Varicose Veins


Varicose veins...

  • Are tortuous dilated superficial veins
  • Are different to reticular veins or telangiectasia
  • Are caused by weak vein walls causing dilation and valve incompetence
  • Are often symptomless
  • Are investigated with Doppler venous scanning.
  • Can be left untreated, compressed, injected or operated on
  • Often recur

Epidemiology and Aeitiology

  • Affect 40% of men and 32% of women
    • However, a higher proportion of women present with varicose veins, possibly due to the cosmetic effect veins have, or because they appear earlier than in males
  • Risk factors:
    • Age
    • Pregnancy
    • ↑ No. of pregnancies
    • Long periods of standing – e.g. occupation as a teacher, shop assistant, surgeon(!) etc

    • Family History


If we go back to our anatomy, we know that there are two venous systems in the lower limbs, the deep and the superficial. Connecting these two systems there are numerous perforating branches. To maintain adequate venous return against gravity, there are two main mechanisms in place.
  1. The presence of valves, which prevent back-flow of blood distally
  2. The deep venous system is assisted by pressures generated by muscles, noticeably the calf muscles. 


In the case of varicose veins it is the former of these two mechanisms that is usually the problem. It used to be thought that valve incompetence, resulting in blood pooling/stasis was the cause of the dilated vein, however that hypothesis has become out of favour, and the current thinking is that weakness in the vein wall causes dilation of the vein. If this occurs around a valve, then the cusps of the valve will no longer meet in the middle and the valve will become incompetent, resulting in backflow of blood, and therefore inadequate drainage. The most common valves involved are those around the saphenofemoral junction (in the groin), however they can occur in other places for example the junction between the short saphenous vein and the popliteal vein.

This is how primary varicose veins develop. Secondary varicose veins are less common, and result from pelvic or abdominal masses which obstruct blood from returning from the lower limbs.
There are several other vein problems that are often mistaken for varicose veins. Typical varicose veins are often referred to as Truncal veinsReticular veins are tortuous dilated veins that are not part of the long/short saphenous vein system, and Telangiectasia (more commonly known as Thread veins or Spiderveins) are dilated venules. These are not varicose veins, but are associated with them, and as such their treatments will be included later.


Apart from their unsightliness, most varicose veins are symptomless. If they are then symptoms include Heavy legs, Aching, Swelling, Itching, Night Cramps, Hot or Burning Sensations, and Restless leg syndrome. As you many have noticed many of those are sensations, and many patients will describe their symptoms as just this “it’s like a sensation, a discomfort”. Often the unsightliness of their veins will cause patients to attribute other leg problems to their veins, and it is important to distinguish whether their symptoms are in fact due to their veins or not.


Complications of varicose veins are split into two main groups, those caused as a direct result of the varicose veins, and those that result from venous hypertension. Although venous hypertension is associated with varicose veins, the size of the varicose veins appears to have no correlation to the degree of venous hypertension.  


History and examination

Look if the veins are present. If there are symptoms – can these be attributed to the veins? If not, treat this separately. Check for history of DVT’s, and risk factors for DVTs (Contraceptive pill/ Hormone replacement therapy).  Although there is no evidence that varicose veins themselves increase the risk of DVTs, if the patients have surgery on their legs then they are at increased risks of DVT post op, and as such may require prophylactic heparin. Skin changes are also important as they increase the chances of ulceration occurring. Is the patient pregnant?
Below is a summary of a clinical examination for varicose veins.

For this examination (apart from the abdominal part) The patient should remove their trousers, keeping underwear on, and be STANDING as the gravity allows the full extent of the veins to be seen. On inspection, the full distribution of the veins should be noted (especially which leg!) and also the presence of any skin changes (eczema/hair loss/redness/ the presence of ulcers). Ensure you check both the front and the back of the legs as the short saphenous runs along the posterior aspect of the leg.
Palpation should be done after asking if the patient is in any pain. Check to see if the veins are tender, which may be a sign of thrombophlebitis, or hard, which could indicate thrombosis. Also palpate the skin surrounding the veins for any signs of dermatosclerosis or atrophic Blanche. Is the skin warm to the touch?
Cough impulses are a sign of incompetence of the saphenofemoral junction. Place your fingers over the junction (5cm inferiomedial to the femoral pulse). Get the patient to cough. If the junction is incompetent then a fluid thrill will be felt.
Trendelenburg tests although being done rarer and rarer are useful tests for assessing the site of incompetence, although not very accurately. Get the patient to lie down with their leg elevated. Tie a tourniquet around the site of the saphenofemoral junction and then get the patient to stand up; you should see a slow reflow of blood into the veins from below the tourniquet. Look at the veins as you release the tourniquet. If the saphenofemoral junction is incompetent, then there will be a sudden flow of blood into the veins from above the tourniquet site. If this is not the case, then repeat, gradually working the tourniquet site further distally, until the site of incompetence is found.
Abdominal Exams are used to try and locate any abdominal or pelvic masses which could cause secondary varicose veins.


Colour Doppler venous scans are the usual investigation of varicose veins, as they show the site and degree of valve incompetence, as well as assessing the deep venous system. If there is concurrent arterial problems, and surgery is being considered then an arteriogram may be required to prevent the formation of ulcers post surgery.
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