Varicose Veins: Diagnosis, Management, and Treatment

Sylvia Zhang, RN; Sheila Melander, PhD, ACNP-BC

Disclosures

Journal for Nurse Practitioners. 2014;10(6):417-424. 

In This Article

Treatment

Varicose veins may be asymptomatic and may only be of cosmetic concern to some patients. However, treatment may be indicated for patients who are symptomatic. The management of varicose veins includes the use of conservative care, such as with lifestyle changes and compression therapy, and the use of more invasive treatments, such as surgery, endovenous thermal ablation, and sclerotherapy. The NP's role in the management of patients with varicose veins will play a larger role in conservative management, especially in education of patients, whereas more invasive treatments will require referrals to specialists who have the qualifications to perform the invasive procedures.

Conservative Management

Lifestyle Changes. Patients who have varicose veins can manage and prevent symptoms with the use of lifestyle changes, and the NP's role in patients' education is paramount in helping patients understand the importance of lifestyle changes. Education should be given regarding daily skin care, the types of clothing to avoid, the need to elevate the legs, and the need for lower extremity exercises. Recommended daily skin care should involve the use of a mild soap and lukewarm water followed by the application of a petrolatum-based moisturizer.[13] Patients should also be educated on the need to avoid wearing constrictive clothing, such as knee-high or panty hose stockings, that can restrict the flow of blood in the lower extremities.[13] The NP should educate patients on the need to elevate the legs above the level of the heart for about 30 minutes 4 times each day.[13] Patients can be told to avoid having the legs in the dependent position for prolonged periods of time to avoid the pooling of blood in the legs.[13] The NP should also teach the patient about different leg exercises that can be performed to aid the calf muscles in the return of blood to the heart. Leg exercises that can be done include walking (slightly uphill if possible), tiptoe movements that involve standing and rising up on the tips of the toes while holding onto a bar or other form of support, and dorsiflexion and plantar flexion of the feet several times each day.[13] Patients can also be educated on the use of compression stockings to help with blood return from the legs to the heart.

Compression Therapy. Compression therapy is often considered the first-line treatment and is the most frequently used treatment for varicose veins and its associated complications, including venous edema and leg swelling, skin changes, and ulcerations.[14] Compression therapy involves wearing elastic compression stockings, multilayer elastic wraps, paste gauze boots, elastic and nonelastic bandages, nonelastic garments, or dressings.[3] Gloviczki et al[3] argues that compression treatment compensates for the increased venous pressure of the lower limbs during ambulation. Compression stockings have been shown to be effective in managing varicose veins symptoms, including pain, skin hyperpigmentation, and edema.[3,14] However, data from a recent systematic review[15] regarding whether compression therapy is effective in slowing the progression of varicose veins or preventing their recurrence were inconclusive. Moreover, Palfreyman and Michaels[15] also note in their review that many of the patients were noncompliant and reluctant to wear the compression stockings for various reasons, including that the stockings are not effective, they are too tight, or they make the patients feel too hot. Besides discomfort, badly fitting compression stockings can also lead to more severe complications, including pressure necrosis, inadequate perfusion of the lower limb, and the need for amputation, especially if there is already arterial disease in the leg.[15] Therefore, careful assessment is required for choosing the correct size of compression stockings, and only those with proper training should prescribe stockings for patients. At this time, the Society for Vascular Surgery and the American Venous Forum recommend compression therapy with at least knee-high stockings for patients presenting with simple varicose veins.[3] Conservative management that includes lifestyle changes related to weight loss and the elevation of the legs may also be included along with compression therapy.[3] Patients should also be educated on the importance of putting the compression stockings on before getting out of bed and the importance of wearing the stockings when ambulatory.[13]

Invasive Treatment

Open Venous Surgery. For patients in whom compression therapy does not resolve the varicose veins symptoms, open surgical treatment of venous abnormalities remains the standard of care and involves ligation, division, and stripping of the affected superficial vein. Surgical treatment of varicose veins can be performed under tumescent local anesthesia and aims to interrupt the reflux at the proximal and distal points of insufficiency and to remove any abnormal venous segments affected by incompetent valves.[16] In open surgical treatment for varicosities in the GSV, ligation and division occurs where the GSV conjoins with the common femoral vein, whereas varicosities in the SSV are ligated and divided about 3 to 5 cm below the saphenopopliteal junction to avoid damaging the sural, or short saphenous, nerve.[3,16] The abnormal venous segment is then resected, stripped, and pulled down through a small incision made below the knee for the GSV and in the popliteal crease for the SSV.[3,16]

