Varicose veins and spider veins of the legs

What are varicose veins?

The veins of the legs carry blood from the leg back towards the heart. Inside them are small valves that stop blood flowing back down. The UK’s National Health Service (NHS) says varicose veins happen when these valves do not work properly: blood collects in the vein, which swells and twists. Varicose veins are usually seen in the legs, but they may appear elsewhere in the body.

They differ from spider veins of the legs, which are also called thread veins. The NHS describes these as tiny, coloured veins that are usually harmless. Varicose veins stand out more and may cause symptoms.

The artery and the vein are one route, out and back, and varicose veins are a problem on the return part of that route.

What symptoms do they cause?

The NHS lists these symptoms:

• Pain, aching or heaviness in the leg
• Swelling of the ankle or lower leg
• Itching, skin discolouration, dry and flaky skin
• Getting worse after standing for a long time and better when the leg is raised

Varicose veins may get worse without treatment, but this usually happens very slowly over several years.

Who is more at risk?

According to the NHS: women, older people, people who are overweight or pregnant, people who stand or sit a lot, people with varicose veins in the family and people who have had a deep vein thrombosis. These raise the risk and do not guarantee that you will get varicose veins.

Examination and Doppler ultrasound

Examination of the leg starts with looking and touching, with the doctor seeing the whole of your lower leg and foot. The next step is usually a Doppler ultrasound. The NHS says a specialist usually uses this ultrasound, which shows blood flow, to confirm varicose veins and plan treatment. The Mayo Clinic also calls it the standard way to assess varicose veins. The guideline of the Society for Vascular Surgery (SVS) and the American Venous Forum also recommends that for varicose veins the history and examination be completed with a Doppler of the deep and superficial veins.

A Doppler makes several things clear: which vein has a failing valve, whether the deep veins are healthy, and which treatment suits this leg. Without this map, choosing a method is guesswork. There is more in the guide section.

Common treatment options

This section describes the well-known options. Which one suits you depends on the examination and the Doppler, and should be discussed with your treating doctor.

• Daily care. The NHS lists: a healthy weight, raising the legs whenever possible, walking, not standing or sitting for long periods, moisturising dry skin and avoiding knocks to the leg. Smoking also damages the veins.
• Compression stockings. The pressure of the stocking on the lower leg helps blood return and can reduce swelling and pain. The NHS says that if there is a problem with the arterial blood flow in the leg, stockings are not suitable, and the doctor checks for this. They are worn during the day and taken off at night.
• Sclerotherapy. A substance (in one method, a foam) is injected into the vein and closes it. The NHS describes it as mostly for when closing the vein with heat is not suitable. The Mayo Clinic says sclerotherapy works best on smaller veins. The SVS recommends phlebectomy (removing the branch through tiny cuts) or sclerotherapy for varicose branches.
• Laser or radiofrequency inside the vein. A thin tube is passed into the vein under ultrasound guidance and closes it with laser or radiofrequency heat. The NHS says this is usually the first choice for varicose veins, is done under local anaesthetic and the patient can usually go home the same day. The SVS also prefers closing the main leg vein with heat to removing it completely.
• Surgery. In this method the vein is tied off through a cut in the groin and pulled out through a second cut lower down, at the knee or ankle. The NHS says it is offered when simpler methods are not suitable, is usually done under general anaesthetic, and you may need one to two weeks off work.

The NHS says the specialist explains which treatment may suit you best, and its benefits and risks.

After closing a vein with heat or an injection, the NHS says about a week in compression stockings and some pain and bruising are normal. Your own doctor will give you the details of this period.

Varicose veins and pregnancy

The NHS says compression stockings are sometimes used in pregnancy, but a procedure on the vein is usually not recommended. Varicose veins often improve after the birth.

Complications you should recognise

The NHS lists these complications: bleeding, varicose eczema (itching and dry skin over the vein), a venous ulcer that is slow to heal, a superficial clot that makes the vein hard and painful, and deep vein thrombosis.

• A vein that is hard, painful and red or warm. This may be a superficial clot. The NHS asks for urgent help with this sign so that a deep clot can be ruled out, so have it seen the same day.
• Sudden swelling and pain in one leg. This may come from a deep clot. See a doctor or go to the emergency department the same day. If you also have shortness of breath or chest pain, call 115 straight away (the emergency number in Iran). If you are outside Iran, call your local emergency number.
• A leg ulcer that has not healed in two weeks. Have a doctor see it.
• Bleeding from a varicose vein. Sit or lie down, raise the leg and press directly on the bleeding spot with a clean cloth. Do not tie a band or anything above the bleeding point, on the side towards the heart. A systematic review in the International Wound Journal says standing makes the bleeding worse and heavy bleeding can quickly become dangerous. Call 115 (the emergency number in Iran; outside Iran, your local emergency number), and even if it stops, have a doctor look at the vein.

When to book an appointment

Book an appointment if you have pain, itching or swelling in the leg, your veins are getting worse or a sore has not healed in two weeks. Do not leave a warning sign waiting for an appointment: the full list is under “When should I call urgently?”.