Varicose Veins

What are varicose veins?

Varicose veins are enlarged, widened veins that usually develop in the legs.

They often appear:

  • Bulging or raised

  • Twisted or rope-like

  • Blue, purple or dark beneath the skin

  • More prominent after standing for long periods

They develop when blood does not flow efficiently through the superficial veins of the leg and begins to reflux, or travel backwards. NICE describes varicose veins as dilated superficial veins associated with reversed blood flow.

Varicose veins are extremely common and, for some people, cause no problems other than their appearance.

For others they can cause significant symptoms or form part of a wider problem known as chronic venous insufficiency.

Why do varicose veins develop?

Veins carry blood back towards the heart.

Because the veins in the legs have to move blood upwards against gravity, they contain small one-way valves that help prevent blood from falling backwards.

If these valves become weak or damaged, they may no longer close properly. Blood can then flow backwards and collect within the vein.

This increases pressure inside the vein and causes it to gradually stretch, widen and become more visible.

Who gets varicose veins?

Anyone can develop them.

They become increasingly common with age and frequently develop during pregnancy.

Other factors which may increase the likelihood include:

  • Family history of varicose veins

  • Previous pregnancy

  • Increasing age

  • Obesity

  • Reduced mobility

  • Previous DVT

  • Previous injury or surgery affecting the leg

  • Spending long periods standing

Sometimes they develop without an obvious reason.

What symptoms can varicose veins cause?

Some people have very prominent veins without any discomfort.

Others experience:

  • Aching

  • Heaviness

  • Throbbing

  • Burning

  • Itching

  • Swelling around the ankles

  • Tired or uncomfortable legs

  • Symptoms that become worse after prolonged standing

Troublesome symptoms such as pain, aching, discomfort, swelling, heaviness and itching are recognised by NICE as symptomatic varicose veins.

Are varicose veins just cosmetic?

Not always.

Many varicose veins cause no significant medical problem and people may choose to leave them untreated.

However, venous pressure can progressively affect the surrounding tissues in some people.

Possible complications include:

  • Persistent swelling

  • Brown pigmentation around the lower leg or ankle

  • Venous eczema

  • Hardening of the skin and underlying tissues

  • Superficial thrombophlebitis

  • Bleeding

  • Venous leg ulceration

These complications are signs of more significant venous disease rather than simply a cosmetic issue.

What is the difference between thread veins and varicose veins?

Thread or spider veins are tiny vessels visible close to the surface of the skin.

Varicose veins are larger superficial veins that have become widened and may bulge or twist beneath the skin.

It is possible to have both at the same time.

A cluster of small veins around the ankle can also sometimes occur alongside chronic venous insufficiency rather than being purely cosmetic.

Are varicose veins the same as a DVT?

No.

A varicose vein is an enlarged superficial vein.

A deep vein thrombosis (DVT) is a blood clot within one of the deeper veins of the leg.

Having varicose veins does not mean you have a DVT.

However, a varicose vein can sometimes develop superficial vein thrombosis, causing the vein to become suddenly hard, tender and painful. NICE recommends vascular referral where superficial vein thrombosis is accompanied by suspected venous incompetence.

When should varicose veins be assessed?

NICE recommends referral to a vascular service when varicose veins are associated with:

  • Pain, aching, discomfort, swelling, heaviness or itching

  • Skin pigmentation caused by venous disease

  • Venous eczema

  • Superficial vein thrombosis and suspected venous incompetence

  • A venous leg ulcer

  • A previously healed venous leg ulcer

Bleeding varicose veins require immediate vascular referral.

So you do not necessarily have to simply “put up with” symptomatic varicose veins because they are not considered cosmetic when they are causing genuine symptoms or complications.

How are varicose veins investigated?

Where specialist treatment is being considered, NICE recommends a duplex ultrasound scan.

This allows the vascular team to examine:

  • The anatomy of the veins

  • The direction of blood flow

  • Whether the valves are functioning normally

  • Where venous reflux is occurring

  • Which veins may require treatment

The scan is then used to plan appropriate treatment.

