Varicose veins – according to estimates from European expert associations, 50% of the European population will suffer from them at some point in their lives. Find all the useful information about varicose veins here: from symptoms and causes to treatment methods and preventative measures.
Varicose veins are knotty, sometimes raised sections of veins that are visible under the skin. Typical symptoms include a slightly blue colouring. The German word ‘Krampfadern’, meaning varicose veins, comes from the Old High German ‘krimpfan’ meaning ‘bending’. The medical term is varices or varicose veins (from the Latin ‘varis’ for ‘knot’), and the condition is referred to as varicosis.
Varicose veins are caused by venous valves that do not close properly. The blood can no longer flow efficiently back to the heart. Pressure in the vessels increases. The venous walls cannot withstand the increased internal pressure, they expand and varicose veins develop. Over time, varicose veins cause pain and other symptoms. The main cause is a congenital weakness of the venous walls and valves.
Varicose veins occur in various areas of the body. The superficial leg veins including their two main veins, the great saphenous vein and the small saphenous vein, are most commonly affected. They can also develop in the thighs and the back of the knee.
Apart from the legs, varicose veins can occur around the anus (haemorrhoids), the testicles (varicoceles), the oesophagus (oesophageal varices) and in the face (telangiectasias). They can basically occur anywhere but mainly affect the legs.
In most cases, varicose veins do not cause any problems. When the condition progresses, various symptoms may occur, such as feelings of tension or heaviness, itching and foot or calf cramps at night. Swollen legs caused by water accumulating in the tissue are also typical. At an advanced stage, the thickened veins with their characteristic twisted and knotted shape are visible through the skin. Patients also mention excessively warm legs. In the area of the varicose veins, the skin can become slightly brown and parchment-like. Scarring of the skin, subcutis and fasciae as well as stasis dermatitis may develop. Sometimes, varicose vein patients will also suffer from fungal infections of the skin or the toe nails.
During high temperatures, over the course of the day or after extended periods of standing or sitting, swelling, pain, feelings of tension and heaviness can increase. It is, however, not possible to draw conclusions about the symptoms from the appearance of varicose veins. Varicose veins that are barely visible can be very painful, whereas very pronounced veins may cause little pain.
In addition to these problems, those affected often find the changes in their skin to be unsightly. They will avoid showing their legs. Their distress may be so severe that they will consider treatment, even if they have no serious physical symptoms.
Chronic venous insufficiency (CVI)
Many years of severe varicose vein development in the superficial veins as well as clot or thrombosis development in the deep veins can lead to chronic venous failure – chronic venous insufficiency (CVI) after years or decades.
Inflammation of the superficial veins
Based on the low blood flow speed in varicose veins, there is an increased risk of blood clots. When these become inflamed, it is referred to as inflammation of the superficial veins. Treatment by a specialist is required immediately in these cases to prevent the spread to the deep vein system and resultant thrombosis.
Deep vein thrombosis (phlebothrombosis)
Varicose veins can advance the development of deep vein thrombosis (phlebothrombosis). Blood accumulates and coagulates to form a blood clot. Your leg will swell. If this complication is not immediately treated, permanent damage to the venous valves may occur. Parts of the clot can travel all the way to the lungs and cause an embolism. That’s why deep vein thrombosis can be fatal.
Venous leg ulcers (ulcus cruris venosum)
If worsening varicose veins are left untreated for several years, there is a risk that the venous blood will be diverted to the superficial venous system, increasingly accumulating in the lower leg. The skin in the ankle region can be damaged so severely that it cannot withstand the pressure any longer, resulting in venous leg ulcers (ulcus cruris venosum).
Varicose veins are usually caused by genetic predisposition. Inherited weak veins or connective tissue causes the veins to expand. The second main cause is advanced age. The veins are working every day, so after many years of stress, the stability of the venous walls is compromised, and the venous valves close completely.
