Varicose veins

Varicose veins are very common and can cause symptoms such as pain, heaviness, itching and swelling of the leg.

Causes of varicose veins

Blood is pumped from the heart to the rest of the body through arteries and returns to the heart through the veins. Blood from the lower legs and feet is propelled back to the heart by the heart pumping and by being pushed by the leg and foot muscles during walking and when the ankle is moved.

The veins contain one-way valves to prevent backflow or the blood falling back towards the toes. These valves can become weak or damaged leading to venous back flow. This causes venous hypertension and/or varicose veins. Oedema and skin changes such as brown staining in the gaiter area are all signs of hypertension.

Many people with varicose veins in the legs have no symptoms but some people find their lower legs are painful or aching, feel swollen and heavy or itchy. Symptoms can often get worse during the day or towards the evening especially around the ankle area. When legs are elevated (such as at night time) the swelling often reduces and symptoms improve.

What do varicose veins look like?

An image of varicose veins around a person's knee - Legs Matter — Varicose veins can appear dark blue and stick out from the skin, a little like raised tunnels. They can develop anywhere in the body, but are often found around the legs and ankles.

Assessment of a patient with varicose veins

You should carry out a comprehensive assessment of everyone who presents with varicose veins.

Make sure you immediately refer anyone with bleeding varicose veins to a vascular service.

You should also refer people to a vascular service if they have the following symptoms:

Symptomatic primary or symptomatic recurrent varicose veins
Lower‑limb skin changes, such as pigmentation or eczema, thought to be caused by chronic venous insufficiency
Superficial vein thrombosis (characterised by the appearance of hard, painful veins) and suspected venous incompetence

People with open and healed venous leg ulceration (a break in the skin below the knee that has not healed within 2 weeks) may also benefit from being referred to a vascular service for assessment of the extent of the venous disease and possible surgery. This vascular service assessment should include a duplex ultrasound to confirm the diagnosis of varicose veins and the extent of truncal reflux, and to plan treatment for people with suspected primary or recurrent varicose veins.

Treatment for varicose veins

At the initial consultation, you should give people who present with varicose veins the following information:

An explanation of what varicose veins are
Possible causes of varicose veins
The likelihood of progression and possible complications, including deep vein thrombosis, skin changes, leg ulcers, bleeding and thrombophlebitis.

You should also address any misconceptions the person may have about the risks of developing complications, and discuss possible treatment options. Make sure you cover symptom relief, an overview of interventional treatments and the role of compression.

You should also offer your patient advice on:

Weight loss and smoking
Light to moderate physical activity
Avoiding factors that are known to make their symptoms worse
When and where to seek further medical help

Compression hosiery should not be used to treat varicose veins unless interventional treatment is unsuitable.

You can also consider these interventional treatments for people with confirmed varicose veins and truncal reflux:

Endothermal ablation and endovenous laser treatment of the long saphenous vein
If endothermal ablation is unsuitable, ultrasound‑guided foam sclerotherapy may be offered
If ultrasound‑guided foam sclerotherapy is unsuitable, surgery may be offered
If incompetent varicose tributaries are to be treated, this may be offered at the same time
If compression bandaging or hosiery for use after interventional treatment is offered, it should not be used for more than 7 days

When discussing treatment options with patients, make sure they are aware of:

The expected benefits and risks of each treatment option
That new varicose veins may develop after treatment
That they may need more than 1 session of treatment
That the chance of recurrence after treatment for recurrent varicose veins is higher than for primary varicose veins

Management of varicose veins during pregnancy

If your patient is pregnant and has varicose veins:

Give them information on the effect of pregnancy on varicose veins
Do not offer them interventional treatment for varicose veins except in exceptional circumstances
Consider using compression hosiery for symptom relief of leg swelling.