Varicose veins

Varicose veins are swollen and twisted veins, most commonly affecting the legs, that can cause discomfort or pain. A range of surgical and non-surgical treatments is available, depending on the severity of the symptoms and a person's circumstances and preferences.

Varicose veins are more common in women than in men and tend to run in families. They usually develop between the ages of 30 and 60 years and tend to worsen with age.

About veins

Veins are the blood vessels that carry blood from the body to the heart (whereas arteries carry blood from the heart to the body).

Veins that lie just beneath the skin surface are referred to as “superficial veins” while the veins found deep inside the muscles are referred to as “deep veins”. Other veins, called "communicating veins", connect the superficial and deep veins, allowing blood to flow between them.

Properly functioning veins have a series of one-way valves that keep the blood flowing in one direction towards the heart.

Causes

Varicose veins occur when the valves within the veins stop working properly and allow blood to backflow. This results in blood pooling in the area below the affected valve causing the vein to enlarge and stretch. Varicose veins appear under the skin as bluish-green lines, which may bulge out or appear twisted and contorted.

The superficial veins in the legs are the most common place for varicose veins to occur – due mainly to problems with vein junctions (where different veins join together) in the upper thigh, behind the knee, and in the calf muscle. However, they can occur in other areas of the body (such as haemorrhoids, which are varicose veins in the anus or rectal area).

Risk factors

Factors that contribute to the development of varicose veins include:

• Increasing age
• Family history (a genetic predisposition)
• Being female. Women are more affected by varicose veins than men, possibly because female hormones make the walls of veins relax more and the valves more prone to leaking
• Obesity
• Pregnancy
• Circulatory problems, such as blood clots (thrombosis)
• Injury or inflammation of the veins
• Chronic constipation may contribute to the development of rectal varicose veins (haemorrhoids).

Lifestyle factors also play a significant role and people who have jobs that involve standing or sitting for prolonged periods of time (e.g., nurses, flight attendants, writers, and teachers) are at higher risk of developing varicose veins.

Symptoms

Common symptoms include:

• Bulging or twisting of the affected vein(s)
• Veins that are dark purple or blue
• Pain or aching in the affected area, especially after sitting or standing for lengthy periods
• Swelling in the legs
• A feeling of heaviness and muscle fatigue in the legs
• Dry, flaky, itchy skin around the affected veins
• Leg cramps at rest, especially at night
• Discolouring (pigmentation changes) of the skin around the ankles.

Some women experience a worsening of symptoms during menstruation.

Spider or thread veins are a smaller type of varicose vein, which are closer to the skin’s surface and appear as clusters of red and blue veins on the face and legs.

Complications

Health complications due to varicose veins may include:

• The skin above the affected veins may become thin making it susceptible to cuts, nicks, and ulcers
• Inflammation caused by blood clotting or vein damage (phlebitis)
• A slightly increased risk of developing blood clots in the deep veins (deep vein thrombosis) connected to varicose veins.

Diagnosis

Varicose veins are usually visible, so it is possible to make a diagnosis simply from their appearance. A doctor will perform a physical examination to assess the extent of the varicose veins.

They may also order an ultrasound test called a doppler, which enables the blood flow and structure of the veins to be seen on a monitor. Doppler ultrasound can also show if any blood clots are present. A duplex ultrasound may also be performed. This is a more advanced scan and displays the image in colour.

Treatment

Treatment may not be medically necessary unless symptoms are causing problems. However, some people may want treatment for cosmetic reasons because they are unhappy with the appearance of varicose veins.

If varicose veins are small and not too uncomfortable, elastic compression stockings may be recommended. These are worn during daily activities and help to compress the veins, keeping them from stretching and limiting any discomfort or pain.

For more problematic cases a range of procedures – surgical and non-surgical – are available to seal or remove varicose veins. A combination of treatment techniques may sometimes be used. Treatment options for varicose veins have changed significantly in the past 25 years and continue to evolve, especially the development of less invasive procedures that do not require having to stay in hospital.

Non-Surgical Treatment:

Sclerotherapy

Sclerotherapy involves using a fine needle to inject a special solution into the affected vein. The solution irritates the lining of the vein causing it to harden (sclerose) and seal off. Blood is therefore prevented from entering that portion of the vein and is forced to flow through other, healthier veins.

Deeper varicose veins can be treated with ultrasound guided sclerotherapy (UGS). The doctor is able to use a duplex ultrasound to see the vein on a screen, enabling them to guide the needle within the vein and inject the sclerotherapy solution.

The majority of people who have had sclerotherapy treatment achieve good results with minimal side effects. However, sclerotherapy is not suitable for everyone. Pregnancy, pre-existing clotting disorders, and allergy to the sclerotherapy solution are contraindications for this treatment.

Endovenous thermal ablation

A small incision is made at one end of the affected vein and a catheter (tube) is inserted, guided by an ultrasound scanner. Once in place, heat generated by a laser or radiofrequency emitter is used to seal or destroy the vein.

Surgical Treatment:

If the vein junction where the varicose vein originates has been shown by an ultrasound scan not to be working properly, then the most common surgical treatment is to tie off the varicose vein at this junction (most commonly the upper thigh, behind the knee, or in the calf muscle). Surgery involves making a small incision in the leg, locating the vein junction, and tying off the varicosed vein. The vein is left in place, but blood is prevented from flowing into it.

Another surgical technique for treating superficial varicose veins is “vein stripping”, which is where the affected vein is completely removed. A small incision is made in the skin at either end of the affected vein and the junction where the varicose vein joins a larger vein is tied off. A flexible wire is then inserted into the varicose vein and withdrawn – removing the vein in the process.

Both types of surgery can be performed under general or spinal anaesthetic and a stay in hospital may be required. This will be determined by the surgeon performing the surgery.

A range of alterative surgical techniques may also be used under different circumstances.

Prevention

Things you can do to help prevent varicose veins include:

• Exercise regularly, which improves circulation and helps with weight loss
• Maintain a healthy body weight
• Avoid tight clothing that constricts the legs, groin or waist, e.g., knee-high pantyhose
• Avoid constipation, e.g., by eating a high-fibre diet
• When standing or sitting for long periods try to get up and walk around every 30 minutes or do calf raises. Contracting the muscles of the lower legs will have a pump-like effect and help return blood to the heart.
• Elevate your legs for a short time several times a day by lying down with pillows under your feet.

References

Fernando, R.S., Muthu, C. Adoption of endovenous laser treatment as the primary treatment modality for varicose veins: the Auckland City Hospital experience. N Z Med J. 2014;127(1399):43-50.

Mayo Clinic (2022). Varicose veins (Web Page). Rochester, MN: Mayo Foundation for Medical Education and Research. https://www.mayoclinic.org/diseases-conditions/varicose-veins/symptoms-causes/syc-20350643 [Accessed: 14/11/22].

NHS (2020). Varicose veins (Web Page). Redditch: National Health Service (NHS)

England. https://www.nhs.uk/conditions/varicose-veins/ [Accessed: 14/11/22]

O’Toole, M.T. (Ed.) (2017). Varicose vein. Mosby’s Dictionary of Medicine, Nursing & Health Professions (10th ed.). St Louis, MI: Elsevier.

Weiss, R. (2020). Varicose veins and spider veins (Web Page). Medscape Drugs and Diseases. New York, NY: WebMD LLC. https://emedicine.medscape.com/article/1085530-overview [Accessed: 14/11/22].

Last Reviewed: November 2022