Varicose veins are large, dilated, tortuous, elongated superficial veins exhibiting reflux or retrograde flow as a result of valvular incompetence, weakness of the venous walls, or increased intraluminal pressure. They occur in 10% to 20% of the population, most commonly in the greater and lesser saphenous veins and their tributaries in the legs. Varicose veins may appear at any age, but the peak incidence is between 50 and 60 years of age. Varicose veins must be distinguished from spider veins or telangiectases, which are tiny, dilated, superficial veins visible on the skin surface.

Primary varicose veins result from intrinsic weakness in the walls of the veins coupled with incompetent, perforating veins; 50% of these cases are familial (genetic). Secondary varicose veins are most often caused by post-thrombotic deep venous insufficiency and the resulting diversion of flow into superficial collateral vessels. They may also arise from superficial thrombosis. Less often, they are caused by arteriovenous fistulas.

• Primary varicose veins
• Family history of varicose veins (50%)
• Female gender (three times more common in women)
• Pregnancy
• Occupations requiring prolonged standing
• Obesity
• Secondary varicose veins
• Proximal obstructing lesions (e.g., tumor)
• Conditions predisposing to deep venous thrombosis, such as surgery or immobilization, hereditary thrombophilia (e.g., protein C or S deficiency, factor V Leiden), acquired thrombophilia (e.g., malignancy), trauma, and arteriovenous fistulas

Primary varicose veins are often asymptomatic, causing only cosmetic concerns. Secondary varicose veins are more likely than primary varicose veins to be accompanied by the following.

• Chronic pain or heaviness or aching in the legs, relieved by elevation
• Ankle edema
• Skin ulcerations
• Superficial thrombosis
• Rupture with bleeding after minor trauma (rare)

Differentiating between primary and secondary varicose veins is critical before invasive therapy is attempted. Chronic venous insufficiency may develop if varicose veins are ablated when the deep venous system is obstructed. Chronic leg pain may not be due to the varicose veins themselves but to superficial or deep venous thrombosis. Additional causes of leg pain that must be considered include the following.

• Sciatica
• Peripheral neuropathy
• Arthritis of hip or knee
• Baker's cyst

The physician must conduct the examination while the patient is standing position so that the veins distend and are therefore easily seen and palpated. The following three tests may be helpful to distinguish primary and secondary varicosities.

• Brodie-Trendelenberg test—to determine valvular incompetence in the saphenofemoral system
• Percussion test—to determine valvular competence in the great saphenous vein
• Perthes test—to determine valvular competence in the deep femoral vein

• Doppler ultrasound—to determine the relationship of varicosities to the saphenous system; to assess competence of the greater and lesser saphenous systems; to rule out deep venous obstruction and arterial occlusive disease
• Duplex ultrasound scanning with color-flow imaging—used for the same purpose as Doppler ultrasound but may also permit more complete and accurate diagnosis, especially in obese patients.
• Venography—to visualize veins filled with a contrast medium; most commonly used to detect thrombophlebitis
• Photoplethysmography—to quantitatively measure venous function; to assess the severity of chronic venous insufficiency

Conservative (noninvasive) therapy is the initial treatment of choice for all patients and may be the only treatment ever needed for all but the most severe cases. These measures include the following.

• Avoidance of prolonged sitting, standing, or walking
• Regular exercise since action of the calf and other leg muscles increases venous return
• Periodic elevation of the legs
• Graduated compression stockings
• Ablative (invasive) procedures, including sclerotherapy and surgery, are indicated for superficial varicose veins accompanied by chronic pain; chronic venous insufficiency with edema, ulceration or other skin changes; and recurrent superficial vein thrombosis.
• Such treatment may also be indicated purely for cosmesis.

Sclerotherapy involves injection of a sclerosing solution (e.g., sodium tetradecyl sulfate) into a varicosity, followed by application of a compression dressing. This produces inflammation in the vessel wall, which leads to fibrosis with obliteration of the vessel lumen. It is used most often for spider veins (telangiectases) and smaller, nonsaphenous varicose veins. Use of sclerotherapy alone and in combination with surgery to treat larger, more extensive varicosities of the greater and lesser saphenous veins is controversial in the U.S.

Phototherapy employs laser or high-intensity pulsed light to destroy telangiectases. It is not used to treat varicose veins per se. Radiofrequency ablation uses a catheter threaded into the varicose vein to heat the vein wall either to obliterate the lumen or shrink it enough to restore valve competence. It is suitable for treating large varicosities in the saphenous system, yet it is a relatively new technique where long-term results are unknown.

