Varicose Veins

Topic Overview

What are varicose veins?

Varicose veins are twisted, enlarged veins near the surface of the skin. They most commonly develop in the legs and ankles.

See a picture of varicose veins .

What causes varicose veins?

Varicose veins develop when you have faulty valves in your veins and weakened vein walls. Normally, the one-way valves in these veins keep the blood flowing efficiently against gravity up toward the heart. When these valves do not function properly, blood pools, pressure builds up, and the veins become weakened, enlarged, and twisted. This is called venous insufficiency.

Some people may be more likely than others to develop varicose veins because of inherited characteristics (genetics) and the aging process. Varicose veins may also result from conditions that increase pressure on the leg veins, such as being overweight or pregnant or having an occupation that requires standing for long periods of time.

What are the symptoms?

People with varicose veins often do not have symptoms but may be concerned about the appearance of the veins. Varicose veins are visible through the skin and appear dark blue, swollen, and twisted. If you have varicose veins, your legs may feel heavy, tired, achy, and painful. Symptoms may be worse after standing or sitting for long periods of time. Varicose veins can also cause skin color changes (stasis pigmentation), dry, thinned skin, skin inflammation, open sores (ulcerations), or bleeding after a minor injury.

Superficial thrombophlebitis (when a blood clot and inflammation develop in a small vein near the surface of the skin) can develop in varicose veins.

Varicose veins are common and are usually not a sign of a serious medical problem. But in some cases varicose veins can signal a blockage in the deeper veins. This condition, called deep vein thrombosis, requires evaluation and possibly treatment.

How are varicose veins diagnosed?

To diagnose varicose veins, your doctor will examine your legs and feet. Varicose veins are easy to see, especially when you are standing. The doctor will also check your legs for tender areas, swelling, skin color changes, ulcers, and other signs of skin breakdown.

Additional testing may also be needed if you are considering varicose vein surgery or other vein treatments.

How are they treated?

Self-care measures such as wearing compression stockings , elevating your legs, and exercising regularly may relieve symptoms and keep varicose veins from getting worse.

Sclerotherapy, endovenous laser or radiofrequency treatment (which uses heat to close off varicose veins), or surgery to treat varicose veins may be considered when symptoms persist. These procedures may also be used if you are concerned about the appearance of varicose veins.

Frequently Asked Questions

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	Should I have a surgical procedure for varicose veins?

Cause

Varicose veins are enlarged veins that usually occur just under the skin (superficial veins). Varicose veins are likely to be caused by one or more factors, including:

• Increased pressure in the leg veins.
• Damage to the leg veins.
• Damage to the valves of the leg veins.

Varicose veins often run in families. You may be born with defective valves or weak walls in your veins, or you may develop them later in life.

Pregnancy is a common cause of varicose veins. During pregnancy, hormones relax the veins and more blood travels through the veins. Extra weight and a heavy uterus place pressure on leg veins, too.

Less commonly, varicose veins may be a sign of a more serious problem that may sometimes need treatment. These serious problems can include:

• Blood clots or blockage in the deep veins or perforating veins.
• Injury to the deep veins.
• Abnormal blood vessels between arteries and veins (arteriovenous fistulas). A person may be born with these problems or develop them later in life.
• Tumors (very rarely).

Symptoms

You may not have symptoms with varicose veins. Most people identify varicose veins by the appearance of twisted, swollen, bluish veins just beneath the skin.

If you have symptoms of varicose veins, they tend to be mild and may include:

• A dull ache, burning, or heaviness in the legs. These symptoms may be more noticeable late in the day or after you have been sitting or standing for a long time.
• Mild swelling, usually involving the feet and ankles only.
• Itching skin over the varicose vein.

More severe symptoms or complications include:

• A buildup of fluid and swelling in the leg.
• Significant swelling and calf pain after sitting or standing for a long time.
• Skin color changes (stasis pigmentation) around the ankles and lower legs.
• Dry, stretched, swollen, itching, or scaling skin.
• Superficial thrombophlebitis (when a blood clot and inflammation develop in a small vein near the surface of the skin).
• Open sores (ulcerations).
• Bleeding and/or bruising after a minor injury.

Symptoms of varicose veins may become more severe a few days before and during a woman's menstrual period.

What Happens

Most varicose veins are not a serious medical problem, but they sometimes can lead to complications.

