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?
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.
Clinical guidelines for varicose veins
These guidelines give you a useful overview and more detailed information on the management of varicose veins:
The NICE guideline for varicose veins (Web page)
The NICE Clinical Knowledge Summary for Varicose Veins (Web page)
The Venous Forum of the Royal Society of Medicine have published guidance on management of varicose veins (PDF download)
Research surrounding varicose veins
You will find lots of research evidence to support practice, including a number of systematic reviews about the management of varicose veins.
The Cochrane Library publishes systematic reviews about the effectiveness of many treatments for varicose veins.
Publications & Evidence for varicose veins
We’ve carefully curated resources to help in your everyday work.
A Randomized Trial of Early Endovenous Ablation in Venous Ulcerations (Web page)
Patient information for varicose veins
The patients, family and friends section has lots of useful, accessible information for your patients.
The Circulation Foundation The Circulation Foundation is the UK’s only dedicated vascular charity. They fund and promote research into the causes, treatment and prevention of vascular disease.
020 7205 7151
Find out more on The Circulation Foundation website
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