What can I do myself?

Simple measures may help reduce symptoms, although they cannot repair a faulty vein valve.

These include:

  • Staying physically active

  • Walking regularly

  • Avoiding prolonged periods standing completely still

  • Moving the ankles and calf muscles when sitting

  • Elevating the legs when resting if they become swollen

  • Maintaining a healthy weight

  • Looking after dry or vulnerable skin

The calf muscles are particularly important because they act as a muscle pump, squeezing the deep veins during walking and helping blood travel back towards the heart.

What about compression stockings?

This is an interesting one because compression stockings are often regarded as the automatic treatment for varicose veins.

In fact, NICE states that compression hosiery should not be offered as the definitive treatment for varicose veins unless interventional treatment is unsuitable.

Compression may still have a role in managing swelling or other venous problems in appropriately assessed patients.

Before significant compression is used, the arterial circulation should also be considered, because compression may not be appropriate where arterial blood supply is substantially reduced.

How are varicose veins treated?

If treatment is clinically appropriate, several methods can be used.

Endothermal ablation

A thin catheter is introduced into the vein and heat is used to close it.

This may be performed using radiofrequency or laser energy.

NICE recommends endothermal ablation as the first treatment option for suitable patients with confirmed truncal venous reflux.

Ultrasound-guided foam sclerotherapy

A special foam is injected into the affected vein under ultrasound guidance.

The solution causes the vein to close and the body gradually redirects blood through healthier veins.

NICE recommends this where endothermal treatment is unsuitable.

Surgery

Traditional surgery involves tying and removing affected veins.

It remains an option where less invasive treatments are unsuitable.

What happens to the blood if a vein is closed?

This understandably worries people.

Closing or removing an incompetent superficial vein does not stop blood returning from the leg.

The treated vein is already functioning poorly. Blood is instead redirected through other healthy veins, particularly the deeper venous system.

Can varicose veins come back after treatment?

Yes.

Treatment can successfully close or remove the veins causing problems, but it cannot prevent every future vein from becoming incompetent.

New varicose veins may therefore develop later, and some patients need more than one treatment session. NICE recommends that this possibility is explained when treatment options are discussed.

What if a varicose vein starts bleeding?

Although uncommon, varicose veins close to the surface can sometimes bleed significantly, particularly where the overlying skin has become fragile.

If this happens:

  1. Lie down.

  2. Raise the affected leg.

  3. Apply firm, continuous direct pressure to the bleeding point.

  4. Seek urgent medical assistance if bleeding is heavy or does not stop.

Anyone who has had bleeding from a varicose vein should subsequently be referred urgently for vascular assessment because it can bleed again.

NICE recommends immediate vascular referral for bleeding varicose veins.

When should I seek urgent medical advice?

Seek urgent assessment if:

  • A vein suddenly becomes hard, hot and painful

  • One leg suddenly becomes significantly swollen

  • There is increasing redness, warmth or tenderness

  • You develop a wound or ulcer

  • A varicose vein bleeds

Sudden leg swelling or pain can sometimes have another cause such as a DVT or cellulitis, so it should not simply be assumed to be the varicose veins.

Varicose veins and your podiatry assessment

At Blackfords Footcare, varicose veins and other signs of venous disease are often visible during examination of the feet and lower limbs.

We may identify associated findings such as:

  • Ankle or lower-leg swelling

  • Thread veins or ankle flare

  • Brown pigmentation

  • Venous eczema

  • Skin thickening

  • Superficial inflammation

  • Wounds or ulceration

Where appropriate, we can also assess the arterial circulation of the feet and lower limbs. This can be particularly important where compression treatment is being considered.

We do not perform specialist treatment of varicose veins within the clinic, but where your symptoms or skin changes indicate significant venous disease, we can explain our findings and recommend appropriate onward assessment.

Varicose veins that cause pain, swelling, skin changes or ulceration are not simply a cosmetic concern and may warrant vascular assessment.