgery]] – A cryoprobe is passed down the long saphenous vein following saphenofemoral ligation. The probe is then cooled with NO<sub>2</sub> or CO<sub>2</sub> to −85°F. The vein freezes to the probe and can be retrogradely stripped after 5 seconds of freezing. It is a variant of stripping. The only purpose of this technique is to avoid a distal incision to remove the stripper.<ref>{{cite journal | vauthors = Schouten R, Mollen RM, Kuijpers HC | title = A comparison between cryosurgery and conventional stripping in varicose vein surgery: perioperative features and complications | journal = Annals of Vascular Surgery | volume = 20 | issue = 3 | pages = 306–311 | date = May 2006 | pmid = 16779510 | doi = 10.1007/s10016-006-9051-x }}</ref>

==== Sclerotherapy ====
A commonly performed non-surgical treatment for varicose and "spider leg veins" is [[sclerotherapy]], in which medicine called a sclerosant is injected into the veins to make them shrink. The medicines that are commonly used as sclerosants are [[polidocanol]] (POL branded Asclera in the United States, Aethoxysklerol in Australia), sodium tetradecyl sulphate (STS), Sclerodex (Canada), hypertonic saline, [[Glycerol|glycerin]] and chromated glycerin. STS (branded Fibrovein in Australia) liquids can be mixed at varying concentrations of sclerosant and varying sclerosant/gas proportions, with air or CO<sub>2</sub> or O<sub>2</sub> to create foams. Foams may allow more veins to be treated per session with comparable efficacy. Their use in contrast to liquid sclerosant is still somewhat controversial{{Medical citation needed|date=April 2022}}, and there is no clear evidence that foams are superior.<ref name="CD001732">{{cite journal | vauthors = de Ávila Oliveira R, Riera R, Vasconcelos V, Baptista-Silva JC | title = Injection sclerotherapy for varicose veins | journal = The Cochrane Database of Systematic Reviews | volume = 2021 | issue = 12 | pages = CD001732 | date = December 2021 | pmid = 34883526 | pmc = 8660237 | doi = 10.1002/14651858.CD001732.pub3 }}</ref> Sclerotherapy has been used in the treatment of varicose veins for over 150 years.<ref name="Goldman" /> Sclerotherapy is often used for telangiectasias (spider veins) and varicose veins that persist or recur after vein stripping.<ref>Pak, L. K. et al. "Veins & Lymphatics," ''in'' Lange's ''Current Surgical Diagnosis & Treatment'', 11th ed., McGraw-Hill.{{page?|date=November 2023}}</ref><ref>{{Cite journal |last1=de Ávila Oliveira |first1=Ricardo |last2=Riera |first2=Rachel |last3=Vasconcelos |first3=Vladimir |last4=Baptista-Silva |first4=Jose Cc |date=2021-12-10 |title=Injection sclerotherapy for varicose veins |journal=The Cochrane Database of Systematic Reviews |volume=2021 |issue=12 |pages=CD001732 |doi=10.1002/14651858.CD001732.pub3 |pmc=8660237 |pmid=34883526}}</ref> Sclerotherapy can also be performed using foamed sclerosants under ultrasound guidance to treat larger varicose veins, including the great saphenous and small saphenous veins.<ref>{{cite book | vauthors = Thibault P | date = 2007 | chapter = Sclerotherapy and Ultrasound-Guided Sclerotherapy | title = The Vein Book | pages = 189–199 | veditors = Bergan JJ | doi = 10.1016/B978-012369515-4/50023-5 | isbn = 978-0-12-369515-4 }}</ref><ref>{{cite journal|vauthors=Padbury A, Benveniste GL |title=Foam echo sclerotherapy of the small saphenous vein|journal= Australian and New Zealand Journal of Phlebology|volume=8|issue=1|date=December 2004}}</ref>

There is some evidence that sclerotherapy is a safe and possibly effective treatment option for improving the cosmetic appearance, reducing residual varicose veins, improving the quality of life, and reducing symptoms that may be present due to the varicose veins.<ref name="CD001732" /> There is also weak evidence that this treatment option may have a slightly higher risk of deep vein thrombosis. It is not known if sclerotherapy decreases the chance of varicose veins returning (recurrent varicose veins).<ref name="CD001732" /> It is also not known which type of substance (liquid or foam) used for the sclerotherapy procedure is more effective and comes with the lowest risk of complications.<ref name="CD001732" />

