Varicose veins in the legs
Table of contents
Varicose veins in the legs are dilated superficial veins that can cause a feeling of heaviness, pain, swelling or skin changes. Assessment may include a clinical examination and a Doppler ultrasound to identify the source of venous reflux and select the most appropriate treatment.
What are varicose veins in the legs?
Varicose veins form when a superficial vein widens, lengthens and deviates from its normal course. They can be seen as bluish, purplish or bulging cords beneath the skin, although their appearance depends on the calibre of the vein, its depth and skin tone.
The veins in the legs must return blood to the heart against the force of gravity. To facilitate this process, they have small internal valves that allow the blood to flow upwards and prevent it from flowing backwards. The contraction of the calf muscles also helps to propel venous flow, particularly when walking.
When the wall of a vein dilates or its valves fail to close properly, some of the blood flows back downwards. This reverse flow is known as venous reflux. The sustained pressure inside the vessel causes the vein to widen progressively, eventually becoming visible as a varicose vein.
The difference between varicose veins, spider veins and chronic venous disease
Varicose veins are part of chronic venous disease, but they are not synonymous with chronic venous insufficiency.
Spider veins are very small, superficial vessels that appear as reddish, bluish or purplish lines. They do not usually protrude from the skin and, although they may occasionally cause discomfort, their impact is mainly cosmetic.
Varicose veins affect larger veins. They can be felt beneath the skin and are more likely to be associated with a sensation of heaviness, pain, swelling or venous reflux.
Chronic venous disease is the broadest concept. It ranges from minor vascular abnormalities to varicose veins, oedema, skin changes and ulcers. The term ‘chronic venous insufficiency’ is usually reserved for forms with a more significant functional impact, particularly where persistent swelling, pigmentation, eczema, skin induration or ulcers are present.
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Why do varicose veins develop?
Varicose veins develop as a result of a combination of changes in the vein wall, progressive dilation and valve malfunction. They are not usually caused by a single factor, but rather by a combination of personal predisposition and various circumstances that increase pressure or hinder the return of blood.
In most people, they are primary varicose veins. This means they arise from changes within the superficial veins themselves, without there necessarily being any pre-existing vascular disease.
Less commonly, they are secondary to a problem that disrupts venous circulation. This can occur following deep vein thrombosis, due to an obstruction of the deep veins, or as a result of certain congenital abnormalities and venous compression.
It is important to distinguish between these situations. In primary varicose veins, treatment is usually directed at superficial reflux. When there is a secondary cause, it may also be necessary to investigate the deep veins or pelvic circulation.
Factors contributing to their development
Family history is one of the most significant factors. Having close relatives with varicose veins does not necessarily mean that you will develop them, but it may indicate greater vulnerability of the vein walls or valves.
The risk increases with age because venous tissues can lose elasticity and the valves can become less effective. However, varicose veins also occur in young adults, particularly where there is a marked genetic predisposition.
They are more common in women, although they also affect many men. Pregnancy is a contributing factor due to increased blood volume, hormonal changes and the pressure exerted by the uterus on the pelvic veins. Some varicose veins first appear during pregnancy, whilst others become more visible after several pregnancies.
Being overweight can increase the pressure on the venous system. Spending many hours standing or sitting also reduces the action of the calf muscles. These factors are not usually the sole cause, but they can contribute to the development of varicose veins or exacerbate symptoms in people who are predisposed to them.
The size or appearance of a varicose vein does not, in itself, reflect its clinical significance. Some highly visible veins cause hardly any discomfort, whilst less conspicuous abnormalities may be accompanied by swelling or changes to the skin.
For this reason, the assessment takes into account the symptoms, the physical examination and, where necessary, the information provided by Doppler ultrasound.
Symptoms of varicose veins
Many varicose veins do not cause pain. In these cases, the only sign may be the presence of dilated or twisted veins beneath the skin.
When symptoms do occur, it is common to experience a feeling of heaviness, tiredness, tightness or a dull ache in the legs. Swelling around the ankles, a sensation of warmth, itching, a stinging sensation, night-time cramps or a throbbing discomfort near a vein may also occur.
These sensations tend to become more noticeable towards the end of the day, during the warmer months or after remaining still for a long time. Walking, moving your ankles, resting or elevating your legs can provide temporary relief.
