Examqo › Examqo library › Vascular surgery › Venous and lymphatic disease · IMLE
Chronic venous disease and varicose veins of the legs
Varicose veins usually arise from valve incompetence of the superficial veins (great or small saphenous); they are classified by CEAP, reflux is diagnosed by duplex, and in a symptomatic patient the preferred treatment is endovenous ablation (laser or radiofrequency) — before open surgery or foam injection — and in a venous ulcer early ablation speeds healing.
Why it matters in the exam
The CEAP classification (2020 revision) describes the clinical grade: C0 no signs, C1 spider veins, C2 varicose veins, C3 oedema, C4 skin changes (C4a pigmentation and eczema, C4b lipodermatosclerosis, C4c small dilated veins around the ankle), C5 healed ulcer and C6 active ulcer. Work-up is duplex while standing: significant reflux in the superficial veins is defined as reverse flow of more than 0.5 seconds, and in the deep veins — more than 1 second. Duplex also checks for old thrombosis or obstruction in the deep system, which changes the plan. Risk factors: age, pregnancies, family history, prolonged standing and obesity.
According to ESVS 2022, in a patient with symptomatic varicose veins (C2 and above) and great saphenous reflux, endovenous thermal ablation under tumescent local anaesthesia is the first choice, with fast recovery and a low recurrence rate; non-thermal alternatives are glue (cyanoacrylate) and foam injection, and open surgery (ligation and stripping) is kept for cases where ablation is unsuitable. Compression stockings relieve symptoms when there is no intervention, but do not correct reflux. Before compression stockings ABI is checked, because strong compression is dangerous with significant arterial disease. Complications of ablation: thrombus extending from the treated vein into the deep vein (EHIT), DVT, nerve injury (the saphenous nerve with great saphenous ablation below the knee, and the sural nerve with small saphenous ablation), and skin burns. In a venous ulcer, the EVRA trial (2018) showed that early ablation — within 2 weeks — in addition to compression bandaging speeds ulcer healing.
Spider veins (C1) are mainly a cosmetic problem and are treated with sclerotherapy.
Key points
- CEAP from C0 to C6.
- Superficial reflux above 0.5 seconds.
- Endovenous ablation — first choice.
- EVRA — early ablation in an ulcer.
- ABI before compression.
Summary table
| CEAP | Finding | Treatment |
|---|---|---|
| C1 | Spider veins | Sclerotherapy (cosmetic) |
| C2–C3 with symptoms | Varicose veins, oedema, saphenous reflux | Endovenous ablation; stockings for relief |
| C4 | Skin changes | Ablation; skin care |
| C5–C6 | Healed or active ulcer | Compression bandaging and early ablation (EVRA) |
In the full version for subscribers
- A simple algorithm
- Memory aid
- Exam traps
- 5 review cards
- Enough for IMLE
The full version is open to subscribers of: Vascular surgery, General surgery, Dermatology and venereology, Family medicine, Medical licensing exam (IMLE).
Subscriber? Read the full topic Plans and prices 25 free questions
Sources
- ESVS Clinical Practice Guidelines on the Management of Chronic Venous Disease of the Lower Limbs, 2022 — Diagnosis and treatment
- CEAP classification revision (American Venous Forum), 2020 — Clinical classes
- Gohel et al., EVRA, N Engl J Med, 2018 — Early endovenous ablation in venous ulceration
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.