Complications of sclerotherapy are rare, but can include blood clots and ulceration. [[Anaphylaxis|Anaphylactic]] reactions are "extraordinarily rare but can be life-threatening," and doctors should have resuscitation equipment ready.<ref>Finkelmeier, William R. (2004) "Sclerotherapy", Ch. 12 in ''ACS Surgery: Principles & Practice'', WebMD, {{ISBN|0-9748327-4-X}}.</ref><ref>{{cite journal |vauthors=Scurr JR, Fisher RK, Wallace SB |title=Anaphylaxis Following Foam Sclerotherapy: A Life Threatening Complication of Non Invasive Treatment For Varicose Veins |journal=EJVES Extra |volume=13 |issue=6 |pages=87–89 |year=2007|doi=10.1016/j.ejvsextra.2007.02.005|doi-access=free }}</ref> There has been one reported case of [[stroke]] after ultrasound-guided sclerotherapy when an unusually large dose of sclerosant foam was injected.<ref>{{cite journal |last1=Forlee |first1=Martin V. |last2=Grouden |first2=Maria |last3=Moore |first3=Dermot J. |last4=Shanik |first4=Gregor |title=Stroke after varicose vein foam injection sclerotherapy |journal=Journal of Vascular Surgery |date=January 2006 |volume=43 |issue=1 |pages=162–164 |doi=10.1016/j.jvs.2005.09.032 |pmid=16414404 |url=https://www.jvascsurg.org/article/S0741-5214(05)01704-0/fulltext |access-date=8 October 2024}}</ref>

==== {{anchor|ETA}} Endovenous thermal ablation ====

There are three kinds of endovenous thermal ablation treatment possible: laser, radiofrequency, and steam.<ref>{{cite journal | vauthors = Malskat WS, Stokbroekx MA, van der Geld CW, Nijsten TE, van den Bos RR | title = Temperature profiles of 980- and 1,470-nm endovenous laser ablation, endovenous radiofrequency ablation and endovenous steam ablation | journal = Lasers in Medical Science | volume = 29 | issue = 2 | pages = 423–429 | date = March 2014 | pmid = 24292197 | doi = 10.1007/s10103-013-1449-4 }}</ref>

The Australian Medical Services Advisory Committee (MSAC) in 2008 determined that [[endovenous laser treatment]]/ablation (ELA) for varicose veins "appears to be more effective in the short term, and at least as effective overall, as the comparative procedure of junction ligation and vein stripping for the treatment of varicose veins."<ref>Medical Services Advisory Committee, [http://www.msac.gov.au/internet/msac/publishing.nsf/Content/7CAA933675966F4DCA25801000123B62/$File/1113-Assessment-Report.pdf ELA for varicose veins]. MSAC application 1113, Dept of Health and Ageing, Commonwealth of Australia, 2008.</ref> It also found in its assessment of available literature, that "occurrence rates of more severe complications such as DVT, nerve injury, and paraesthesia, post-operative infections, and haematomas, appears to be greater after ligation and stripping than after EVLT". Complications for ELA include minor skin burns (0.4%)<ref name="Elmore">{{cite journal | vauthors = Elmore FA, Lackey D | title = Effectiveness of endovenous laser treatment in eliminating superficial venous reflux | journal = Phlebology | volume = 23 | issue = 1 | pages = 21–31 | year = 2008 | pmid = 18361266 | doi = 10.1258/phleb.2007.007019 }}</ref> and temporary [[paresthesia]] (2.1%). The longest study of endovenous laser ablation is 39 months.<ref>{{Cite web|last=Publishing|first=BIBA|date=2007-02-13|title=What is the best treatment for varicose veins?|url=https://vascularnews.com/what-is-the-best-treatment-for-varicose-veins/|access-date=2021-08-31|website=Vascular News|language=en-GB}}</ref>