The severity of the discomfort is not always related to the size of the varicose veins. Furthermore, the heaviness, cramps and swelling may also have muscular, joint-related, neurological, lymphatic or cardiovascular causes. Therefore, not all symptoms experienced by someone with varicose veins should automatically be attributed to their veins.
How they may develop
The progression varies from person to person. Some varicose veins remain stable for years and cause hardly any discomfort. Others grow in size or are progressively accompanied by oedema and skin changes.
When venous pressure remains high, some of the fluid can leak from the veins into the surrounding tissues. This explains the swelling that appears around the ankles and which, in the early stages, is usually most noticeable at the end of the day.
Over time, itching, dryness, eczema or a brownish discolouration of the skin may develop. In more advanced stages, the tissue beneath the skin may harden and lose elasticity. These changes are usually concentrated in the lower leg, particularly around the ankle.
The presence of these changes indicates that the problem goes beyond a mere cosmetic issue and warrants a specialist assessment. However, not everyone with varicose veins goes on to develop advanced forms of the condition.
Possible complications
Most people with varicose veins do not develop serious complications. However, sustained venous pressure can lead to inflammation, skin lesions, bleeding or the formation of clots in the superficial veins.
A varicose vein that suddenly becomes hard, painful, warm and red may indicate superficial venous thrombosis, formerly known as superficial phlebitis. Although it affects a vein close to the skin, in some cases it may spread or be located near the deep venous system, so a Doppler ultrasound scan may be necessary.
Very superficial varicose veins may also bleed following a minor knock, when scratching, or even spontaneously. Bleeding is usually controlled by elevating the leg and applying direct pressure to the affected area, but the vein responsible must subsequently be assessed. NICE recommends immediate referral to a vascular service when a varicose vein has bled.
The most advanced skin complication is a venous ulcer, a wound that usually appears on the lower leg and which is difficult to heal whilst venous pressure persists. Its treatment requires addressing both the skin lesion and the underlying circulatory problem.
A sudden change should not automatically be attributed to varicose veins
Common venous symptoms usually develop gradually. Sudden swelling in one leg, particularly if accompanied by pain, warmth or a change in colour, requires medical assessment to rule out deep vein thrombosis.
If you also experience shortness of breath, chest pain, fainting or a coughing up of blood, you need urgent medical attention.
How are varicose veins diagnosed?
Diagnosis begins with a clinical interview and an examination of the legs. The specialist asks when the varicose veins first appeared, what symptoms they cause, how they change throughout the day, and whether there is a family history of the condition, a history of pregnancy, thrombosis or previous venous treatments.
The examination is usually carried out with the person standing, as in this position the veins fill with blood and can be observed more clearly. As well as assessing their distribution, the doctor checks for oedema, pigmentation, eczema, skin hardening, sores or scars from previous procedures.
It may also be necessary to check the arterial pulses. Some symptoms initially attributed to varicose veins may be due to arterial disease, and certain levels of compression are not appropriate when arterial circulation is compromised.
The examination allows dilated veins to be identified, but it does not always pinpoint the source of the reflux or reveal how the venous system as a whole functions. Doppler ultrasound is used to obtain this information.
Venous Doppler ultrasound
Doppler ultrasound, also known as venous duplex ultrasound, is the main test used to investigate symptomatic varicose veins and plan their treatment.
It is a non-invasive scan that uses ultrasound to visualise the veins and analyse the direction of blood flow. It allows us to check whether the valves are closing properly, locate reflux, examine the saphenous veins and their branches, and assess the condition of the deep venous system.
It also helps to rule out thrombosis or blockages and enables a venous map to be drawn up prior to surgery. This information prevents the situation where only the visible veins are treated without knowing the point at which the problem originates.
Guidelines recommend using Doppler ultrasound to confirm the presence and extent of reflux and to plan treatment for primary or recurrent varicose veins. Other, more invasive tests are reserved for complex situations that cannot be adequately explained by ultrasound alone.
Diagnostic test: Venous Doppler ultrasound of the legs View the test factsheet →
When do they require treatment?
Not all varicose veins require treatment. If they do not cause discomfort, there are no changes to the skin and they do not affect quality of life, it may be sufficient to maintain healthy habits and monitor their progress.
Treatment should be considered when they cause pain, heaviness, swelling, itching or limitations in daily activities. It is also particularly important if there are skin changes, superficial thrombosis, bleeding, a venous ulcer or recurrence following a previous procedure.
