Understanding what causes varicose veins helps both in prevention and selection of treatment.

2.1 Pathophysiology

At the core of varicose vein development is venous reflux:

1. Normally: Veins have bicuspid valves that direct blood toward the heart.

2. In varicosities: Valve leaflets fail, blood flows backward, pooling occurs, pressure rises → veins dilate permanently.

3. The cycle perpetuates: Dilatation → more valve failure → worsening reflux.

2.2 Primary vs. Secondary Causes

1. Primary varicose veins: Result from congenital weakness in vein walls or valves.

2. Secondary varicose veins: Develop after DVT, trauma, pelvic tumors, or AV fistulas, disrupting normal venous outflow.

2.3 Risk Factors (Detailed)

1. Genetics: Family history doubles the risk.

2. Ageing: Structural changes in collagen and elastin reduce vein integrity.

3. Hormonal factors: Progesterone relaxes vein walls → common in pregnancy & HRT.

4. Pregnancy:

   • ↑ Blood volume (by 30–50%)

   • Uterus compresses pelvic veins

   • Risk increases with multiple pregnancies

Occupational exposure: Prolonged standing (nurses, teachers, factory workers) or sitting (office staff, drivers).

Lifestyle: Obesity, sedentary living, smoking.

Medical history: Previous DVT, leg trauma, or pelvic surgeries.

Symptoms may vary from mild discomfort to severe disease. They often worsen after prolonged standing or by end of day, improve on leg elevation.

Common Symptoms

1. Visible bulging or twisted veins under skin, typically bluish or purplish.

2. Leg heaviness, aching, fatigue, especially after standing or walking.

3. Swelling (edema) in lower legs and ankles.

4. Itching, burning, or tingling around affected veins.

5. Muscle cramping, restless legs at night.

Physical Signs / Severe Indicators

1. Skin discoloration (hyperpigmentation), eczema, dryness around ankles.

2. Lipodermatosclerosis: skin becomes hardened, thickened, sometimes inverted champagne-bottle shape.

3. Venous ulcers: open sores, usually near ankles, slow to heal.

4. Spontaneous bleeding from dilated superficial veins.

5. Thrombophlebitis: inflammation of a vein with clot formation (pain, redness, tenderness).

To plan treatment, assessment includes both clinical examination and imaging to map the venous reflux and anatomy.

Clinical Assessment

1. History: When symptoms started, what aggravates or relieves them (standing, walking, leg elevation), any past DVT or leg surgeries.

2. Physical exam: examine legs in standing and supine positions; note visible varicosities, skin changes; palpate for tenderness or hard cords.

Classification

1. Use CEAP classification (Clinical, Etiologic, Anatomic, Pathophysiologic) to grade disease severity (C0-C6).

2. Venous Clinical Severity Score (VCSS) for tracking changes.

Imaging / Diagnostic Tests

1. Duplex ultrasound / venous Doppler: Key test to confirm reflux, measure diameter of saphenous veins, identify incompetent perforator veins.

2. Mapping: To identify truncal veins, tributaries. Helps guide thermal ablation or other treatments.

3. In rare cases, venography if ultrasound inconclusive.

Recent guidelines (2022-2025) strongly recommend minimally invasive treatments over older surgical stripping, especially for truncal reflux. Conservative treatment remains foundational.

5.1 Conservative / Non-Invasive Treatments

1. Compression therapy: Graduated compression stockings (20-30 mmHg or higher depending on severity). These reduce symptoms (ache, swelling), slow progression. NICE / UK guidelines recommend compression especially if interventional treatments are not yet done.

2. Leg elevation: Elevating legs to heart level periodically to reduce venous pressure.

3. Exercise: Especially walking, calf-muscle strengthening, to improve calf pump.

4. Weight management: Reduces pressure on leg veins.

5.2 Minimally Invasive / Interventional Therapies

1. Endothermal ablation (radiofrequency ablation (RFA) or endovenous laser ablation (EVLA / EVLT)) for truncal reflux veins. These are now first-line in many settings.

2. Ultrasound-guided foam sclerotherapy (UGFS): Alternative when thermal ablation is unsuitable. Good for tributary veins.

3. Chemical / liquid sclerotherapy: For smaller veins and cosmetically problematic veins.

4. Phlebectomy / ambulatory phlebectomy: Removal of varicose tributaries via small incisions. Often combined with ablation.

5.3 Surgical Treatments

1. Vein stripping and ligation: Traditional approach; less favored now for truncal reflux due to more morbidity and slower recovery.

2. High ligation: At junctions (saphenofemoral or saphenopopliteal) when needed.

5.4 Emerging / Advanced Options

1. Medical / nutritional adjuncts: Some guidelines (SVS etc.) review role of venoactive drugs (phlebotonics) for symptom relief.

2. Non-thermal, non-tumescent techniques / adhesives / glues: sealing veins without heat in certain patients.

3. CHIVA method (Conservative Hemodynamic treatment) — preserving veins with selective interruption of reflux instead of removal. Some meta-analyses suggest good long-term recurrence rates.

Prevention focuses on lifestyle and early intervention; management includes minimizing progression and optimizing outcomes after treatment.

