Patient Information - Varicose Veins General Information

'The information contained in this patient information sheet is not a substitute for medical advice or
treatment, and the Society recommends consultation with your doctor or health care professional'

1. What are Varicose Veins?

• Varicose veins are veins under the skin of the legs, which have become widened, bulging, and tortuous. They are very common and do not cause medical problems in most people.

• Blood flows down the legs through the arteries, and back up the legs through the veins.
• There are two main systems of veins in the legs - the deep veins which carry most of the blood back up the legs to the heart, and the veins under the skin, which are less important and which can form varicose veins.
• All these veins contain valves, which should only allow the blood to flow towards the heart. Failure of the valves allows blood to flow backwards down the veins and produce a head of pressure when standing. This excess pressure leads to dilation of the veins and the appearance of varicose veins.

2. What causes varicose veins?

• Varicose veins and spider veins often run in families and there may be a hereditary component. Women are more likely to suffer from varicose veins and up to 50% of women may be affected. Hormonal factors including puberty, pregnancy, menopause, the use of birth control pills, and HRT affect the disease.
• It is very common for pregnant women to develop varicose veins during the first trimester. Pregnancy causes increases in hormone levels and blood volume which in turn cause veins to enlarge. In addition, the enlarged uterus causes increased pressure on the veins. Varicose veins due to pregnancy often improve within 3 months after delivery. However, with successive pregnancies, abnormal veins are more likely to remain. Other predisposing factors include ageing, standing occupations, obesity and leg injury.

3. How do varicose veins present?

• Very many people have no symptoms at all from their varicose veins, except for the fact that they are noticeable, and their appearance can be embarrassing. Simply having varicose veins is not a good reason for going to a doctor or having treatment.
• Other than cosmetic embarrassment the commonest symptoms from varicose veins are aching, discomfort, and heaviness of the legs, which are usually worse at the end of the day. Sometimes the ankle can swell, too. These symptoms are not medically serious, but can be treated if they are sufficiently troublesome.
• Although varicose veins can get worse over the years, this often happens very slowly and worry that "they might get worse" is not a good reason for treatment if the veins are not causing symptoms.
• In a few people the high pressure in the veins causes damage to the skin near the ankle, which can become brown in colour, sometimes with scarred white areas. Eczema (a red skin rash) can develop.

• If these skin changes are allowed to progress, or if the skin is injured, an ulcer may result. Skin changes are therefore a good reason for going to see your GP and for referral to a specialist.
• In many areas there are special leg ulcer bandaging clinics, supervised by the skin specialists and run by specially trained nurses. Your GP may refer you there, rather than to a surgeon in the first instance.
• Other problems, which varicose veins can occasionally produce, are phlebitis and bleeding. Phlebitis (sometimes called thrombophlebitis) means inflammation of the veins, and is often accompanied by some thrombosis (clotting of blood) inside the affected veins, which become hard and tender. This is not the same as deep vein thrombosis (DVT) and is not usually dangerous. It does not mean that the varicose veins necessarily have to be treated.
• The risk of bleeding as a result of knocking varicose veins worries many people, but this is very rare. It will always stop with firm pressure and the veins can then be treated to remove the risk of further bleeding.
• Varicose veins are associated with DVT in some patients. It is not clear whether varicose veins themselves increase the risk of DVT, but certainly DVT leads to varicose veins and skin damage around the ankle.

4. What tests can be used to investigate varicose veins?

• Most varicose veins originate from leaking valves at groin level or behind the knee. It is important to accurately locate the site of the valve leaks.
• At your outpatient appointment the doctor will use a small probe to assess your veins. It is called continuous wave Doppler. The probe can detect the direction of blood flow which is audible, both in the skin veins and in the deep veins. It indicates  where the veins have come from and helps in the planning of any operation that might be required.
• Sometimes a more detailed scan, called a Duplex scan, will be required if the simple Doppler probe doesn’t give the whole answer. This is usually done by appointment on a different day. It looks in detail at the skin veins and deep veins. It can detect leaking valves and evidence of previous blood clots in the deep veins (deep vein thrombosis or DVT).
• Very occasionally, if the scan is not clear, an X-ray of the veins, called a venogram, may be required. This involves the injection of dye (contrast) into a vein in the foot. The contrast can be seen outlining the veins in the calf and thigh, and is the best way of detecting previous damage to the deep veins. Other scans which are sometimes used include MRI and CT. 

5. Who is at risk?

• Varicose veins are very common and affect women more than men.
• Pregnancy is often the time when varicose veins first begin. They often disappear after the first pregnancy, but tend not after subsequent pregnancies.
• Jobs involving long periods of standing often make the symptoms of aching worse.

• Surgery: The operation is usually performed under general anaesthesia. Through tiny incisions, the varicose veins are removed. This deals with the cosmetic problem.
• To deal with the cause of the veins, an incision is usually made in the groin. The main skin vein is tied off and divided. It is then stripped out of the thigh to knee level where there is another tiny incision to retrieve it.
• Sometimes if the main vein on the back of the knee contains leaky valves, a further horizontal incision is required here to ligate it as well.
• Perforator surgery: Some patients have leaky valves in perforator veins, which are veins connecting the deep and skin vein systems. This occurs particularly in the calf on its inner aspect. Ligation of these veins may occasionally be indicated. It can be done either through a long incision down the back of the calf, or more commonly now using a keyhole technique.
• The keyhole technique (subfascial endoscopic perforator surgery or SEPS) involves a small incision in the upper calf through which a telescope is passed under the skin. The perforators are then ligated under direct vision without any other skin incisions.
• There are some new types of venous surgery which are minimally invasive and these include laser ablation and radiofrequency ablation.

8. Is treatment successful?

• Stockings are effective in controlling symptoms and preventing skin complications. They are only effective if worn regularly.
• Injection of varicose veins can be successful, but the long term outcome of the new treatment of foam sclerotherapy requires further evaluation.
• Surgery is followed by a recurrence rate of about 1 in 7 over a ten year period. This recurrence may be due to poorly planned or performed surgery, new vein formation, or due to new valve leaks beginning elsewhere. 

9. Can I help myself?

• Simple measures such as wearing support stockings will control the symptoms for many people. Stockings may help to prevent progression or enlargement of varicose vein. If you are overweight you should try and lose weight.

The Vascular Society is grateful to Mr Simon Parvin and members of the Audit and Research Committee for writing this information leaflet.

March 2006