Congenital weakness of the veins and connective tissue
Increasing age
Leg injuries
Previous vascular diseases such as deep vein thrombosis
Nicotine and alcohol consumption
High blood pressure
Lack of exercise (e.g. work mainly involving standing or sitting)
Being overweight
Hormonal changes during pregnancy or the menopause
(Varicose veins associated with pregnancy usually disappear completely after the birth.)
Taking hormone products (e.g. contraceptive pill)
Constricting clothing
Shoes with high heels
Extreme heat
Varicose veins affect about 20 percent more women than men. However, both genders have an equal risk of a pulmonary embolism, which can be attributed to the fact that men often seek medical help later.
Even if varicose veins are mainly caused by genetic predisposition, there is a lot you can do to prevent them. Varicose veins can therefore be prevented altogether or their progression halted. The elasticity of the venous walls and unobstructed blood flow can be actively influenced in a positive way, even if there is an increased risk.
Preventative measures:
The specialist medical fields that deal with varicose veins include internal medicine, angiology, phlebology and specialised general medicine.
The first step of the diagnosis process is taking a medical history to clarify congenital predisposition and risk factors. This is followed by palpation and looking at the affected veins, in particular where the superficial veins connect to the deep vein system in the groin, back of the knee and lower leg. During this process, the person being treated will change positions from standing to sitting and then lying. Increased skin temperature, hardening or reddening of the skin or pressure sensitive areas can be signs of inflammation of the superficial veins. The foot pulse is taken.
The most common diagnostic procedure in cases of varicose veins is an ultrasound examination using colour-coded duplex sonography with a Doppler ultrasound probe. These procedures are effective for detecting impairments in blood circulation, venous valves not closing fully, and for assessing the extent of vein damage. The direction of blood flow can be depicted using a colour scale.
Light reflection rheography records the pumping function of the veins, and venous occlusion plethysmography the capacity as well as the venous return. These two methods are standard practice, in particular as part of checking up on serious vascular disorders as well as before and after surgery.
Pressure measurements were common in the past. These days, they are generally replaced by modern and more reliable examination methods, including new imaging technology. X-ray examinations using contrast agent (phlebography) are rarely used now. Magnetic resonance imaging (magnetic resonance phlebography) or computer tomography based on contrast agents is used only for rare symptoms.
Laboratory examinations of individual coagulation factors can be important in cases of deep vein thrombosis, or if there is an embolism with no discernible cause.
Varicose veins can be categorised by different criteria:
Categorisation by cause
Categorisation by severity
Based on the classification of chronic venous insufficiency (CVI) according to Widmer, modified by Marshall, the degrees of severity are distinguished as follows:
Categorisation by symptom
The clinical symptoms of varicose veins are differentiated in accordance with the CEAP classification ** (158, 239, 267). This categorisation is used internationally.
A = asymptomatic or S = symptomatic can be added to C1 to C6.
** CEAP stands for “Clinical condition”, “Etiology” (cause), “Anatomic localisation” (where the condition occurs) as well as “Pathophysiology” (type of pathological change).
Categorisation by affected vein
Varicose veins can also be categorised by the affected vein.
* Blood flows from the muscle vein to the subcutis while a high degree of pressure is exerted. This expands the superficial vein which appears as a visible spherical swelling.
Varicose veins can be treated using a range of conservative and invasive methods. This decision should always be made in consultation with a doctor, based on all necessary examination results. During the decision-making process, the type of varicose veins, their stage, possible concomitant diseases and the patients’ wishes play an important role. Conservative treatment can stop the condition progressing. Removal of the damaged vein, however, is only possible with (minimally) invasive procedures. Depending on the symptoms, removal may be medically indicated and urgently required. In other cases, the patient can choose the time at their leisure.
Those affected will sometimes try to treat their varicose veins using home remedies but the effectiveness of these has not been proven scientifically.