Prevention

1. Stay physically active; avoid long periods of standing or sitting.

2. Use compression stockings in people at risk (family history, pregnancy, occupations with prolonged standing).

3. Maintain healthy body weight.

4. Avoid tight clothing or footwear that impairs venous return.

5. Limit high-salt diet (reduces fluid retention).

6. Elevate legs during rest; use calf muscle pump (e.g., walking, foot flexes while seated).

Management / Follow-Up

1. After interventional treatment, wearing compression stockings for prescribed duration (usually several days to weeks) as per guidelines.

2. Regular follow-up with ultrasound to check vein closure / detect recurrence, especially of treated truncal veins.

3. Monitor for complications (skin changes, ulcers, thrombophlebitis).

Untreated or poorly managed varicose veins can lead to serious health issues.

1. Venous ulcers: Particularly hard to heal, can lead to infections.

2. Skin changes: Pigmentation, eczema, lipodermatosclerosis.

3. Bleeding: Even minor trauma can cause bleeding from superficial varicosities.

4. Superficial thrombophlebitis: Pain, swelling, redness.

5. Deep vein thrombosis (DVT): Less common but risk increases especially after interventions or when associated with other risk factors.

6. Chronic leg swelling and discomfort: Leading to impairment of mobility / quality of life.

How patients can cope, adapt, and optimize quality of life when they have or are being treated for varicose veins.

Daily Living & Self-care

1. Use compression stockings as prescribed.

2. Leg elevation when sitting or lying down, especially after long periods of standing.

3. Move frequently: walk, flex calves, avoid crossing legs.

4. Skin care: keep skin moisturized, avoid injuries, inspect skin regularly in lower legs.

Pain / Discomfort Management

1. Over-the-counter analgesics or anti-inflammatories as needed under doctor's guidance.

2. Supportive footwear; avoid high heels.

Cosmetic / Psychological Aspects

1. Varicose veins may cause self-consciousness; discuss cosmetic options.

2. Counseling/support groups for individuals distressed by appearance or chronic pain.

Monitoring & Long-Term Outlook

1. Recognize early signs of worsening (e.g., increased swelling, skin discoloration, ulceration) and seek evaluation.

2. Recurrence is possible even after treatment, especially if risk factors persist.

1. What are varicose veins?

Varicose veins are enlarged, twisted, and bulging veins that usually appear on the legs and feet. They develop when the vein valves become weak or damaged, causing blood to pool and the veins to swell. They are often blue, purple, or dark in color and may look rope-like on the skin surface.

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2. What causes varicose veins?

The main cause is faulty vein valves. Normally, valves in the veins ensure one-way blood flow back to the heart. When they fail, blood collects in the veins, leading to pressure and swelling. Risk factors include:

1. Family history of varicose veins

2. Prolonged standing or sitting

3. Pregnancy

4. Obesity

5. Aging

6. Hormonal changes (e.g., menopause, birth control pills)

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3. What are the common symptoms of varicose veins?

Symptoms may include:

1. Aching, throbbing, or heaviness in the legs

2. Swelling in ankles and feet

3. Burning or itching around the veins

4. Skin discoloration near affected veins

5. Cramps or restless legs at night
   In severe cases, skin ulcers may develop near the ankles.

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4. Are varicose veins dangerous?

For most people, varicose veins are mainly a cosmetic issue and cause discomfort but are not life-threatening. However, untreated severe varicose veins can lead to complications such as ulcers, bleeding, blood clots, and chronic venous insufficiency.

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5. How are varicose veins diagnosed?

Doctors usually diagnose varicose veins with a physical examination. In addition, a duplex ultrasound may be done to check blood flow and rule out deep vein problems. This helps in planning treatment options.

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6. What are the treatment options for varicose veins?

Treatment depends on severity and patient needs:

1. Lifestyle changes – exercise, weight management, elevating legs, compression stockings.

2. Minimally invasive procedures – sclerotherapy (injection), endovenous laser therapy (EVLT), or radiofrequency ablation.

3. Surgery – vein ligation and stripping, used in severe cases.
   Modern treatments are often outpatient procedures with quick recovery.

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7. Do compression stockings really help?

Yes. Compression stockings improve circulation by applying gentle pressure on the legs, helping veins move blood upward. They can relieve pain, swelling, and discomfort but do not permanently remove varicose veins. They are often recommended as the first line of treatment.

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8. Can varicose veins come back after treatment?

Yes, recurrence is possible. While modern procedures like EVLT and sclerotherapy have high success rates, new varicose veins may develop over time due to ongoing vein weakness, aging, or lifestyle factors. Regular follow-up and lifestyle changes help reduce recurrence.

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9. How can varicose veins be prevented?

Prevention tips include:

1. Exercising regularly to improve leg circulation

2. Maintaining a healthy weight

3. Avoiding long periods of standing or sitting

4. Elevating legs when resting

5. Wearing compression stockings if advised

6. Eating a fiber-rich diet to prevent constipation and pressure buildup

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10. When should I see a doctor for varicose veins?

Seek medical attention if you experience:

1. Severe leg pain or swelling

2. Skin changes such as darkening, thickening, or ulcers near the ankles

3. Bleeding from varicose veins

4. Signs of blood clots (sudden swelling, warmth, or redness in the leg)