Overview: what are varicose veins?

The varicose veins are dilated, tortuous veins that develop when blood flow in the superficial venous system of the legs becomes inefficient. The leg comprises two main venous networks. The deep venous system, located within the muscles, is responsible for returning most of the blood to the heart. Running above it, the superficial veins drain blood from the skin and subcutaneous tissues. These two systems are connected by perforating veins, which carry blood from the superficial network into the deep system.

All these veins contain unidirectional valves that channel blood upward and prevent it from flowing back down under the influence of gravity. These valves are especially numerous in the lower leg, where standing generates the highest venous pressure. Varicose veins develop when these valves fail to close properly. Instead of rising, part of the blood column reverses, increasing pressure within the superficial veins. This elevated pressure stretches the vein wall and further aggravates valvular incompetence. At the same time, the stagnant blood flow triggers a low-grade inflammation of the vein wall, gradually weakening its structure.

Together, valvular dysfunction, venous wall weakness, and chronic inflammation promote the development and progression of varicose veins.

Varicose veins are very common, and the reported prevalence of varicose veins varies widely across studies. Despite these variations, research consistently shows that varicose veins become more common with age and are more often observed in populations exposed to prolonged standing, overweight, physical inactivity, and chronic heat exposure. Wearing very tight clothing may also increase the risk of developing varicose veins.

Varicose veins occur in both women and men, although they are more common in women. Studies have shown that pregnancy and hormonal fluctuations contribute to this higher prevalence among women.

Most varicose veins develop along the saphenous system. The saphenous system includes two main superficial veins of the leg, the great saphenous vein (GSV) and the small saphenous vein (SSV). These veins and their branches constitute the primary superficial venous network of the lower extremities. The great saphenous vein originates at the medial malleolus, ascends along the inner side of the leg and thigh, and terminates in the groin where it joins the deep venous system. The small saphenous vein begins at the lateral malleolus, travels up the back of the calf, and connects to the deep veins behind the knee. Because these veins lie close to the skin and carry blood under relatively low pressure, they are the most susceptible to becoming varicose when their valves no longer function properly.

Varicose veins may manifest in various forms depending on the part of the venous system involved and the underlying venous dysfunction.

Truncal varicose veins.

Truncal varicose veins are large, dilated veins that develop along the main superficial veins of the leg, most often the great or small saphenous vein. They are generally very large with a diameter exceeding 3 mm, rope-like and distinctly prominent. They form when venous valve failure permits sustained reflux, leading to progressive dilation of the vein. Truncal varicose veins are the most clinically significant type. Because they affect the primary drainage pathways of the superficial venous system, they are frequently associated with sensations of heaviness, pain, swelling, and skin changes. Population-based studies suggest that they account for a substantial proportion of clinically diagnosed varicose veins, particularly in older adults, those standing for prolonged periods, or individuals with a family history of venous disease.

Reticular veins.

Reticular veins are medium-sized, bluish veins located just under the skin. They are not connected to the main branches of the great and small saphenous vein systems. They are often less prominent than truncal varices and can form a network, particularly behind the knees or on the thighs. Reticular veins are common and may occur alone or be associated with deeper venous reflux. They are more common in women and are often influenced by hormonal factors. Although generally less symptomatic, they can nonetheless be bothersome.

Telangiectasias.

The telangiectasias, also known as spider veins, thread veins, starbursts, or reticular veins, are very small vessels (less than 1 mm in diameter) that appear red or purple. They are primarily cosmetic and often occur without significant venous reflux. Hormonal changes, genetics, and local variations in skin pressure play a significant role in their development. Although they are generally asymptomatic, their presence can sometimes indicate early venous dysfunction.

Perforating varicose veins.

Perforating varices result from failure of the veins that connect the superficial and deep venous systems. When these valves become incompetent, blood refluxes from the deep veins into the superficial network, creating localized areas of high pressure. The pathology of perforating veins is less visible but often more painful and is strongly associated with skin changes, inflammation, and venous ulcers, particularly around the medial malleolus. Though less common than truncal or reticular varicosities, perforating varices contribute to the progression of venous disease to a chronic, advanced stage.

The CEAP classification is an international system used by physicians to describe and determine the stage of varicose veins.

CEAP stands for Clinical, Etiological, Anatomical, and Pathophysiological.

This classification is primarily used to assess the progression or stage of varicose veins. Clinically, varicose veins are classified from C0 to C6. Early stages include telangiectasias or uncomplicated varicose veins, while more advanced stages are characterized by swelling, skin changes, and even venous ulcers.

Large epidemiological studies show that symptoms differ by sex and depend on the type of varicose veins. Although some individuals remain asymptomatic, many experience a range of functional, sensory, and cutaneous symptoms that progressively worsen as venous hypertension advances. These symptoms generally intensify after prolonged standing and improve with leg elevation. Common symptoms associated with truncal varicose veins include:

• Sensation of heaviness and fatigue in the legs.

  Among the earliest symptoms of varicose veins are a sensation of heaviness, fatigue, and tension in the legs. This phenomenon is due to venous blood stasis and worsens after prolonged standing, at night, and in hot weather.

• Throbbing pain and a burning sensation.

