Varicose veins: causes, symptoms and modern treatment

What are varicose veins?

The veins in your legs carry blood back to the heart against gravity. Small one-way valves stop the blood from falling back, and the calf muscles act as a pump each time you walk. When the valves in the surface veins fail, blood flows backwards (venous reflux), pressure rises and the veins gradually stretch, bulge and twist.

The great and small saphenous veins and their branches are most often affected. Varicose veins are part of a wider spectrum called chronic venous disease, ranging from fine thread veins to serious skin damage and leg ulcers.

Vein problems are treated by vascular surgeons or vein specialists. They are linked to other cardiovascular conditions mainly through shared risk factors such as excess weight and inactivity.

Causes and risk factors

Varicose veins are very common and become more so with age. Your risk is higher with:

• family history – they often run in families;
• age – valves and vein walls weaken over time;
• being female and pregnancy – hormonal changes and extra blood volume strain the veins; they often improve after birth, but not always completely;
• excess weight – increases pressure in the leg veins;
• standing or sitting for long periods – for example in retail, nursing, driving or desk jobs;
• a previous deep vein thrombosis – which can damage the valves (post-thrombotic syndrome).

Symptoms of varicose veins

Not every varicose vein causes problems. Common symptoms include:

• visible, bluish, bulging and twisted veins, more obvious when standing;
• heavy, tired or aching legs, worse in the evening and in hot weather;
• swollen ankles that improve with rest and leg elevation;
• night cramps and itching over the veins;
• relief when walking or raising the legs.

In more advanced disease, skin changes appear: brown discolouration around the ankles, venous eczema, hardening of the skin (lipodermatosclerosis) and finally a venous leg ulcer – a slow-healing wound, usually above the inner ankle. Doctors grade the condition using the CEAP classification, from C0 (no visible signs) to C6 (active ulcer).

Other possible complications are superficial thrombophlebitis (a painful, red, hard vein) and bleeding from a varicose vein after a knock.

Diagnosis: duplex ultrasound

Assessment starts with an examination of your legs while you stand. The key test is a colour duplex ultrasound scan of the leg veins. It is painless, radiation-free and shows:

• which veins are affected and where the reflux begins;
• the size and course of the veins;
• whether the deep veins are open and free of clots.

A scan is needed before any treatment, because it determines which method is suitable. If a problem in the pelvic or abdominal veins is suspected, CT or MR venography may occasionally be used (see MRI and CT). When swelling is the main complaint, your doctor may also check for other causes such as heart failure or kidney disease.

Treatment options

Treatment depends on your symptoms, the scan findings and your preferences. International guidance, including NICE and the European Society for Vascular Surgery, generally favours endovenous techniques over open surgery for suitable patients.

The sealed vein is gradually absorbed, and blood is redirected through healthy veins. Walking from day one and wearing compression for a set period are usually advised afterwards. New varicose veins can appear over the years, because the underlying tendency remains.

Self-help and prevention

• Keep moving – walking activates the calf muscle pump (see physical activity).
• Aim for a healthy weight.
• Avoid standing or sitting still for long periods; take breaks and flex your ankles.
• Raise your legs above heart level when resting.
• Wear compression stockings if recommended – the right class and size matter.
• Protect the skin of your lower legs from injury and keep it moisturised.

Over-the-counter venoactive products may ease symptoms for some people but do not remove varicose veins. Ask a doctor or pharmacist before using them.

When to see a doctor

See your GP, who can refer you to a vascular specialist, if your veins cause pain, heaviness or swelling, if the skin around your ankle is darkening or changing, if you have a wound that is not healing, or if a vein becomes red, tender and hard.

Seek urgent help for sudden swelling, pain and warmth in one leg (possible deep vein thrombosis), or bleeding from a vein that does not stop with pressure and leg elevation. Call 112 (or your local emergency number) for sudden breathlessness, chest pain or coughing up blood – these can be signs of a pulmonary embolism.

Varicose vein treatment abroad / in Türkiye

Varicose vein treatment is available in many clinics across Europe. Some patients from Bulgaria and other countries nevertheless choose treatment abroad, for example at large accredited hospital groups in Istanbul, where endovenous ablation and sclerotherapy are routine. These are usually day-case procedures or involve a short stay, but follow-up ultrasound is still needed.

Before deciding, check the doctor's specialty and experience (vascular surgeon or interventional specialist), ask for a written plan describing the scan findings and the proposed technique, find out how many days you should stay, and arrange the follow-up scan at home. Organisers such as New City Clinic in Istanbul coordinate hospital, doctor, hotel, transfers and interpreter, while the medical decision rests with the treating team. Avoid long flights immediately after a procedure without your doctor's agreement, because of the risk of clots.