Varicose veins affect up to 20% of men and up to a third of women in the UK. But despite how common they are, there are several misconceptions about them, from confusion over what causes them to how symptoms present. To clear things up, it helps to understand how varicose veins develop, who is at risk and how they are treated.
Varicose veins are veins that become bigger than normal (dilated). Varicose veins only occur in the veins that sit under your skin (superficial veins) as opposed to the veins that sit within your muscles, closer to the core of your body (deep veins).
Veins carry blood from your tissues and organs back to your heart and consequently are structurally different to arteries that pump blood from your heart to the rest of your body. Your arteries are made to cope with the higher blood pressure needed to get blood to all the parts of your body. Meanwhile, your veins carry blood at a lower pressure and to do this effectively they contain valves that prevent blood from flowing backwards ie away from the heart.
Focusing on your legs, there are two main superficial veins in each of your legs. One vein starts on the inside of your foot and runs along the inside of your leg and thigh until it reaches your groin where it connects to the deep veins. The other main superficial vein starts from the outer side of your foot and runs along the back of your leg until it reaches the back of your knee where it joins the deep veins. There are also small veins called communicators or perforators that connect the superficial and deep veins and connect the superficial veins together.
Varicose veins develop when there is a problem with the valves in your veins. This causes the veins to become bigger, longer and tortuous (twisted).
Varicose veins most often develop in the legs. This is because when you stand or sit, greater pressure is applied to the superficial veins in your legs, which over time can weaken or damage their valves. When these valves stop working properly, blood in your veins stops exclusively flowing towards your heart but also flows backwards.
For the veins in your legs that carry blood from your feet back to your heart, blood flow is no longer exclusively upwards but up and down due to the effect of gravity, which your faulty veins can’t effectively combat.
Varicose veins can run in families. If one of your parents has varicose veins, your risk is increased. If both of your parents have varicose veins, your risk is further increased.
Lifestyle factors also affect your risk, specifically working in jobs that require standing for long periods of time. Chefs, hairdressers, waiters and waitresses, and surgeons are all more likely to develop varicose veins.
Hormones play a part too, making varicose veins more common in women than men. In women, pregnancy also increases the risk as the growing size of the womb pushes against veins in the pelvis, which consequently increases the pressure on veins in the legs.
Pregnant women with varicose veins often find that after delivering their first baby, their varicose veins disappear. However, with subsequent pregnancies, the varicose veins return and can be worse. In some cases, after multiple pregnancies, the varicose veins may remain even after delivery.
Previous deep vein thrombosis (DVT) is also a risk factor for varicose veins.
Most people realise they have varicose veins when they notice bulging, blue or dark purple veins on their legs. This may be the only symptom as varicose veins can often cause no other problems, besides cosmetic issues.
That said, varicose veins can cause an aching, burning, heavy or throbbing sensation in your legs, swollen ankles and feet, leg muscle cramps (especially at night) and changes in your skin, including dryness and itching. These symptoms often ease overnight while you are sleeping and your legs are therefore elevated. However, throughout the day, symptoms usually worsen.
As mentioned earlier, there are several common myths about varicose veins. Here we’ll tackle the top four misconceptions and concerns that, as a Consultant Vascular and Endovascular Surgeon, I often hear from patients:
“Haemorrhoids are varicose veins,” and “if I have haemorrhoids, I’m more likely to have varicose veins.”
Haemorrhoids refer to enlarged veins around the anus. However, they are not varicose veins and if you have haemorrhoids, you are not more likely to have varicose veins or vice versa.
“If I have varicose veins, I’m more likely to get thread veins, which are painful.”
Thread veins are tiny veins (capillaries) near the surface of your skin that have become damaged. They are not caused by varicose veins and as with haemorrhoids, you can have one without the other. Also, thread veins are not painful and are usually only treated for cosmetic reasons.
“Varicose veins cause DVT.”
Although DVT is a risk factor for developing varicose veins, varicose veins do not generally cause DVT. There is, however, one exception. If you have varicose veins, you can develop a complication called thrombophlebitis, where a vein becomes inflamed due to a blood clot. This condition usually gets better on its own after a few weeks as the blood clot is cleared. However, there is a small chance that if the blood clot develops in a superficial vein near the groin, it can dislodge and pass into the deep veins, causing a DVT.
“The bigger my varicose veins, the worse my symptoms will be.”
There is no link between the size of your varicose veins and the severity of your symptoms. Some people may have very large varicose veins but no other symptoms, while others may not have any visible varicose veins but experience all of the other symptoms eg swelling, discomfort and skin changes.
With the misconceptions about varicose veins cleared up, it is important to note that varicose veins, left untreated, can cause several legitimate complications.
Around 5% of people with varicose veins will develop a venous ulcer in their lifetime, irrespective of their age or the size of their varicose veins. It is not yet clear why some people with varicose veins develop venous ulcers and others don’t. And while venous ulcers can be treated and resolved, this often takes several months.
Around 10% of people with varicose veins will develop venous skin changes, which include eczema, inflammation, changes to skin pigmentation and lipodermatosclerosis.