Two prospective randomized trials found speedier recovery and fewer complications after radiofrequency ablation (ERA) compared to open surgery.<ref>{{cite journal | vauthors = Rautio TT, Perälä JM, Wiik HT, Juvonen TS, Haukipuro KA | title = Endovenous obliteration with radiofrequency-resistive heating for greater saphenous vein insufficiency: a feasibility study | journal = Journal of Vascular and Interventional Radiology | volume = 13 | issue = 6 | pages = 569–575 | date = June 2002 | pmid = 12050296 | doi = 10.1016/S1051-0443(07)61649-2 }}</ref><ref>{{cite journal | vauthors = Lurie F, Creton D, Eklof B, Kabnick LS, Kistner RL, Pichot O, Sessa C, Schuller-Petrovic S | display-authors = 6 | title = Prospective randomised study of endovenous radiofrequency obliteration (closure) versus ligation and vein stripping (EVOLVeS): two-year follow-up | journal = European Journal of Vascular and Endovascular Surgery | volume = 29 | issue = 1 | pages = 67–73 | date = January 2005 | pmid = 15570274 | doi = 10.1016/j.ejvs.2004.09.019 | doi-access = free }}</ref> Myers<ref>{{cite journal| vauthors = Myers K |title=An opinion – surgery for small saphenous reflux is obsolete!|journal= Australian and New Zealand Journal of Phlebology|volume=8|issue=1|date=December 2004}}</ref> wrote that open surgery for [[small saphenous vein]] reflux is obsolete. Myers said these veins should be treated with endovenous techniques, citing high recurrence rates after surgical management, and risk of nerve damage up to 15%. By comparison ERA has been shown to control 80% of cases of small saphenous vein reflux at 4 years, said Myers. Complications for ERA include burns, paraesthesia, clinical [[phlebitis]] and slightly higher rates of [[deep vein thrombosis]] (0.57%) and [[pulmonary embolism]] (0.17%). One 3-year study compared ERA, with a recurrence rate of 33%, to open surgery, which had a recurrence rate of 23%.{{citation needed|date=February 2021}}

Steam treatment consists in injection of pulses of steam into the sick vein. This treatment which works with a natural agent (water) has results similar to laser or radiofrequency.<ref>{{cite journal | vauthors = van den Bos RR, Malskat WS, De Maeseneer MG, de Roos KP, Groeneweg DA, Kockaert MA, Neumann HA, Nijsten T | display-authors = 6 | title = Randomized clinical trial of endovenous laser ablation versus steam ablation (LAST trial) for great saphenous varicose veins | journal = The British Journal of Surgery | volume = 101 | issue = 9 | pages = 1077–1083 | date = August 2014 | pmid = 24981585 | doi = 10.1002/bjs.9580 | doi-access = free }}</ref> The steam presents a lot of post-operative advantages for the patient (good aesthetic results, less pain, etc.)<ref>{{cite journal| vauthors = Milleret R |title=Obliteration of varicose veins with superheated steam |journal= Phlebolymphology |date=2011 |volume=19 |issue=4 |pages=174–181}}</ref> Steam is a very promising treatment for both doctors (easy introduction of catheters, efficient on recurrences, ambulatory procedure, easy and economic procedure) and patients (less post-operative pain, a natural agent, fast recovery to daily activities).<ref>{{cite journal | vauthors = Woźniak W, Mlosek RK, Ciostek P | title = Assessment of the efficacy and safety of steam vein sclerosis as compared to classic surgery in lower extremity varicose vein management | language = english | journal = Wideochirurgia I Inne Techniki Maloinwazyjne = Videosurgery and Other Miniinvasive Techniques | volume = 10 | issue = 1 | pages = 15–24 | date = April 2015 | pmid = 25960788 | pmc = 4414100 | doi = 10.5114/wiitm.2015.48573 }}</ref>

ELA and ERA require specialized training for doctors and special equipment. ELA is performed as an outpatient procedure and does not require an operating theatre, nor does the patient need a [[general anaesthetic]]. Doctors use high-frequency ultrasound during the procedure to visualize the anatomical relationships between the saphenous structures.{{citation needed|date=February 2021}}

Some practitioners also perform phlebectomy or ultrasound-guided sclerotherapy at the time of endovenous treatment. This is also known as an [[ambulatory phlebectomy]]. The distal veins are removed following the complete ablation of the proximal vein. This treatment is most commonly used for varicose veins off of the great saphenous vein, small saphenous vein, and pudendal veins.<ref>{{cite book |doi=10.1016/B978-012369515-4/50030-2 |chapter=Principles of Ambulatory Phlebectomy |title=The Vein Book |date=2007 |last1=Almeida |first1=Jose I. |last2=Raines |first2=Jeffrey K. |pages=247–255 |isbn=978-0-12-369515-4 }}</ref> Follow-up treatment to smaller branch varicose veins is often needed in the weeks or months after the initial procedure.

