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, returns most of the blood to the heart. Above it, the superficial veins drain blood from the skin and subcutaneous tissues. These two systems are connected by perforator veins, which transfer blood from the superficial network into the deep system.

All these veins contain unidirectional valves that direct the blood upwards and prevent it from flowing back down under the influence of gravity. These valves are particularly abundant in the lower part of the leg, where the pressure on the veins when standing is at its greatest. Varicose veins develop when these valves no longer close properly. Instead of rising, part of the blood column falls back, increasing the pressure within the superficial veins. This increased pressure stretches the vein wall and further exacerbates valvular failure. At the same time, this stagnant blood flow triggers a low-grade inflammation of the vein wall, progressively weakening its structure.

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

Varicose veins are extremely common, and reported prevalence rates vary widely between studies. Despite these differences, research consistently indicates that varicose veins become more prevalent with age and are observed more frequently in populations subjected 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 affect both women and men, although women are more frequently affected. Studies have reported that pregnancy and hormonal fluctuations contribute to this higher prevalence among women.

Most varicose veins develop along the saphenous system. The saphenous system comprises two principal 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 limbs. The great saphenous vein begins at the medial malleolus, ascends along the inner aspect of the leg and thigh, and terminates in the groin where it joins the deep venous system. The small saphenous vein originates at the lateral malleolus, runs up the back of the calf and then connects to the deep veins situated behind the knee. Because these veins lie close to the skin and carry blood at relatively low pressure, they are the most prone to becoming varicose when their valves no longer function properly.

Varicose veins can manifest in different forms depending on which part of the venous system is affected 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 wide with a diameter greater than 3 mm, rope-like and clearly prominent. They form when failure of the venous valves permits sustained reflux, resulting in progressive dilation of the vein. Truncal varicose veins are the most clinically significant type. As 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 studies suggest that they represent a significant proportion of clinically diagnosed varicose veins, particularly in older individuals, those who stand for prolonged periods, or those with a family history of venous disease.

Reticular veins.

Reticular veins are medium-sized, bluish vessels situated just beneath the skin. They are not connected to the main branches of the great or small saphenous systems. They are often less prominent than truncal varicose veins and may form a network, particularly behind the knees or on the thighs. Reticular veins are common and may occur in isolation 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 cause discomfort.

Telangiectasias.

The telangiectasias, also referred to 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 in nature and often occur without significant venous reflux. Hormonal fluctuations, genetics and local variations in skin pressure play an important role in their development. While they are generally asymptomatic, their presence can sometimes indicate an early venous dysfunction.

Perforating varicose veins.

Perforator varicose veins arise from failure of the veins connecting the superficial and deep venous systems. When these valves become incompetent, blood refluxes from the deep veins into the superficial network, generating localised areas of high pressure. The pathology of perforator veins is less apparent but often more painful, and is strongly associated with skin changes, inflammation and venous ulcers, particularly around the medial malleolus. Although less frequent than truncal or reticular varicose veins, perforator varicose veins contribute to the progression of venous disease towards a chronic, advanced stage.

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

CEAP stands for Clinical, Aetiological, Anatomical and Physiopathological.

This classification primarily serves to assess the progression or stage of varicose veins. Clinically, varicose veins are classified from C0 to C6. Early stages include telangiectasias or varicose veins without complications, while more advanced stages are characterised by swelling, skin changes, and even venous ulcers.

Large epidemiological studies demonstrate that symptoms vary by sex and depend on the type of varicose veins. While some individuals remain asymptomatic, many experience a spectrum of functional, sensory and cutaneous symptoms that progressively worsen as venous hypertension develops. These symptoms typically intensify after prolonged standing and are alleviated by leg elevation. Common symptoms associated with truncal varicose veins include:

• A sensation of heaviness and fatigue in the legs.

  Among the earliest symptoms of varicose veins are sensations of heaviness, fatigue and tension in the legs. This phenomenon is due to venous blood stasis and is aggravated 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 start of their menstrual cycle due to hormonal effects on venous tone.

• Swelling (oedema).