  Throbbing pain and a burning sensation often follow the path of the affected veins. Venous hypertension irritates the surrounding tissues, and symptoms may intensify in women at the beginning of their menstrual cycle due to hormonal effects on venous tone.

• Swelling (edema).

  Patients with varicose veins frequently develop swelling in the ankle or lower leg, especially after prolonged periods of standing. This corresponds to stage C3, where fluid leaks into tissues due to sustained venous pressure. In the early stages, the veins may be thin and barely visible, sometimes measuring less than 3 millimeters in diameter. As venous pressure increases over time, fluid begins to leak from the vessels into the surrounding tissues, leading to persistent edema. Concurrently, the affected veins gradually expand, becoming more apparent, bluish, and tortuous. In more advanced cases, these dilated veins are easily palpable under the skin of the calves or thighs, indicating worsened venous insufficiency.

• Itching (venous pruritus).

  Localized itching around dilated veins is common and indicates early inflammation and varicose eczema. Persistent itching can lead to small skin scratches, increasing the risk of infection.

• Agitation and nocturnal cramps.

  Nocturnal cramps and leg restlessness are associated with impaired venous return and a reduction in oxygen supply to the muscles. This results in the accumulation of metabolic waste products that may trigger involuntary muscle contractions. Minor electrolyte imbalances related to venous insufficiency can also contribute, making cramps more common during the night.

• Cutanous modifications.

  Long-standing venous hypertension leads to pigmentation (stage C4a), varicose eczema with redness, scaling, skin dryness, lipodermatosclerosis (C4b) corresponding to painful hardening with inflammation, and white atrophy, these scar-like white patches resulting from microcirculatory lesions. These manifestations indicate progression to advanced venous disease (Raetz et al., 2019). In advanced cases, the fragile skin may deteriorate, leading to slow-healing venous ulcers. These signs reflect chronic inflammation, impaired circulation, and damage to surrounding tissues. Fortunately, most varicose veins remain without complications.

However, if varicose veins are not treated and venous pressure continues to increase, serious complications can occur. These include a painful inflammation of the superficial veins (superficial thrombophlebitis), bleeding following minor trauma, chronic skin changes, and, in rare cases, an increased risk of blood clots, such as deep vein thrombosis or venous thromboembolism. Early recognition and appropriate management significantly reduce the risk of complications.

Varicose veins are generally identified through a combination of clinical examination and targeted imaging, enabling healthcare professionals to assess the severity of the condition, the underlying venous dysfunction, and to guide appropriate management.

1. Clinical evaluation.

The diagnosis of varicose veins begins with a clinical evaluation. When a person notices visible and enlarged veins or experiences symptoms such as a feeling of heaviness in the legs, swelling, pain, itching, or nocturnal cramps, the first step is to consult a healthcare professional, typically a primary care physician or a vascular specialist. The physician starts the examination by asking the patient about their symptoms, family history, and lifestyle.

2. Physical examination.

A clinical examination is then conducted, typically with the patient standing, as varicose veins are more apparent when the veins are under pressure. The physician looks for bulging veins, changes in skin pigmentation, swelling around the ankles, and signs of eczema or skin hardening. The lower limbs may also be gently palpated to check for tenderness, induration, or signs of inflammation.

3. Duplex ultrasound.

To confirm the diagnosis and assess the severity of the issue, a duplex Doppler ultrasound is typically performed. It is a painless and non-invasive examination that combines conventional ultrasound with Doppler technology. This allows the physician to observe the veins in real-time and evaluate the blood flow through them. The duplex ultrasound can identify the affected veins, determine if the venous valves are leaking, specify the direction of blood flow, and detect any obstructions or clot formation. For this reason, duplex ultrasound is considered the gold standard for diagnosing varicose veins and planning treatment.

Based on the clinical examination and the ultrasound results, the doctor can assess the severity of the varicose veins and discuss the different management options. These can range from lifestyle advice and compression therapy to minimally invasive procedures or surgery, depending on the symptoms and the disease stage.

In the early stages and in mild forms, varicose veins can be treated with preventive and conservative measures. These include regular physical activity to activate the calf muscle pump, avoiding prolonged standing or sitting, maintaining a healthy body weight, elevating the legs at rest, and wearing properly fitted compression stockings. These strategies help reduce venous pressure, improve blood flow, and relieve symptoms, although they do not eliminate existing varicose veins.

When symptoms persist or veins become more noticeable, minimally invasive treatments are often recommended. This includes procedures such as sclerotherapy, where a solution is injected into the affected vein to close it, and endovenous thermal techniques, like laser or radiofrequency ablation, which use heat to seal defective veins from the inside. These treatments are generally performed on an outpatient basis, require little recovery time, and are highly effective for treating superficial varicose veins.

In more advanced cases or when minimally invasive methods are not suitable, a surgical treatment may be considered. Procedures such as ligation and vein stripping or phlebectomy involve removing or tying off damaged veins to redirect blood flow towards healthier veins. Surgery is typically reserved for severe forms of the condition, recurrences of varicose veins, or complicated cases.

The choice of treatment is guided by clinical findings and duplex ultrasound results.

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