Varicose veins

Your arteries carry blood from the heart down to your legs. Your veins carry it back up, against gravity. To do that, leg veins have tiny one-way valves, like little doors, that open to let blood move up and close to stop it falling back down. Your calf muscles squeeze the veins with every step and help push the blood along.

When those valves weaken, blood leaks backward and pools in the lower leg. Doctors call this venous reflux or venous insufficiency. The extra pressure stretches the veins near the skin until they bulge and twist. Those stretched veins are varicose veins.

Varicose veins are part of a range of vein problems. At the mild end are spider veins, fine red or purple lines in the skin. At the severe end are skin changes and open sores near the ankle.

On a duplex ultrasound, the technologist squeezes your calf and watches the vein on screen. Healthy blood flows up only. In a leaky vein, color on the screen flips to show blood flowing back down for more than half a second.

Some people have large varicose veins and no symptoms at all. Others have only small visible veins but a lot of discomfort. Symptoms usually get worse through the day and after long periods of standing, and better when you raise your legs.

Leg pain is not always from veins. Pain when walking that goes away within minutes of rest can be a sign of blocked arteries, called peripheral arterial disease. We check for both.

Most varicose veins are uncomfortable rather than dangerous. A few problems need prompt attention.

The key test is a duplex ultrasound of the leg veins. It is painless, uses no radiation and takes about 30 to 60 minutes. You stand or lie tilted so the veins fill, while the technologist maps which veins leak and how badly. The test also rules out old or new clots in the deep veins.

The ultrasound matters because the bulging veins you see are often not the source of the problem. Usually a longer vein deeper under the skin, most often the great saphenous vein running up the inside of the leg, is leaking and feeding the visible branches. Treating only the surface veins without fixing that leak leads to the veins coming back.

Less often, the problem is a blockage higher up, in the pelvis or abdomen. For example, a pelvic vein squeezed by an artery (May-Thurner syndrome) or scarred by an old clot. If your ultrasound or symptoms suggest that, we may add a CT or MRI scan of the veins.

Treatment is chosen to fit your ultrasound findings and your goals. Many people start with simple steps. If symptoms continue, the leaky vein can be closed from the inside. Your body then reroutes blood through healthy veins, and the bulging branches shrink.

Stockings ease symptoms while you wear them, but they do not fix the valves. Many insurance plans ask you to try stockings for a few months before they will cover a procedure.

Endovenous thermal ablation uses a thin laser fiber or radiofrequency catheter placed through a needle stick, guided by ultrasound. Sclerotherapy injects a medicine called a sclerosant, as a liquid or a foam, directly into the vein. Other closure methods use a medical glue. We most often use ultrasound-guided sclerotherapy, and for more extensive veins this can be done in the hospital as an outpatient with moderate sedation, meaning you are relaxed and drowsy but breathing on your own.

Old-style vein stripping surgery under general anesthesia is now rarely needed. Small surface veins are covered on our spider veins page.

Most vein procedures take under an hour. You are awake, the skin is numbed, and most people feel pressure and a few stings. You walk out of the room and go home the same day.

1. Same day
   Walk for 10 to 20 minutes right after. Wear your stocking as instructed. Walking helps prevent clots.
2. First few days
   Mild tightness or a pulling feeling along the treated vein is normal. Most people are back at desk work in 1 to 2 days. Over-the-counter pain medicine is usually enough.
3. First 1–2 weeks
   Avoid heavy lifting, hot tubs and long flights if you can. Bruising fades. A follow-up ultrasound is often done within a week or two to confirm the vein is closed and no clot has formed.
4. 1–3 months
   Bulging veins shrink and aching improves. Some small veins may need a touch-up session.

When I look at a leg ultrasound, I am less interested in the veins you can see than in the one feeding them. If I can find and close that leak, the visible veins often shrink on their own and the heaviness gets better. I also tell patients honestly that vein disease is a lifelong tendency, so we treat what bothers you now and check again if new veins appear.

Fabio Komlos, MD, interventional radiologist · About Dr. Fabio Komlos

Not every varicose vein has to be treated. If your veins do not bother you and your skin is healthy, it is reasonable to wear stockings when you need them, stay active and keep an eye on things. Treatment makes sense when you have aching, swelling, skin changes, bleeding or clots, or when the veins affect how you live.

During pregnancy, veins often get worse and then improve in the months after delivery. We usually wait at least 3 months after the baby is born before treating, because many veins settle down.

Insurance coverage for vein treatment depends on your symptoms, your ultrasound results and your plan. Treatment of veins for looks alone is usually considered cosmetic.