Complications can include:

• Bleeding from a varicose vein, which may occur without an injury or after an injury to the thin skin over the varicose vein. Bleeding can be heavy, but it can be controlled by elevating the leg and applying pressure to the area that is bleeding.
• Blood clots or inflammation (superficial thrombophlebitis), when a blood clot and inflammation develop in a small vein near the surface of the skin. Unlike blood clots in deep veins, clots in superficial veins rarely travel to the heart or lungs, where they could cause serious blockages.
• Dry, stretched, swollen, itching, or scaling skin.
• Thin, fragile, easily injured skin at or above the ankle.
• Open sores (ulcers), usually near the ankles.
• Skin color changes (stasis pigmentation) around the ankles and lower legs.
• Fungal and bacterial infections, which may arise from skin problems resulting from fluid buildup (edema) in the leg and increased risk of tissue infection (cellulitis).

Varicose veins most often are a result of problems in the superficial veins just under the skin. But they can happen along with problems or disease in the deep veins and perforating veins, which connect the deep and the superficial veins. Complications are much more common when they are caused by or linked with these deeper veins.

You can limit the progress and discomfort of varicose veins by:

• Exercising. Walking, bicycling, and swimming are recommended for varicose veins.
• Wearing compression stockings. They improve circulation and are a mainstay of treatment for varicose veins that are causing symptoms.
• Regularly elevating the legs. Elevating your legs helps keep the blood from pooling in your lower legs and improves blood flow to the rest of your body.
• Avoiding long periods of standing or sitting. Sitting or standing still for long periods of time puts added stress on the veins in your legs.

What Increases Your Risk

Factors that increase your risk of developing varicose veins include:

• Pregnancy (particularly repeated pregnancies).
• Being female.
• Advancing age.
• Being overweight (tends to be a stronger factor in women). Having low muscle mass and high body fat decreases the support for the veins.
• Family history of varicose veins.
• Prolonged sitting or standing.
• Conditions that increase pressure in the abdomen, such as liver disease, fluid in the abdomen, previous groin surgery, or heart failure.
• Injury to the veins.
• Blood clots.

When To Call a Doctor

Call your doctor if you have varicose veins and:

• Your leg suddenly becomes swollen and painful. You might have a blood clot in a deep vein, which can be serious and may need prompt attention.
• Skin over a varicose vein begins to bleed on its own or when it is injured. The skin over varicose veins is often thin and can bleed heavily. If this happens, elevate your leg and apply pressure directly to the vein to stop the bleeding.
• Your leg has a tender lump. This could be a clot or inflammation in a vein just under the skin, which is usually not dangerous but may need treatment.
• You develop an open sore (ulcer).
• Your varicose vein symptoms don't improve with home treatment, or there are symptoms you are concerned about.

Watchful Waiting

Varicose veins are common and are generally not a serious health problem. With a doctor keeping an eye on the condition, most people can manage varicose veins with home treatment, such as exercising, wearing compression stockings, and elevating the legs.

Who To See

Primary care doctors (including internists, family medicine doctors, and general practitioners) can diagnose, treat, and monitor varicose veins and most of the complications they may cause.

Sclerotherapy or surgery may be done by:

• A surgeon who specializes in blood vessel problems (vascular surgeon).
• A dermatologist.
• A plastic surgeon.
• Other doctors with special training and experience in sclerotherapy or varicose vein surgery.

To prepare for your appointment, see the topic Making the Most of Your Appointment.

Exams and Tests

The most important tools in diagnosing varicose veins are the physical examination and medical history. Varicose veins are typically diagnosed based on their appearance, and no other special tests are needed to confirm the diagnosis.

If a problem with the deep veins or complications are suspected based on your symptoms and exam, other tests may be done.

If you are considering varicose vein surgery or sclerotherapy, further testing can help pinpoint the location of the vein problem so that treatment will have the best chance of success.

• Duplex Doppler ultrasound is the most commonly used noninvasive test that can help your doctor study blood flow in your leg veins.
• Venogram may be done to assess complications of varicose veins, such as those related to the deep veins. This test is rarely helpful in the diagnosis or treatment of varicose veins.

Treatment Overview

The goals of varicose vein treatment are to reduce symptoms and prevent complications. For some, the goal may be improved appearance. Home treatment-especially exercising, wearing compression stockings , and elevating the legs-is the first and often best approach.

If home treatment does not help, there are treatment options. Vein surgery, called ligation and stripping, is a standard treatment for problem varicose veins. But laser or radiofrequency vein treatments are likely to give good results with less risk, less pain, and a shorter recovery time.¹ Because these are fairly new treatments, long-term results aren't yet known. If you plan to have laser or radiofrequency treatment, look for a doctor with a lot of experience.