Vein remedies are available in the form of sprays, creams or gels for applying to the skin, as well as in the form of ingestible capsules. Various medicinal plants, such as horse chestnut or red vine leaves, are said to have a vessel-sealing effect. However, you cannot expect more than a slight anti-inflammatory effect and subjective relief. Some people use creams with plant-based ingredients, or containing the anticoagulant heparin or chondroitin polysulfate. However, it is doubtful whether the active ingredients actually penetrate the skin and have an effect on the leg veins. Then again, regular application of cream has a beneficial massage effect and is therefore recommended.
Exercise and contrast showers do improve circulation in the legs but they do not help to reduce, let alone remove, varicose veins. Those who would like to hide their varicose veins can use waterproof concealers and make-up.
When it comes to prescription medication, suitable options include anticoagulants such as low molecular weight injectable heparins, cumarins as well as medicines known as direct oral anticoagulants. Furthermore, platelet inhibitors like acetyl acid can be administered.
In cases of varicose veins, consistent compression therapy is indispensable and usually the first choice for treatment. The gentle pressure from the outside interacts with the internal pressure of the vascular walls. This reduces the risk of the vein expanding. A compression stocking supports the vessels from the outside. Circulation in the leg veins is optimised, preventing congestion and localised accumulation of the blood. Due to the pressure, the venous valves close more efficiently and the muscle pump of the veins works more smoothly. Although existing varicose veins cannot be reduced by compression therapy, this treatment can alleviate symptoms and often prevent the condition from worsening. After removal of varicose veins, wearing compression stockings reduces the risk of swelling and blood clots.
Health insurance providers will cover the majority of the cost for two pairs of compression stockings per year. Some products require the patient to pay an additional charge of 10 Euros maximum. The patient may have to pay more depending on the model. In order to have the best possible effect, the stockings should fit precisely. Therefore, they are measured by medical supply retailers.
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If, together with the treating doctor, the decision is made to remove varicose veins, and this is not contraindicated for other medical reasons, there is a range of recommended methods, which can also be combined.
Since the middle of the last century, surgical methods have become established that no longer require the entire leg to be cut open. During the procedure known as “stripping”, the affected saphenous vein is removed using a probe. In Germany, this is the treatment method that is used most often and it is also covered by the health insurance provider. If a different procedure is more promising from a medical perspective, it is worth discussing cost coverage with the health insurance provider. Internationally, minimally invasive endovenous procedures are more common.
Surgical vein stripping and mini phlebectomy
During stripping or partial stripping, expanded saphenous veins are fully or partly removed surgically. The surgeon will insert a probe into the blood vessel via a small cut in the groin. This opening is then used to remove the affected saphenous vein including its side branch veins from the leg in one go. To remove side branch varicose veins, a mini phlebectomy is used. Rare complications of varicose vein stripping, also known as Babcock Method, include numbness and tingling caused by injuries to the small nerves in the leg that can get damaged when the vein is removed. Bleeding in the subcutaneous tissue and bruising are common. Consistent compression therapy afterwards is necessary.
Crossectomy
During crossectomy, a saphenous varicose vein is cut off at the cross where the affected vein meets the deep leg vein. This prevents the blood flowing back. This method takes place under local anaesthesia and is therefore particularly suitable for elderly people with large varicose veins, where the risk of general anaesthetic would be too great. Subsequent compression therapy is also recommended after this procedure.
Sclerotherapy (endovenous)
Using a fine needle, a liquid sclerotisation agent (polidocanol) is injected directly into the damaged vessel. For larger varicose veins, the effective ingredient is foamed up. It damages the interior venous wall which reacts with an inflammatory process, causing the vein to stick together and seal. The varicose vein is turned into a strand of connective tissue over time, which is known as sclerosis. After that, the additional tissue is broken down. Treatment success is therefore only fully visible after a few weeks. This treatment is almost completely painless. The body will break down the sclerotisation agent within 48 hours and excrete it. Consistent compression therapy afterwards is recommended. Usually, several treatment sessions are required because the amount of the active ingredient is restricted for medical reasons. All types of varicose veins can be treated using sclerosis, apart from saphenous veins.