Lipodermatosclerosis is caused by scar tissue affecting the skin and fat that lies underneath it. It causes the lower leg to become very narrow, which is often described as looking like an inverted champagne bottle.
It occurs in people with long-standing varicose veins as a result of chronic (long-term) venous hypertension ie a persistent increase in the pressure in your veins. This causes blood cells to ooze out of your varicose veins into the surrounding tissue, which leads to scar tissue. The overlying skin consequently becomes unhealthy and much more vulnerable to forming ulcers as the result of even the smallest scratch or trauma.
The potential complications caused by varicose veins make it important to see a Vascular Consultant, especially if you’ve just noticed you have them or are experiencing other associated symptoms. You can then be examined to determine whether you need treatment and if so, what your options are.
Although varicose veins are often visible, this isn’t always the case. In either case, an ultrasound scan is needed to check the blood flow in the veins in your affected leg to confirm a diagnosis. This will determine whether or not the valves in your veins are working properly. If blood flows exclusively upwards towards your heart, the valves are working. If blood flow is up and down, your valves aren’t working properly and you have varicose veins.
Once you have a diagnosis of varicose veins, whether or not you need treatment depends on your symptoms and whether you have cosmetic concerns. Your Vascular Surgeon will discuss your treatment options with you, including the risks, so you can make an informed decision.
Varicose vein treatment, depending on your symptoms, risk factors and personal preferences, falls into two main categories: lifestyle changes to manage your symptoms and surgery.
To manage your symptoms, avoid sitting or standing for long periods of time, and when sitting, try to keep your legs elevated. Staying active and taking part in regular exercise also helps as this improves your blood flow.
Your Vascular Consultant may also recommend wearing compression stockings. It is important that you seek medical advice to ensure you wear the right size compression stockings. Also, you should put your compression stockings on first thing in the morning and only remove them when you go to bed at night — this will help prevent pain from developing. Putting on your compression stockings only when you feel pain will not ease your pain
Varicose vein surgery usually involves minimally invasive (endovenous) procedures rather than open surgery. This is because open surgery has a longer recovery time and a higher risk of infection and bleeding, as well as the complications of going under general anaesthetic. However, in some cases, depending on the vein affected, open surgery is the best option.
This is carried out under general anaesthetic and recovery usually takes one to two weeks, after which you can return to work and your usual activities.
Open surgery involves disconnecting the affected superficial vein from the deep vein in the groin or the back of the knee and then stripping part of the vein out. If small veins are also affected, additional small cuts can be made to remove them — this is called avulsion.
These minimally invasive procedures treat the affected vein from within, rather than stripping it out and are performed under local anaesthetic. You can return to work and your normal activities one to two days after your procedure.
There are three main types of endovenous procedures:
As open surgery is performed under general anaesthetic, it carries the same risks of any surgery that involves general anaesthesia ie chest infection, DVT, heart attack and pulmonary embolism (a clot in the veins of the lung).
Open surgery itself has a risk of bleeding, bruising, DVT, wound infection and numbness caused by inadvertent damage to nearby nerves when stripping out the vein. There is also a 5-15% chance that your varicose vein will return after your surgery.
Endovenous ablation (either radiofrequency or laser) also has complications, although they are fewer than for open surgery and are rare. They include bruising, skin pigmentation, DVT, pulmonary embolism and skin burns. The chance that your varicose vein will return after your procedure is less than 5%.
Foam sclerotherapy has similar complications as endovenous ablation, including bruising, changes to your skin pigmentation, DVT and pulmonary embolism. You may also experience some discomfort for several weeks after your procedure. There is up to a 50% chance if your varicose vein affects either of your main veins that it will return after this procedure. Foam sclerotherapy is therefore only used for small varicose veins.
Varicose vein treatment is a very active area of research. Currently, methods are being developed to reduce the rates of varicose veins returning after foam sclerotherapy. One potential approach is combining foam injection with mechanically irritating the vein to destroy it.
Turning to endovenous ablation, researchers are looking at new approaches that avoid the need to protect the tissue surrounding the veins with fluid. One avenue of investigation is injecting a special glue into the vein, rather than burning it.
As for open surgery, innovations are focused on how to avoid making multiple small cuts to additionally treat small varicose veins. Studies are looking at burning these small veins from within using small instruments.
While these innovations are being developed, at Spire Healthcare we continue to offer the very latest, approved techniques for varicose vein treatment.
At Spire Healthcare, we offer comprehensive varicose vein treatment packages for your peace of mind. They include a thorough pre-operative assessment, your procedure and follow up assessment.
With your own dedicated, experienced Vascular Consultant who you’ll see every time and a range of finance options, you can look forward to effective treatment for your varicose veins.
Mr Mohamed Abdelhamid is a Consultant Vascular and Endovascular Surgeon at Spire St Anthony's Hospital, St George’s NHS University Hospital and St Helier NHS Hospital. He graduated from Cairo University Medical School, Egypt and also completed a Masters in Surgical Science. Moving to the UK in 2004, Mr Abdelhamid undertook general and vascular surgery training in London and later trained in endovascular surgery in Perth, Australia. Today, he specialises in endovascular interventions for aortic disease, peripheral arterial disease and varicose veins.