==== Medical Adhesive ====
Also called medical super glue, medical adhesive is an advanced non-surgical treatment for varicose veins during which a solution is injected into the diseased vein through a small catheter and under the assistance of ultrasound-guided imagery. The "super glue" solution is made of cyanoacrylate, aiming at sealing the vein and rerouting the blood flow to other healthy veins.<ref>{{Cite web| vauthors = Yazdani N |date=2021|title=Medical Adhesive Closure|url=https://www.melbournevein.com.au/treatments/medical-adhesive-closure/|website=Melbourne Varicose Veins}}</ref>

Post-treatment, the body will naturally absorb the treated vein which will disappear. Involving only a small incision and no hospital stay, medical super glue has generated great interest within the last years, with a success rate of about 96.8%.<ref>{{Cite web| vauthors = Yassine Z |date=2021|title=Medical Super Glue|url=https://www.theveininstitute.com.au/medical-superglue-venaseal/|website=The Vein Institute}}</ref>

A follow-up consultation is required after this treatment, just like any other one, in order to re-assess the diseased vein and further treat it if needed.{{citation needed|date=October 2021}}

==== Echotherapy Treatment ====
In the field of varicose veins, the latest medical innovation is high-intensity focused ultrasound therapy ([[High-intensity focused ultrasound|HIFU]]). This method is completely non-invasive and is not necessarily performed in an operating room, unlike existing techniques. This is because the procedure involves treating from outside the body, able to penetrate the skin without damage, to treat the veins in a targeted area.<ref>{{Cite news |last=Chollet |first=Daniel |date=12 October 2022 |title=ULTRasOns. au diable les varices |pages=28 |work=le Régional L'écho}}</ref> This leaves no scars and allows the patient to return to their daily life immediately.

==Epidemiology==
Varicose veins are most common after age 50.<ref>{{Cite book|title=Diseases of the Human Body| vauthors = Tamparo C |publisher=F.A. Davis Company|year=2011|edition=5th|isbn=978-0-8036-2505-1|location=Philadelphia, PA|pages=335}}</ref> It is more prevalent in females.<ref>{{cite web |title=Varicose Veins – How to Prevent Them in Time? |url=https://vitalmarket.si/vse-o-glukozaminu/ |access-date=11 March 2017 |language=SL}}</ref> There is a hereditary role. It has been seen in smokers, those who have [[Constipation|chronic constipation]], and in people with occupations which necessitate long periods of standing such as wait staff, nurses, conductors (musical and bus), stage actors, umpires (cricket, javelin, etc.), the King's guards, lectern orators, security guards, traffic police officers, vendors, surgeons, etc.<ref name="Bailey&Love" />

== References ==
{{reflist}}

== External links ==
* {{Commons category-inline}}

{{Medical resources
|  DiseasesDB     = 13734
|  ICD10          = {{ICD10|I|83||i|80}}, {{ICD10|I|85||i|80}}, {{ICD10|I|86||i|80}}, {{ICD10|K64}}, {{ICD10|O22.0}}, {{ICD10|O22.1}}, {{ICD10|O22.4}}, {{ICD10|O87.2}}, {{ICD10|O43.8}}, {{ICD10|O87.8}}, {{ICD10|P02.6}}, {{ICD10|Q27.8}}
|  ICD9           = {{ICD9|454}}-{{ICD9|456}}, {{ICD9|671}}
|  ICDO           =
|  OMIM           = 192200
|  MedlinePlus    = 001109
|  eMedicineSubj  = med
|  eMedicineTopic = 2788
|  MeshID         = D014648
}}

{{Vascular diseases}}
{{Authority control}}

[[Category:Vascular surgery]]
[[Category:Medical conditions related to obesity]]
[[Category:Diseases of veins, lymphatic vessels and lymph nodes]]
[[Category:External signs of ageing]]
[[Category:Wikipedia medicine articles ready to translate]]