Note 04
Chronic Venous Disease and Varicose Veins: An Evidence-Based Review
Introduction
Chronic venous disease (CVD) is one of the most common conditions encountered in vascular surgical practice, affecting up to 25–30% of adults and imposing a significant socioeconomic burden through reduced quality of life, loss of productivity, recurrent healthcare utilization, and chronic wound care.
Varicose veins represent the most visible manifestation of superficial venous insufficiency but should be viewed as part of a spectrum of chronic venous disease rather than an isolated cosmetic problem.
The vascular trainee should understand that modern management has shifted from traditional vein stripping towards minimally invasive endovenous interventions supported by robust randomized evidence and international guideline recommendations.
Epidemiology
Population studies demonstrate:
* Varicose veins affect approximately 20–30% of adults.
* Chronic venous insufficiency affects 5–15% of adults.
* Venous ulceration affects approximately 1–2% of the population during their lifetime.
* Women are affected more frequently than men.
* Incidence increases with age.
Major risk factors include:
* Increasing age
* Family history
* Obesity
* Pregnancy
* Occupations involving prolonged standing
* Previous deep vein thrombosis
* Reduced mobility
Pathophysiology
The primary pathological process is:
Venous Valve Failure
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Venous Reflux
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Ambulatory Venous Hypertension
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Microcirculatory Dysfunction
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Inflammation
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Tissue Damage
The visible varicosity is therefore a consequence rather than the primary disease process.
Mechanisms of Tissue Injury
Persistent venous hypertension results in:
* Endothelial activation
* Leukocyte trapping
* Inflammatory mediator release
* Increased capillary permeability
* Tissue edema
* Microvascular ischemia
Over time this progresses to:
* Hyperpigmentation
* Venous eczema
* Lipodermatosclerosis
* Atrophie blanche
* Venous ulceration
Clinical Classification
The CEAP Classification remains the international standard.
Clinical (C)
C0 – No visible disease
C1 – Telangiectasia / reticular veins
C2 – Varicose veins
C3 – Edema
C4a – Pigmentation / eczema
C4b – Lipodermatosclerosis / atrophie blanche
C5 – Healed ulcer
C6 – Active ulcer
All patients undergoing intervention should have CEAP classification documented.
Clinical Assessment
History
Symptoms include:
* Heaviness
* Aching
* Swelling
* Pruritus
* Night cramps
* Restlessness
* Skin changes
* Ulceration
History should also assess:
* Previous DVT
* Superficial thrombophlebitis
* Prior venous interventions
* Family history
* Pregnancy history
Physical Examination
Assess:
* Distribution of varicosities
* Edema
* Skin changes
* Lipodermatosclerosis
* Ulceration
* Arterial perfusion
Peripheral pulses must always be assessed before recommending compression therapy.
Duplex Ultrasound
Gold Standard Investigation
Current ESVS, SVS, and NICE guidelines strongly recommend duplex ultrasound mapping before intervention.
Objectives:
* Identify source of reflux
* Assess GSV
* Assess SSV
* Assess accessory veins
* Assess perforators
* Evaluate deep venous system
* Exclude DVT
A treatment plan should never be based solely on clinical appearance.
Evidence-Based Treatment
1.Compression Therapy
Compression remains fundamental in the management of:
* Venous edema
* Venous ulceration
* Patients unsuitable for intervention
However:
Compression does not correct reflux.
It improves symptoms and reduces venous hypertension but does not eliminate the underlying pathology.
2.Endovenous Thermal Ablation
Current First-Line Therapy
According to:
* ESVS 2022 Guidelines
* SVS/AVF Guidelines
* NICE CG168
Endovenous thermal ablation is recommended as first-line treatment for truncal venous reflux whenever anatomy permits.
Endovenous Laser Ablation (EVLA)
Mechanism:
Thermal destruction of the vein wall
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Fibrosis
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Permanent occlusion
Evidence
Multiple randomized controlled trials have demonstrated:
* Occlusion rates >90–95%
* Significant improvement in quality of life
* Faster recovery than surgery
* Less postoperative morbidity
Five-year outcomes from major trials consistently demonstrate durable vein closure and symptom improvement.
Radiofrequency Ablation (RFA)
Mechanism:
Controlled thermal energy delivery.
Evidence demonstrates:
* Similar efficacy to EVLA
* Comparable long-term occlusion rates
* Less postoperative pain in some studies
Current guidelines consider EVLA and RFA equally acceptable first-line treatments.
3.Ultrasound-Guided Foam Sclerotherapy
Particularly useful for:
* Tributaries
* Recurrent veins
* Selected truncal reflux
* Patients unsuitable for thermal ablation
Advantages:
* Office-based procedure
* No anesthesia required
Limitations:
* Higher recurrence rates
* More frequent reinterventions
4.What Happened to Vein Stripping?
Historically:
High Ligation + Stripping was the gold standard.
However, randomized trials have shown:
* Similar long-term efficacy
* Increased postoperative pain
* Longer recovery
* More wound complications
Consequently, surgery has become a second-line option in many centers.
Nevertheless, surgery remains valuable in:
* Extremely tortuous veins
* Large aneurysmal segments
* Recurrent disease
* Unsuitable anatomy
Venous Ulcers
The EVRA Trial
One of the most important studies in modern venous practice.
The Early Venous Reflux Ablation (EVRA) Trial demonstrated:
Early intervention plus compression
compared with
Compression alone
resulted in:
* Faster ulcer healing
* Longer ulcer-free survival
* Improved quality of life
Median ulcer healing:
Approximately 56 days with early intervention versus 82 days with deferred intervention.
This trial fundamentally changed ulcer management worldwide.
Recurrence
Recurrence may occur because of:
* Neovascularization
* Disease progression
* Untreated reflux sources
* Inadequate preoperative mapping
Good duplex planning remains the most effective method of reducing recurrence.
Common Errors
Treating visible veins without identifying reflux source
Ignoring deep venous pathology
Failure to assess arterial circulation
Inadequate duplex mapping
Treating venous ulcers as wound problems alone
Overlooking perforator disease
Current Guideline-Based Treatment Algorithm
Symptomatic truncal reflux
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Duplex confirmation
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EVLA or RFA (preferred)
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Foam sclerotherapy (selected cases)
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Surgery when endovenous treatment unsuitable
Compression therapy remains adjunctive throughout the treatment pathway.
Take-Home Message
The most important question in venous surgery is not:
“Where is the varicose vein?”
The most important question is:
“Where is the source of reflux?”
If the source of reflux is not identified and treated appropriately, recurrence is not a complication,it is an expected outcome.
Understanding venous hemodynamics, meticulous duplex mapping, and adherence to evidence-based treatment strategies remain the foundations of successful modern venous practice.