  Patients with varicose veins frequently develop swelling in the ankle or lower leg, especially after prolonged standing. This corresponds to stage C3, where fluid leaks into the tissues due to sustained venous pressure. In the early stages, the veins may be thin and barely visible, sometimes measuring less than 3 millimetres in diameter. As venous pressure increases over time, fluid begins to seep from the vessels into the surrounding tissues, resulting in persistent oedema. Simultaneously, the affected veins gradually dilate, becoming more pronounced, bluish, and tortuous. In more advanced cases, these dilated veins are easily palpable beneath the skin of the calves or thighs, reflecting a worsening venous insufficiency.

• Itching (venous pruritus).

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

• Restlessness and nocturnal cramps.

  Nocturnal cramps and restless legs are associated with impaired venous return and a reduction in oxygen supply to the muscles. This results in the accumulation of metabolic waste, which can trigger involuntary muscle contractions. Mild electrolyte imbalances related to venous insufficiency may also contribute, making cramps more frequent during the night.

• Cutaneous modifications.

  Long-standing venous hypertension leads to skin pigmentation (stage C4a), varicose eczema with redness, scaling, skin dryness, lipodermatosclerosis (stage C4b) corresponding to painful hardening with inflammation, and atrophie blanche, which are white scar-like patches resulting from microcirculatory damage. 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 the surrounding tissues. Fortunately, most varicose veins remain uncomplicated.

However, if varicose veins are not treated and venous pressure continues to increase, severe complications can occur. These include 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, allowing healthcare professionals to assess the severity of the condition, the underlying venous dysfunction, and to guide appropriate management.

1. Clinical assessment.

The diagnosis of varicose veins begins with a clinical assessment. When a person notices visible and dilated 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 general practitioner or a vascular specialist. The doctor initiates the examination by questioning the patient about their symptoms, family history, and lifestyle.

2. Physical examination.

A clinical examination is then carried out, typically with the patient standing, as varicose veins are more visible when the veins are under pressure. The doctor 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 condition, a duplex Doppler ultrasound is usually performed. This is an uncomplicated and non-invasive examination that combines conventional ultrasound with Doppler technology. It allows the physician to observe the veins in real time and evaluate the blood flow through them. 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 formations. For this reason, duplex ultrasound is considered the standard for diagnosing varicose veins and planning treatment.

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

In the early stages and in mild forms, varicose veins can be managed through preventive and conservative measures. These include engaging in regular physical activity to activate the calf muscle pump, avoiding prolonged standing or sitting, maintaining a healthy body weight, elevating the legs while at rest, and wearing properly fitted compression stockings. These strategies help to reduce venous pressure, improve blood flow, and alleviate 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 ablation or radiofrequency ablation, which use heat to seal defective veins from the inside. These treatments are typically performed on an outpatient basis, require little recovery time, and are highly effective for treating superficial varicose veins.

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

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

• NASH R. & al. Varicose veins. BMJ (2000).

• GOUGH M. J. & al. Treatment options for primary varicose veins—a review. European journal of vascular and endovascular surgery (2005).

• COWAN A. R. & al. The symptoms of varicose veins: difficult to determine and difficult to study. European Journal of Vascular and Endovascular Surgery (2007).

• BLACK C. M. Anatomy and physiology of the lower-extremity deep and superficial veins. Techniques in Vascular and Interventional Radiology (2014).

• EVANS C. J. & al. Progression of varicose veins and chronic venous insufficiency in the general population in the Edinburgh Vein Study. Journal of Vascular Surgery: Venous and Lymphatic Disorders (2015).

• WAKEFIEDL T. W. & al. Pathophysiology of varicose veins. Journal of Vascular Surgery: Venous and Lymphatic Disorders (2017).

• COLLINS K. & al. Varicose veins: diagnosis and treatment. American Family Physician (2019).

• SHARIF A. & al. Global impact and contributing factors in varicose vein disease development. SAGE Open Medicine (2022).

• MAJUMBER A. & al. Clinical presentation of varicose veins. Indian Journal of Surgery (2023).

• JAIN D. K & al. Varicose veins: A comprehensive review on pathophysiology, prevention and treatment. World Journal of Pharmaceutical Research (2025).

• WANG F. & al. Global prevalence and risk factors of varicose veins among health care workers: a systematic review and meta-analysis. BMC Nursing (2025).