• Ligation and stripping. Incisions are made over the varicose veins, and the vein is tied off (ligated) and removed (stripped).
• Sclerotherapy. A chemical (sclerosant) is injected into a varicose vein to damage and scar the inside lining of the vein, causing the vein to close. This usually works best for small veins.
• Laser treatment. Laser energy is used to scar and destroy varicose veins. This is called ablation. Endovenous laser therapy uses a laser fiber inserted into the vein. Laser ablation inside the vein makes the vein close up.
• Radiofrequency treatment. Radiofrequency energy (instead of laser energy) is used inside a vein to scar and close it off. It can be used to close off a large varicose vein in the leg. This ablation treatment is new and may not be available in your area.

Treatment may be necessary to remove the damaged veins, treat complications, or correct an underlying problem that is causing the varicose veins. The size of your varicose veins affects your treatment options. Generally, larger varicose veins are treated with surgery (ligation and stripping), endovenous laser, or radiofrequency treatment. In some cases, a combination of treatments may work best. Smaller varicose veins and spider veins are usually treated with sclerotherapy or laser therapy on your skin.

Some people may want to improve how their legs look, even though their varicose veins are not causing other problems. In these cases, surgery, sclerotherapy, or laser or radiofrequency treatment may be appropriate-as long as there are no other health problems that make these treatments risky. For more information, see:

Should I have a surgical procedure for varicose veins?

What To Think About

Doctors recommend home treatment as a first step for varicose veins. This may be all you need to relieve symptoms. But you may still want surgery or vein treatment if you are not satisfied with their appearance or your symptoms are not well controlled.

If you are thinking about having surgery or a vein treatment, you may want to know which treatment is best for you. No single approach is best for treating all varicose veins. Sclerotherapy, endovenous laser, or radiofrequency treatment may be best for smaller veins. Surgery may work better for larger veins, though laser or radiofrequency treatment may also work well (long-term studies are not yet done). Talk to your doctor about your choices.

Many treatment methods-including all types of surgery, sclerotherapy, laser, and radiofrequency ablation-can scar or discolor the skin.

People whose deep veins are also damaged or who have problems with perforating veins, which connect the deep and superficial veins, may not be able to treat their varicose veins with conventional therapy, such as surgery or sclerotherapy. Tests, such as Doppler ultrasound, may help your doctor determine whether your varicose veins can be treated.

Prevention

Varicose veins may be prevented to some extent by:

• Wearing compression stockings. They improve circulation and are a mainstay of treatment for varicose veins that are causing symptoms.
• Regularly elevating the legs. Elevating your legs helps keep the blood from pooling in your lower legs and improves blood flow to the rest of your body.
• Avoiding long periods of standing or sitting. Sitting or standing still for long periods of time puts added stress on the veins in your legs.
• Exercising and controlling your weight. Walking, bicycling, and swimming are recommended for varicose veins.

These suggestions can relieve your symptoms, slow the progression of varicose veins, and prevent complications such as sores or bleeding. They are especially important if you have a family history of varicose veins. These measures may help you avoid surgery or other medical treatment for your varicose veins.

Home Treatment

Home treatment is recommended for most people with varicose veins that aren't causing more serious problems. Home treatment can relieve symptoms and slow down the progress of varicose veins. For many people with varicose veins, home treatment is the only treatment they need.

If you have varicose veins, you can help control the problem and keep it from getting worse if you:

• Wear compression stockings. Compression stockings improve circulation and are the mainstay of treatment for varicose veins.
• Elevate your legs. Prop up your legs at or above the level of your heart when possible.
• Avoid long periods of sitting and standing. Standing or sitting for long periods puts added stress on the veins in your legs.
• Exercise and control your weight. Walk, bicycle, or swim to improve blood circulation in your legs.

Superficial varicose veins can sometimes cause minor problems like bruising or bleeding if you scratch or cut the skin over a larger vein. Small blood clots may occasionally form in the surface veins (superficial phlebitis). Most of these problems can be safely treated at home.

• If you bump your leg so hard that you know it is likely to bruise, elevate your leg and apply ice or a cold pack as soon as you can for the next hour or two. This may help reduce the amount of bleeding under the skin and minimize bruising.
• If you cut or scratch the skin over a vein, it may bleed a lot. Elevate your leg and apply firm pressure with a clean bandage over the site of the bleeding. Continue to apply pressure for a full 15 minutes. Do not check to see if the bleeding has stopped sooner. If the bleeding hasn't stopped after 15 minutes, apply pressure again for another 15 minutes. You can repeat this up to three times for a total of 45 minutes.