Radiofrequency and laser therapy (thermal, endovenous)
During these two endovenous thermal catheter procedures, varicose veins are sealed using heat. Heat sources used are either high-energy laser light or electromagnetic waves. The rotating probe is inserted via a catheter through the varicose vein to just before the deep leg vein in the groin. When it is pulled back slowly, the energy emitted will heat the venous wall up to 120 degrees. This causes the vessel to contract and dissolve over time. Side branch veins are usually removed afterwards using mini stripping. Due to the high temperatures, cooling and anaesthesia are generally required. Unlike in the case of stripping, an incision in the groin is not necessary. This minimises the risk of injuring lymph vessels and nerve trunks. This procedure is relatively painless. After treatment, patients can get up again straight away, they can return home after one day at the latest and are usually able to work again after a week. Subsequent compression treatment is necessary.
The treatment methods that preserve the veins and correct circulation, CHIVA and valvuloplasty where the varicose veins remain in the body, are rarely used. This also applies to mechanical/chemical ablation where a rotating catheter destroys the venous wall and sclerotisation is performed at the same time. Treatment using vein adhesive is also less common.
Varicose veins are not always perceived as a problem. But when should varicose veins be treated or even removed? In contrast to spider veins, varicose veins are not just a cosmetic problem but can lead to symptoms and complications. That’s why they should be examined by a doctor and checked regularly. Varicose veins do not get better by themselves, and in fact will usually get worse with age. As soon as symptoms occur that cannot be alleviated with treatment , or as soon as complications arise, the damaged veins should be removed promptly. Whether or not you plan on removing varicose veins, they should always be treated with compression therapy.
The science is not yet clear on the question of whether varicose veins should be removed as early as possible.
Have you undergone successful removal or treatment of varicose veins? Now there are a few things to keep in mind to ensure that the healing goes smoothly. Depending on the method used, it is important to consider the following:
After anaesthesia, you should have someone to accompany you and take you home. For 24 hours, you should not drive or leave your home by yourself. Alcohol consumption and operating heavy machinery are not recommended during the first few days. In cases of complications, such as fever, vomiting, shivering, pain and respiratory problems, you should seek medical advice.
Prescribed medication should be taken according to the instructions.
The bandage should be removed by medical staff during your first follow-up appointment.
After that, compression stockings must be worn consistently for as long as they have been prescribed.
If you feel up to it, it is fine to go for gentle strolls, with a companion if you like. This can help with recovery. You will need to consult a doctor before doing any more intense form of exercise.
Heat and intense light, such as in a sauna or during sun bathing, should be avoided until the wound has healed. Warm showers are permitted.
During the first few days in particular, you should elevate your legs to relieve them. This will prevent lymphatic congestion. Avoid long periods of standing or sitting and crossing your legs.
It is important that you go to your check-up appointments to ensure the healing process is progressing, and to counteract any complications as soon as possible.
After anaesthesia, you should have someone to accompany you and take you home. For 24 hours, you should not drive or leave your home by yourself. Alcohol consumption and operating heavy machinery are not recommended during the first few days. In cases of complications, such as fever, vomiting, shivering, pain and respiratory problems, you should seek medical advice.
Prescribed medication should be taken according to the instructions.
The bandage should be removed by medical staff during your first follow-up appointment.
After that, compression stockings must be worn consistently for as long as they have been prescribed.
If you feel up to it, it is fine to go for gentle strolls, with a companion if you like. This can help with recovery. You will need to consult a doctor before doing any more intense form of exercise.
Heat and intense light, such as in a sauna or during sun bathing, should be avoided until the wound has healed. Warm showers are permitted.
During the first few days in particular, you should elevate your legs to relieve them. This will prevent lymphatic congestion. Avoid long periods of standing or sitting and crossing your legs.
It is important that you go to your check-up appointments to ensure the healing process is progressing, and to counteract any complications as soon as possible.
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Chronic venous insufficiency (CVI) is a disorder of the leg veins that can have serious consequences.