The decision should not be based solely on the size or appearance of the veins. The results of the Doppler ultrasound, the impact of the symptoms, your general health and personal preferences are all part of a shared decision.
Where there is treatable reflux, current techniques allow the affected vein to be closed off. The blood is then redirected to other vessels that are functioning properly.
Treatment of varicose veins
Treatment may combine measures to relieve symptoms with procedures aimed at closing off or removing the affected veins.
There is no single technique suitable for all cases. The choice is based on the venous map obtained via Doppler ultrasound and depends on the course, diameter and depth of the vein, previous treatments and the team’s experience.
Measures to relieve symptoms
Walking and taking regular exercise activate the calf muscles and promote blood return. Swimming, cycling and moving your ankles can also be beneficial.
For sedentary jobs or those that require you to stand for many hours, it is a good idea to change your posture and take short walks at regular intervals. Elevating your legs during breaks can temporarily reduce heaviness and swelling.
Maintaining a healthy weight can also reduce the pressure on your legs. These measures relieve symptoms, but they do not make an existing varicose vein disappear or repair its valves.
Compression stockings
Graduated compression stockings apply greater pressure around the ankle and gradually reduce this pressure towards the upper leg. In this way, they reduce fluid build-up and facilitate venous return.
They can be useful in cases of heaviness, oedema or advanced venous disease, during pregnancy, or when surgical intervention is not appropriate. They also play an important role in the treatment of venous ulcers.
Compression controls the symptoms but does not eliminate reflux. In people with symptomatic varicose veins and treatable reflux, current guidelines favour surgical intervention over the indefinite use of stockings as the sole measure, provided the person is a suitable candidate.
The size and level of pressure must be tailored to the individual. Before using high-compression stockings, it may be necessary to check that arterial circulation is adequate.
Procedures for closing or removing the affected veins
Most current treatments are carried out on an outpatient basis. On the same leg, it may be necessary to close a main vein and also treat some visible branches using a different technique.
Endovenous laser and radiofrequency
Endovenous thermal ablation seals off the vein by applying heat from within. The specialist inserts a thin catheter under ultrasound guidance and administers a local anaesthetic around the vein.
The energy may come from a laser or radiofrequency. In both cases, the vein wall is sealed and the body gradually transforms it into a fibrous cord which eventually shrinks.
These techniques have a long track record of clinical use and are among the preferred options when there is reflux in a saphenous vein and the anatomy allows the procedure to be carried out. Patients are usually able to walk shortly after the procedure.
HIFU: high-intensity focused ultrasound
HIFU enables certain veins to be closed using energy applied from outside the skin. The ultrasound waves are focused on a precise point on the vein wall and generate heat in a controlled manner, without inserting a catheter into the vessel.
It is, therefore, an extracorporeal and non-invasive thermal technique. The procedure is guided by ultrasound to locate the vein and control the application of energy.
It may be considered in selected patients where the depth, course and relationship of the vein to the skin and other tissues allow it to be treated safely. Its indication must be based on a detailed Doppler ultrasound scan and the specific expertise of the team.
Studies published in recent years show promising results in the closure of reflux points, saphenous segments and some perforating veins. However, the accumulated experience and long-term comparative evidence remain more limited than those available for laser and radiofrequency treatments. Therefore, HIFU should be presented as an emerging and selective alternative, not as the preferred option for any type of varicose vein.
Non-thermal endovenous techniques
There are procedures that seal the vein from the inside without using heat. These include cyanoacrylate medical adhesive and mechanochemical ablation.
These techniques can avoid the need for anaesthetic injection along the entire length of the vein and may be useful in certain locations, for example where the vessel runs close to a nerve.
They are not necessarily superior to laser or radiofrequency treatments. The choice depends on the anatomy, potential specific adverse effects, the available evidence and the preferences of the patient. Current guidelines recommend both thermal and non-thermal techniques for selected patients.
Sclerotherapy
Sclerotherapy involves injecting a substance that causes the vein to close in a controlled manner. It can be administered as a liquid in small vessels or as a foam to increase contact with the walls of larger veins.
It is frequently used to treat spider veins, varicose branches, residual veins and some recurrences. When the vein cannot be seen directly, the procedure is carried out under ultrasound guidance.
It may require several sessions. If there is significant reflux in a main vein, the choice between sclerotherapy and other techniques should be based on the venous map and not solely on the simplicity of the procedure.
