Varicose veins and venous insufficiency
The veins of the legs have valves that force the blood upwards towards the heart. When these valves fail, blood flows back down (reflux), pools and the veins dilate: this is how varicose veins develop.
What exactly are varicose veins?
Varicose veins are dilated, tortuous superficial veins 3 mm or more in diameter. Below that size we speak of reticular veins and spider veins or telangiectasias. All are part of chronic venous disease, which ranges from symptoms without visible signs to leg ulcers.
It is one of the most common diseases: in the international Vein Consult programme, involving more than 91,000 people seen in general practice worldwide, 83.6% had some symptom or sign of chronic venous disease.
Factors that favour their development
- Family history: the clearest factor.
- Age: frequency increases over the years.
- Female sex, pregnancy and hormonal changes.
- Jobs involving many hours standing or sitting still.
- Excess weight and a sedentary lifestyle.
- A history of deep vein thrombosis.
Common symptoms
- Heaviness and tired legs, which worsen at the end of the day and in hot weather.
- Swelling of the ankles and feet.
- Pain, tingling, itching, cramps and restless legs at night.
- Visible varicose veins, reticular veins and spider veins.
- In advanced stages, dark patches, hardening of the skin (lipodermatosclerosis), eczema and ulcers.
The size of the varicose veins does not always match the symptoms: some people have large varicose veins and few symptoms, and vice versa.
How it is classified: the CEAP scale
Specialists use the international CEAP classification to describe severity with common criteria:
- C0: no visible signs (symptoms may be present).
- C1: spider veins or reticular veins.
- C2: varicose veins.
- C3: oedema (swelling).
- C4: skin changes (pigmentation, eczema, lipodermatosclerosis).
- C5: healed ulcer.
- C6: active ulcer.
How it is diagnosed
The key test is venous duplex ultrasound, which the European guidelines (ESVS 2022) recommend for every patient with varicose veins before deciding on treatment. It is a scan without radiation or needles that shows which veins have reflux, where the varicose veins originate and whether the deep venous system is working properly. This “map” is used to plan the treatment of each leg.
Treatment options
General measures and medical treatment
Walking every day, avoiding long periods of immobility, controlling weight and raising the legs when resting relieve the symptoms. Compression stockings improve heaviness and swelling. Venoactive drugs may slightly reduce oedema according to a 2020 Cochrane review, although they do not cure varicose veins.
Treatments that eliminate varicose veins
Thermal ablation (radiofrequency or laser)Closes the diseased saphenous vein from the inside with heat. The European guidelines recommend it as the first option for saphenous reflux in preference to conventional surgery.
Adhesive (VenaSeal)Seals the vein with cyanoacrylate, without heat and under local anaesthesia. An alternative included in the European guidelines.
Foam sclerotherapyInjection of a sclerosing drug, useful for smaller varicose veins, tributaries and recurrences.
Phlebectomy and CHIVARemoval of varicose veins through micro-incisions, or haemodynamic surgery that preserves the saphenous vein.
There is no single treatment for everyone. The choice depends on the size and location of the diseased veins, the symptoms and each patient’s preferences, and techniques are often combined.
Radiofrequency ablation · VenaSeal · Sclerotherapy and laser · Surgery and CHIVA · Medical treatment
Can they come back?
Yes. Venous disease is chronic and, even when the diseased veins are treated, new varicose veins may appear over time. That is why a thorough initial assessment and regular check-ups are important.
When to seek help without delay
- Colour changes or hardening of the skin around the ankle, or a wound that does not heal.
- Bleeding from a varicose vein.
- A hard, red, painful cord along a vein (possible thrombophlebitis).
- Sudden painful swelling of one leg: go to A&E, it may be a deep vein thrombosis.
Videos on this topic (in Spanish)
References
- De Maeseneer MG, Kakkos SK, Aherne T, et al. European Society for Vascular Surgery (ESVS) 2022 Clinical Practice Guidelines on the Management of Chronic Venous Disease of the Lower Limbs. Eur J Vasc Endovasc Surg. 2022;63(2):184-267.
- Rabe E, Guex JJ, Puskas A, et al. Epidemiology of chronic venous disorders in geographically diverse populations: results from the Vein Consult Program. Int Angiol. 2012;31(2):105-115.
- Martinez-Zapata MJ, Vernooij RW, Simancas-Racines D, et al. Phlebotonics for venous insufficiency. Cochrane Database Syst Rev. 2020;11:CD003229.
Patient information reviewed by Dr Óscar Merino, vascular surgeon. It does not replace an individual medical assessment.
Do you have varicose veins or tired legs?
Full duplex ultrasound assessment at Clínica Rotger, Palma.
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