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Varicose Veins

by James D. Douketis, MD

Varicose veins are dilated superficial veins in the lower extremities. Usually, no cause is obvious. Varicose veins are typically asymptomatic but may cause a sense of fullness, pressure, and pain or hyperesthesia in the legs. Diagnosis is by physical examination. Treatment may include compression, wound care, sclerotherapy, and surgery.

Varicose veins may occur alone or with chronic venous insufficiency.


Etiology is usually unknown, but varicose veins may result from primary venous valvular insufficiency with reflux or from primary dilation of the vein wall due to structural weakness. In some people, varicose veins result from chronic venous insufficiency and venous hypertension. Most people have no obvious risk factors. Varicose veins are common within families, suggesting a genetic component. Varicose veins are more common among women because estrogen affects venous structure, pregnancy increases pelvic and leg venous pressures, or both. Rarely, varicose veins are part of Klippel-Trénaunay-Weber syndrome, which includes congenital arteriovenous fistulas and diffuse cutaneous capillary angiomas.

Symptoms and Signs

Varicose veins may initially be tense and palpable but are not necessarily visible. Later, they may progressively enlarge, protrude, and become obvious; they can cause a sense of fullness, fatigue, pressure, and superficial pain or hyperesthesia in the legs. Varicose veins are most visible when the patient stands. For unclear reasons, stasis dermatitis and venous stasis ulcers are uncommon. When skin changes (eg, induration, pigmentation, eczema) occur, they typically affect the medial malleolar region. Ulcers may develop after minimal trauma to an affected area; they are usually small, superficial, and painful. Varicose veins occasionally thrombose, causing pain. Superficial varicose veins may cause thin venous bullae in the skin, which may rupture and bleed after minimal trauma. Very rarely, such bleeding, if undetected during sleep, is fatal.

Pearls & Pitfalls

  • Varicose veins rarely lead to stasis dermatitis or stasis ulcers, but ulceration may develop following minor injury to an affected area.


  • Clinical evaluation

Diagnosis is usually obvious from the physical examination. Trendelenburg test (comparing venous filling before and after release of a thigh tourniquet) is no longer commonly used to identify retrograde blood flow past incompetent saphenous valves. Duplex ultrasonography is an accurate test, but it is not clear whether it is routinely necessary.


  • Compression stockings

  • Sometimes sclerotherapy or surgery

Treatment aims to relieve symptoms, improve the leg’s appearance, and, in some cases, prevent complications. Treatment includes compression stockings and local wound care as needed.

Injection therapy (sclerotherapy) and surgery are indicated for prevention of recurrent variceal thrombosis and for skin changes; these procedures are also commonly used for cosmetic reasons. Sclerotherapy uses an irritant (eg, Na tetradecyl sulfate) to induce a thrombophlebitic reaction that fibroses and occludes the vein; however, many varicose veins recannulate. Surgery involves ligation or stripping of the long and sometimes the short saphenous veins. These procedures provide good short-term symptom relief, but long-term efficacy is poor (ie, patients often develop recurrent varicose veins). Laser therapy is being used experimentally by some surgeons.

Regardless of treatment, new varicose veins develop, and treatment often must be maintained indefinitely.

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