Outpatient phlebectomy
Phlebectomy enables varicose veins close to the skin to be removed via small punctures. It is carried out under local anaesthetic and can be used on its own or in combination with saphenous vein ablation.
Before the procedure, it must be checked whether the visible veins are caused by a deeper reflux site that also requires treatment.
Conventional surgery
The surgery involves ligating and removing specific venous segments via small incisions. For decades, it was the standard treatment for varicose veins associated with reflux in the saphenous veins.
It is now mainly reserved for situations where endovenous techniques are not possible, are not available or are unsuitable due to anatomical characteristics.
It remains an effective option, although it is usually associated with more incisions, bruising and a longer recovery time than catheter-based procedures. European guidelines prioritise endovenous techniques where these can be performed safely.
Medicines for varicose veins
There is no medication that can make a varicose vein disappear or permanently repair its valves.
Some venoactive drugs may temporarily relieve heaviness, pain, cramps or a feeling of swelling. Their role is primarily symptomatic.
They may be considered when no intervention is planned, whilst awaiting a procedure, or if certain symptoms persist after treatment. They are not a substitute for Doppler ultrasound or treatment of reflux where there are significant symptoms, skin changes or complications.
Varicose veins during pregnancy
Varicose veins may appear for the first time or become more visible during pregnancy. Increased blood volume, hormonal changes and pressure from the uterus on the pelvic veins make it harder for blood to return from the legs.
In many women, they subside in the months following childbirth. For this reason, interventional treatments are usually postponed until the changes associated with pregnancy have stabilised, except in exceptional circumstances.
During pregnancy, physical activity, frequent ankle movements, elevating the legs and properly fitted compression stockings can be used to relieve discomfort.
A leg that swells suddenly and painfully during pregnancy should not automatically be attributed to varicose veins; in such a situation, it is necessary to rule out deep vein thrombosis.
Can varicose veins be prevented?
There is no single measure capable of completely preventing varicose veins when there is a family history of the condition, ageing of the veins or a history of multiple pregnancies.
Staying active, avoiding prolonged periods of inactivity, managing your weight and moving your legs during long journeys can help improve venous return and reduce some discomfort. These measures are beneficial for circulatory health, but do not guarantee that varicose veins will not develop.
Heat can temporarily dilate the veins and make heaviness or swelling more noticeable, but it is not considered, in itself, to be the main cause of the condition. Crossing your legs has also not been shown to be a direct cause.
Prevention should be understood primarily as a way of supporting venous function and preventing inactivity from exacerbating an existing predisposition.
Can they reappear after treatment?
Treatment can successfully close the selected veins, but it does not eliminate the predisposition to developing venous disease.
Over time, other branches may dilate, new connections may form, or a treated vessel may partially reopen. For this reason, some people may require more than one session or a repeat procedure several years later.
The appearance of new varicose veins does not necessarily mean that the previous treatment was carried out incorrectly. It may also be part of the natural progression of the condition.
When symptoms reappear, a new Doppler ultrasound scan allows the source of the reflux to be identified and a decision to be made as to whether conservative measures are sufficient or whether further treatment is advisable. Guidelines recommend informing patients from the outset that new varicose veins may develop and that some cases require more than one session.
Living with varicose veins in the legs
Most people with varicose veins can lead an active life. Walking and exercising do not usually harm the veins; on the contrary, movement activates the calf muscles and facilitates blood return.
Where there is swelling or more advanced venous disease, it is important to look after the skin. Keeping it moisturised helps to reduce dryness and itching, whilst any wounds around the ankle should be monitored as they may heal poorly if venous pressure persists.
The decision to treat varicose veins should not be based solely on their appearance. Symptoms, their impact on daily life, the condition of the skin, the results of a Doppler ultrasound scan and personal preferences all play a significant role.
Current treatments make it possible to manage most symptoms and address complications through outpatient procedures. However, venous disease can progress, so it is advisable to keep an eye out for any changes that may occur over time.
When to seek advice
It is advisable to seek an assessment when varicose veins cause pain, a feeling of heaviness or persistent swelling, interfere with daily activities, or are accompanied by itching, eczema, skin discolouration or hardening of the skin.
You should also seek advice if a vein suddenly becomes hard, hot, red or painful; if a wound appears that does not heal; if a varicose vein bleeds; or if the veins reappear after treatment.
Bleeding from a varicose vein requires immediate vascular assessment. Sudden, painful swelling in a single leg requires rapid assessment to rule out deep vein thrombosis.