Signs of a small blood clot in a superficial varicose vein (superficial phlebitis) include tenderness and swelling over the vein. The vein may feel firm. If your doctor has told you how to care for superficial phlebitis, follow his or her instructions.

• Often doctors will recommend that you elevate your leg and apply heat with a warm, damp cloth or a heating pad set on low (to prevent burns, put a towel or cloth between your leg and the heating pad).
• Your doctor may also tell you to take a nonsteroidal anti-inflammatory drug (for example, two aspirin or ibuprofen tablets taken 3 to 4 times a day at first and less often as your symptoms go away).
• Talk to your doctor if you are not sure that your symptoms are caused by a superficial blood clot or if you are not sure how to treat your symptoms.

Medications

Medicines are not generally used to treat varicose veins.

Anticoagulant medicines (blood thinners) are often needed to treat deep vein thrombosis (blood clots that develop in deep veins), which can cause varicose veins to develop.

Surgery

Surgery may be used to treat varicose veins if:

• The varicose veins have not responded to home treatment and your symptoms are bothering you.
• You are concerned about the way varicose veins look, and laser treatment, radiofrequency treatment, or sclerotherapy is not likely to improve their appearance to your satisfaction.

For more information on making the decision about surgery, see:

Should I have a surgical procedure for varicose veins?

Tying off (ligation) and removing (stripping) larger varicose veins is a standard surgical treatment. But newer, less invasive techniques are likely to give good results with less risk.^{1, 2} These techniques include laser treatment (including endovenous laser); microphlebectomy, or stab avulsion; and radiofrequency treatment.

Direct vein reconstruction of damaged veins caused by deep vein problems or diseases is not done often, because it is considered an experimental treatment.

Surgery Choices

Vein ligation and stripping involves tying off (ligation) and removing (stripping) larger varicose veins.

What To Think About

If you are considering surgery, you will probably need to have tests (such as duplex ultrasound) to pinpoint where damaged valves are in your veins. These tests can increase the chances of having a successful surgery.

Some people may want to have surgery to improve how their legs look, even though their varicose veins are not causing other problems. Surgery may be appropriate in some cases as long as you do not have other health problems that make the treatment risky.

Keep in mind that surgery for varicose veins done only for cosmetic reasons (that is, not medically necessary) is usually not covered by insurance.

In some cases, a combination of surgery and sclerotherapy may be used to treat varicose veins. Sclerotherapy is a nonsurgical procedure in which a chemical is injected into the vein, causing the vein to close off.

Other Treatment

There are several nonsurgical vein treatments for treating varicose veins.

Sclerotherapy is commonly used for treating spider veins or individual, small veins or after surgery (ligation and stripping) on larger varicose veins. But more recent advances now make sclerotherapy an effective option for larger veins. Laser therapy has traditionally been used on smaller varicose veins, especially spider veins. Laser and radiofrequency techniques are now treatment options for larger veins.

Other Treatment Choices

Sclerotherapy is a nonsurgical procedure in which a chemical is injected into the vein, causing the vein to close off.

Newer techniques

• Laser therapies (including endovenous laser) use the heat of laser energy to scar and close off varicose veins.
• Microphlebectomy, or stab avulsion, is a technique in which several tiny incisions are made in the skin through which the varicose vein is removed.
• Radiofrequency treatment uses radiofrequency energy to close off a large varicose vein.

What To Think About

People who have laser or radiofrequency treatment generally feel less pain and heal faster than people who have vein surgery.¹

Some people may want to have vein treatment to improve how their legs look, even though their varicose veins are not causing other problems. Vein treatments may be appropriate in some cases as long as you do not have other health problems that make the treatment risky. For more information on making this decision, see:

Should I have a surgical procedure for varicose veins?

Keep in mind that vein treatments done only for cosmetic reasons are not likely to be covered by insurance.

Complications of varicose veins may require further treatment, especially if you have developed severe varicose veins or chronic venous insufficiency.

Other Places To Get Help

Organizations

Related Information

• Deep Vein Thrombosis
• Pregnancy
• Venous Skin Ulcer

References

Citations

1. Bartholomew JR, et al. (2005). Varicose veins: Newer, better treatments available. Cleveland Clinic Journal of Medicine, 72(4): 312-328.

2. Tisi P (2007). Varicose veins, search date March 2006. Online version of BMJ Clinical Evidence. Also available online: http://www.clinicalevidence.com.

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