Varicose Veins

Symptoms

• Aching, heavy, and uncomfortable legs
• Swollen feet and ankles (edema)
• Appearance of bulging, twisted, dark purple or blue veins
• Muscle cramps in legs, particularly at night
• Burning or throbbing sensation in the legs
• Itching over or near the veins (venous eczema/stasis dermatitis)
• Symptoms are often worse during warm weather or after standing for long periods and may improve with leg elevation
• Restless legs syndrome
• Skin discoloration (hyperpigmentation), usually a brownish color around the ankles
• Hardening of the skin and fat under the skin (lipodermatosclerosis)
• Bleeding from a varicose vein if injured, requiring immediate pressure and medical attention
• Superficial Thrombophlebitis: a blood clot in a superficial vein, causing the area to become hard, red, hot, and very tender
• Signs of Deep Vein Thrombosis (DVT): sudden, severe pain, swelling, and tenderness in one leg (usually the calf), heavy ache, warm skin in the area (a medical emergency)
• Venous Ulcer: a sore or ulcer develops on the skin, typically near the ankle, that does not heal, indicating advanced venous disease

Causes & Risk Factors

• The primary underlying cause is venous hypertension, which results from reflux (backward flow of blood) through incompetent venous valves, venous outflow obstruction, or failure of the calf muscle pump.
• Valvular Incompetence: Veins contain one-way valves to prevent blood from flowing backward. When these valves weaken or become damaged, blood pools in the veins, increasing pressure and causing them to dilate and become varicose.
• Weakened Vein Walls: An inherent weakness in the vein walls can cause them to lose their elasticity, stretch, and dilate, leading to valve dysfunction.
• Primary Varicose Veins: Occur due to inherent weakness in the vein wall or valves, with no known preceding event. This is the most common cause.
• Secondary Varicose Veins: Result from a previous condition that damaged the veins, most commonly deep vein thrombosis (DVT) leading to post-thrombotic syndrome.
• Increasing age
• Family history of varicose veins
• Female sex
• Pregnancy, especially multiple pregnancies (due to hormonal changes and increased venous pressure)
• Obesity or being overweight
• Occupations requiring long periods of standing or sitting
• Sedentary lifestyle
• History of Deep Vein Thrombosis (DVT)
• History of previous leg injury

Diagnosis

• A healthcare professional will ask about your symptoms, their duration, and how they affect your daily life.
• They will inquire about your family history of varicose veins or venous disease, and your personal history of DVT, leg injury, or surgery.
• For women, obstetric history is relevant.
• Your occupation and lifestyle (e.g., prolonged standing) will also be discussed.
• Visual inspection of the legs in the standing position to assess the location and extent of varicose veins, spider veins, and any skin changes like swelling, pigmentation, eczema, or ulcers.
• Palpation (feeling) for tenderness, warmth, or hardened cords, which could suggest thrombophlebitis.
• Assessment of peripheral pulses to ensure there is no significant arterial disease.
• Duplex Ultrasound: This is the gold standard and recommended investigation for anyone with suspected varicose veins who is being considered for treatment.
• Duplex ultrasound combines B-mode imaging to visualize the veins and Doppler ultrasound to assess blood flow direction and velocity.
• It confirms the diagnosis, identifies the source and extent of venous reflux (backward flow) or obstruction, and provides a 'map' of the superficial and deep venous systems to guide treatment.
• Diagnosis is primarily clinical, based on the presence of visible, palpable varicose veins (typically 3 mm or more in diameter).
• Duplex ultrasound is used to confirm underlying venous incompetence (reflux) before any interventional treatment.

Treatment Options

• Leg Elevation: Elevating the legs when resting can reduce swelling and relieve symptoms.
• Exercise: Regular physical activity, such as walking, improves circulation and the function of the calf muscle pump.
• Weight Management: For individuals who are overweight or obese, losing weight can reduce pressure on the veins.
• Compression Stockings: Recommended for managing symptoms like aching, pain, and swelling, especially for those with more advanced disease (C2-C6), pregnant individuals, or those who cannot have interventional treatment. They do not cure varicose veins but can alleviate discomfort.
• Venoactive Drugs (VADs): Medications such as diosmin, hesperidin, and horse chestnut seed extract may be used to relieve symptoms like pain, heaviness, and edema. However, national guidelines like NICE do not recommend pharmacological treatment for varicose veins, while European guidelines suggest they may be used for symptom relief.
• Endothermal Ablation (Radiofrequency or Laser): This is often the first-line treatment. A thin catheter is inserted into the affected vein, and laser or radiofrequency energy is used to heat and seal the vein shut. It is typically performed under local anesthetic and has high success rates.
• Ultrasound-Guided Foam Sclerotherapy (UGFS): If endothermal ablation is not suitable, UGFS may be offered. A chemical irritant mixed with air or gas is injected into the vein under ultrasound guidance, causing it to scar and close. It can be used for both main and smaller varicose veins.
• Conventional Surgery (High Ligation and Stripping): If both endothermal ablation and UGFS are unsuitable, open surgery may be considered. This involves tying off the main superficial vein (e.g., the great saphenous vein) at the groin and then removing it. This procedure usually requires general or spinal anesthesia and is less common as a first-line treatment today.
• Ambulatory Phlebectomy: This procedure involves making small incisions over the varicose veins and removing them with a small hook. It is often performed in conjunction with an ablation procedure.
• Referral to a vascular service is recommended for patients with symptomatic primary or recurrent varicose veins, lower-limb skin changes (pigmentation, eczema), superficial vein thrombophlebitis (especially if veins are large or near a major junction), a venous leg ulcer (healed or active), or bleeding from a varicose vein.

Frequently Asked Questions