Complications resulting from surgical treatment occur in less than 2% of cases, with the most commonly reported side effects being postoperative bleeding, hematomas, and wound infection at the incision site.[16,17] However, in other studies, wound complications were found to be as high as 3% to 10%.[2,18] The recurrence of varicose veins at 2 years after surgical treatment has been reported at rates between 6.6% and 37% and has been attributed to technical errors (eg, the GSV breaking during stripping), tactical errors (eg, misjudging the location of the reflux), neovascularization, and the progression of venous disease.[3,19] In another updated review,[20] surgical treatment is still reported to have better long-term outcomes compared with newer treatments, such as endovenous ablations and sclerotherapy. Contraindications for elective varicose vein surgery are acute DVT and pelvic vein thrombosis.[5,16] All patients should receive a thorough risk assessment before surgical treatment. Patients with 1 or more risk factors for developing DVTs should receive mechanical prophylaxis and low-molecular-weight heparin before surgery.[18] Surgical treatment can then be considered when the patient is more stable.

Endovenous Thermal Ablations. Endovenous thermal ablations are relatively new procedures and include endovenous laser therapy (EVLT) and radiofrequency ablation (RFA). EVLT involves the use of a laser light to generate the intense thermal energy needed to ablate the vein, whereas RFA uses an electric current to generate the thermal energy needed.[21] There are several advantages of ablation procedures over surgical treatment, including less pain and discomfort and the ability to resume normal activity and return to work earlier.[3] Both types of endovenous thermal ablations are also performed under tumescent local anesthesia and involve the placement of a percutaneous catheter in the affected vein while being guided by ultrasonography.[3,6,21] The abnormal venous segment is treated by occluding (ie, ablating) it through the delivery of heat (ie, thermal energy) with a percutaneously placed laser fiber in EVLT and a radiofrequency catheter in RFA, resulting in endothelium destruction and fibrotic occlusion of the vein in both.[3] After the procedures, an elastic compression stocking is placed on the affected leg for at least 1 week, and early ambulation is encouraged.[3]

A duplex scan is performed before the procedure and 1 week after the procedure to evaluate the lower limbs for the existence of any deep vein occlusions.[6] Although there are no absolute contraindications to ablation procedures, patients with DVTs may require thrombosis prophylaxis and should proceed with EVLT selectively because of the possible importance of their superficial venous system for venous outflow from the lower limbs.[3] Reported complications from EVLT include the development of DVTs, superficial thrombophlebitis, bruising, skin burns, and pigmentation.[21] However, in an updated study,[6] positive outcomes and satisfaction with results reported at 2 years have been as high as 95% with an absence of reflux at 83.8% at 5-year follow-ups for RFA and between 77% and 100% for EVLT. In a recent study,[22] patients who underwent RFA reported less pain, increased quality of life, more satisfaction, and a shorter recovery period when compared with those who underwent surgical treatment. However, 1 study comparing EVLT with surgical treatment found no difference in the reflux and varicose vein recurrence rates for primary varicose veins.[19]

Sclerotherapy. Sclerotherapy can be performed as an outpatient procedure and involves injecting a chemical, either liquid or foamed, into the abnormal vein in order to destroy the endothelium and induce fibrotic obstruction of the vein and may also be performed under ultrasonography.[3,23] Sclerosing agents used include sodium tetradecyl sulfate and polidocanol.[6] Complications reported from sclerotherapy are rare and include pigmentation, pain, an allergic reaction to the sclerosing agent, itching of the skin, thrombophlebitis, nerve damage, DVTs, and skin necrosis.[3] When compared with surgical treatment and endovenous thermal ablations, sclerotherapy outcomes are similar to those produced by ablations. Murad et al[20] reported that sclerotherapy yielded better short-term outcomes and is associated with less pain and a faster recovery period. In 2010, Nael and Rathbun[23] found that 99% of the patients treated with foam sclerotherapy experienced complete or near complete elimination of their varicose veins after the first injection and that 93% of the patients experienced symptom relief. However, another more recent study in 2011 also reported recurrence rates as high as 64% at the 5-year follow-up.[6]

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