Surgical therapy involves removal of varicose veins by various techniques including classic stripping and ligation and the more recently developed stab-avulsion technique, which uses smaller incisions.

Nutritional supplements and herbs may be beneficial in enhancing the integrity of the vasculature, stimulating circulation, and relieving discomfort.

• Include dietary fiber in the form of complex carbohydrates (e.g., whole grains) to avoid constipation, which may contribute to venous congestion. Include foods rich in bioflavonoids, such as dark berries, dark leafy greens, garlic, and onions, which strengthen collagen tissues. Drinking fluids and getting regular exercise also help prevent constipation.
• Vitamin C (500 to 1,000 mg tid), vitamin E (200 to 600 IU/day), and zinc (15 to 30 mg/day) are essential for vascular health.

Herbs may be used as dried extracts (pills, capsules, or tablets), teas, or tinctures (alcohol extraction, unless otherwise noted). Dose is 1 heaping tsp. herb/cup water steeped for 10 minutes (roots need 20 minutes). Commercial preparations often contain a combination of the following herbs. They may also be taken individually, as noted.

• Horse chestnut (Aesculus hippocastanum) 500 mg tid or standardized Aescin 10 mg tid
• Butcher's broom (Ruscus aculeatus) standardized extract (9% to 11% ruscogenin) 100 mg tid
• Gotu kola (Centella asiatica) 1,000 mg bid to qid or standardized extract (asiaticoside 40%, Asiatic acid 30%, madecassoside 1% to 2%) 60 mg once to twice daily
• Bilberry (Vaccinium myrtillus) standardized extract (25% anthocyanoside) 80 to 160 mg tid

Combine the following in equal parts to support the vasculature and tone the circulatory system: yarrow (Achillea millefolium), hawthorn (Crataegus monogyna), ginkgo (Ginkgo biloba), marigold (Calendula officinalis), horse chestnut (Aesculus hippocastanum), and ginger (Zingiber officinalis). Take 30 to 60 drops tincture bid to tid or drink three to four cups of tea daily.

An experienced homeopath would consider the individual's constitution. Some of the most common acute remedies are listed below. Acute dose is three to five pellets of 12X to 30C every one to four hours until symptoms resolve.

• Aesculus for generalized venous congestion, especially with hemorrhoids and constipation
• Fluoricum acidum for painful varicose veins and sensation of heat
• Hamamelis for weak veins and easy bruising or bleeding; varicose veins with stinging pains
• Secale for varicosities with burning, constricting pains that are worse with exertion

Cold compresses of witch hazel (Hamamelis virginiana) and yarrow (Achillea millefolium) tea may provide temporary relief.

May be helpful in improving the overall circulatory system and reducing venous congestion.

May be beneficial in alleviating venous congestion and mechanically stimulating circulation.

Varicose veins, while treatable, will eventually recur and progress regardless of the treatment chosen. Recurrences may develop in residual varicose veins not completely removed by surgery or obliterated by sclerotherapy or in veins not previously affected. This may be assessed by periodic monitoring.

Regular exercise increases venous return. Both weight loss and exercise decrease the likelihood of thrombosis.

Both primary and secondary varicose veins develop progressively. Once a vein segment dilates, valvular incompetence develops and blood refluxes distally. This increases hydrostatic pressure distally, causing further vein dilation and elongation. Eventually this process may propagate throughout the length of the vein and into peripheral branches and perforating veins. Varicose veins are not thought to lead to venous ulceration unless accompanied by deep venous or greater or lesser saphenous vein insufficiency. Thus, varicose veins may account for only 20% to 30% of venous ulcers.

Complications of sclerotherapy include cutaneous hyperpigmentation; allergic reactions to sclerosing agents; thrombus formation; edema; telangiectatic matting; cutaneous necrosis; and ulceration. Arterial injection with sclerosing agents may lead to limb amputation; pulmonary embolism; deep venous thrombosis; and nerve damage.

Varicose vein disease is a chronic condition. New varicosities often occur after treatment, such as residual varicosities from incomplete surgery or sclerotherapy.

The incidence of varicose veins during pregnancy varies from 8% to 20% and is most common in multiparous women. These varicosities may be caused by compression of the iliac veins by the uterus, which results in increased pressure in the lower veins, or by the effects or estrogen and progesterone, which make the walls of the veins more pliable. Elevation of legs may be particularly effective.

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