Varicose Veins
Varicose veins are enlarged, twisted, and visibly bulging veins, most often appearing in the legs. They are part of a broader spectrum of chronic venous disease and develop when the valves inside the leg veins do not work properly, allowing blood to pool. Varicose veins can be a cosmetic concern, a source of discomfort, or, in more advanced cases, contribute to skin changes, swelling, and ulcers. Ultrasound is the primary diagnostic tool, and treatment options range from compression and lifestyle measures to minimally invasive procedures and surgery.
What is it?
The veins in the legs are responsible for returning blood from the lower body back to the heart. To do this against gravity, the veins use a combination of muscle pumps (especially the calf muscles) and one-way valves that open to let blood flow upward and close to prevent it from flowing back down. When these valves do not work properly—a condition called venous insufficiency—blood can pool in the veins, causing them to stretch, enlarge, and become twisted. Varicose veins are the visible, enlarged surface veins that often result from this process.
Varicose veins are part of a broader spectrum of chronic venous disease. Mild forms can include spider veins (small, web-like red or blue veins close to the skin’s surface) and reticular veins (slightly larger but still relatively superficial veins). Varicose veins themselves are larger and visibly bulging or twisted, often appearing on the calves, thighs, or behind the knees. More advanced chronic venous disease can produce significant swelling, skin changes (such as brownish discoloration, hardening, or eczema-like changes), and venous ulcers, particularly around the ankles.
Several factors contribute to the development of varicose veins. A family history of vein disease is one of the strongest contributors, and there is often an inherited tendency for valve dysfunction or vein wall weakness. Female sex, increasing age, pregnancy (because of increased blood volume, hormonal changes, and pressure from the growing uterus), obesity, prolonged standing or sitting (especially in certain occupations), prior deep vein thrombosis (which can damage vein valves), and prior trauma or surgery to the legs can all increase risk. Conditions that increase pressure in the abdomen or pelvis—such as pelvic masses or, in some patients, anatomic compression of pelvic veins—can also contribute.
Symptoms vary widely. Many people with varicose veins primarily notice the cosmetic appearance of the visible veins. Others experience aching, throbbing, heaviness, fatigue, or cramping in the legs—often worse at the end of the day, after prolonged standing or sitting, or in warm weather. Itching or burning over the veins, mild swelling, and a feeling of restlessness in the legs (sometimes contributing to restless legs symptoms) are also common. Symptoms often improve with leg elevation or activity. Some patients experience superficial thrombophlebitis (clotting within a superficial vein), bleeding from a varicose vein after minor trauma, or, in more advanced disease, skin changes and venous ulcers that can be painful and slow to heal.
Diagnosis usually begins with a careful clinical evaluation, including examination of the legs in the standing position. Doppler ultrasound is the primary imaging test for evaluating varicose veins. It provides detailed information about the size and course of the veins, the function of the valves (showing whether blood is flowing backward through the veins), the location of incompetent perforator veins, and the presence of any deep vein disease or clots. Additional imaging—such as CT or MR venography—is occasionally used to evaluate the pelvic and abdominal veins, particularly when symptoms are atypical, recurrent, or when pelvic vein involvement is suspected.
Important to Know
Management of varicose veins is individualized and depends on the severity of disease, symptoms, cosmetic concerns, and overall health. For many patients with mild varicose veins, conservative measures provide significant relief, while more bothersome or advanced disease often benefits from procedural treatment.
Conservative measures include leg elevation when resting, regular physical activity (especially calf-pumping activities such as walking, cycling, and swimming), weight management, avoiding prolonged standing or sitting without breaks, and skin care to prevent dryness and skin breakdown. Compression stockings are a cornerstone of conservative management and can substantially improve symptoms by supporting the veins and reducing pooling. Different levels of compression are available, and patients with significant disease or skin changes often benefit from prescription-strength stockings recommended by a clinician.
For varicose veins that remain bothersome despite conservative measures, or for more advanced chronic venous disease, several minimally invasive procedures are available. Endovenous thermal ablation—using laser energy (EVLA) or radiofrequency (RFA)—is now a common first-line treatment for incompetent saphenous veins. These procedures use a catheter inserted into the abnormal vein to deliver heat that seals it closed, redirecting blood flow to healthier veins. Mechanochemical and chemical ablation techniques use mechanical disruption or specialized sclerosing solutions to achieve similar results without heat. Sclerotherapy involves injecting a solution directly into smaller varicose or spider veins to scar them closed and is particularly effective for cosmetic concerns and tributaries. Ambulatory phlebectomy uses small skin incisions to remove larger varicose veins. Traditional surgical stripping is still used in selected cases. The choice of procedure depends on the specific veins involved, anatomy, symptoms, and patient preferences.
Treatment of advanced chronic venous disease often involves a combination of approaches. Venous ulcers are managed with specialized wound care, compression therapy, and treatment of the underlying vein disease. Patients with significant pelvic vein involvement may benefit from targeted treatment of those veins.
Even after successful treatment, varicose veins can recur or new ones can develop over time. Ongoing use of compression stockings, healthy lifestyle measures, and periodic follow-up are often recommended.
Care is typically coordinated by primary care clinicians, vascular surgeons, vascular medicine specialists, interventional radiologists, dermatologists with vein expertise, and other relevant providers. Imaging findings are interpreted alongside symptoms, examination, and the patient’s overall goals and preferences.
Although varicose veins are very common and often considered a “minor” condition, untreated significant venous disease can lead to substantial discomfort and complications. Early evaluation and appropriate management can substantially improve quality of life.
Red flag symptoms include sudden severe leg pain or swelling (which may suggest deep vein thrombosis), shortness of breath or chest pain (which may suggest pulmonary embolism), heavy bleeding from a varicose vein, signs of infection of the leg or skin (such as redness, warmth, fever), non-healing or rapidly worsening leg ulcers, or sudden change in skin color of the leg. These warrant prompt or urgent medical evaluation.