Varicose veins - Treating varicose veins

Varicose veins don't always need treatment. If your varicose veins are not causing you discomfort, you may not need to have treatment.

Treatment of varicose veins is usually necessary:

to ease symptoms – if your varicose veins are causing you pain or discomfort
to treat complications – such as leg ulcers, swelling or skin discolouration
for cosmetic reasons – but this kind of treatment is rarely available on the NHS, so you'll usually have to pay for it to be done privately

If treatment is necessary, your doctor may first recommend up to six months of self care at home, including:

using compression stockings
taking regular exercise
avoiding standing up for long periods
elevating the affected area when resting

Compression stockings

Compression stockings are specially designed to steadily squeeze your legs to improve circulation. They are often tightest at the ankle and get gradually looser as they go further up your leg. This encourages blood to flow upwards towards your heart.

Compression stockings may help relieve the pain, discomfort and swelling in your legs caused by your varicose veins. However, it's not known whether the stockings help prevent your varicose veins getting worse, or if they prevent new varicose veins appearing.

The National Institute for Health and Care Excellence (NICE) only recommends using compression stockings as a long-term treatment for varicose veins if all other treatments are not suitable for you.

If you are pregnant and you have varicose veins, NICE says you may be offered compression stockings for the duration of your pregnancy.

Compression stockings are available in a variety of different sizes and pressures. Most people with varicose veins will be prescribed a class 1 (light compression) or class 2 (medium compression) stocking. They are also available in:

different colours
different lengths – some come up to your knee, while others also cover your thigh
different foot styles – some cover your whole foot and some stop before your toes

Compression tights are also available, but not on the NHS. They can be bought from pharmacies or directly from the manufacturers.

You may need to wear compression stockings for the rest of your life if you have deep venous incompetence. Deep venous incompetence is where you have problems with the valves, or blockages, in the deep veins in your legs.

In these circumstances, you will need to wear compression stockings even if you have had surgery to treat some varicose veins.

Wearing compression stockings

You usually need to put your compression stockings on as soon as you get up in the morning and take them off when you go to bed.

They can be uncomfortable, particularly during hot weather, but it's important to wear your stockings correctly to get the most benefit from them.

Pull them all the way up so the correct level of compression is applied to each part of your leg. Don't let the stocking roll down, or it may dig into your skin in a tight band around your leg.

Speak to your GP if the stockings are uncomfortable or don't seem to fit. It may be possible to get custom-made stockings that will fit you exactly.

If custom-made compression stockings are recommended, your legs will need to be measured in several places to ensure they are the correct size. If your legs are often swollen, they should be measured in the morning, when any swelling is likely to be minimal.

If compression stockings are causing the skin on your legs to become dry, try applying a moisturising cream (emollient) before you go to bed to keep your skin moist.

You should also keep an eye out for sore marks on your legs, as well as blisters and discolouration.

Caring for compression stockings

Compression stockings usually have to be replaced every three to six months. If your stockings become damaged, speak to your GP because they may no longer be effective.

You should be prescribed two stockings (or two sets of stockings if you are wearing one on each leg) so that one stocking can be worn while the other is being washed and dried. Compression stockings should be hand washed in warm water and dried away from direct heat.

Further treatment

If your varicose veins need further treatment, or if they are causing complications, the type of treatment will depend on your general health and the size, position and severity of your veins.

A vascular specialist (a doctor who specialises in veins) will be able to advise you about the most suitable form of treatment for you.

Endothermal ablation

One of the first treatments offered will usually be endothermal ablation. This involves using energy either from high-frequency radio waves (radiofrequency ablation) or lasers (endovenous laser treatment) to seal the affected veins.

These treatments are described in more detail below.

Radiofrequency ablation

Radiofrequency ablation involves heating the wall of your varicose vein using radiofrequency energy. The vein is accessed through a small cut made just above or below the knee.

A narrow tube called a catheter is guided into the vein using an ultrasound scan. A probe is inserted into the catheter that sends out radiofrequency energy.

This heats the vein until its walls collapse, closing it and sealing it shut. Once the vein has been sealed shut, your blood will naturally be redirected to one of your healthy veins.

Radiofrequency ablation is carried out under local anaesthetic (you are awake). The procedure may cause some short-term side effects, such as pins and needles (paraesthesia).

You may need to wear compression stockings for up to a week after having radiofrequency ablation.

Endovenous laser treatment

As with radiofrequency ablation, endovenous laser treatment involves having a catheter inserted into your vein and using an ultrasound scan to guide it into the correct position. A tiny laser is passed through the catheter and positioned at the top of your varicose vein.

The laser delivers short bursts of energy that heat up the vein and seal it closed. The laser is slowly pulled along the vein using the ultrasound scan to guide it, allowing the entire length of the vein to be closed.

Endovenous laser treatment is carried out under local anaesthetic. After the procedure you may feel some tightness in your legs, and the affected areas may be bruised and painful. Nerve injury is also possible, but it's usually only temporary.

Ultrasound-guided foam sclerotherapy

If endothermal ablation treatment is unsuitable for you, you'll usually be offered a treatment called sclerotherapy instead.

This treatment involves injecting special foam into your veins. The foam scars the veins, which seals them closed. This type of treatment may not be suitable if you have previously had deep vein thrombosis.

The injection is guided to the vein using an ultrasound scan. It's possible to treat more than one vein in the same session. Both standard sclerotherapy and foam sclerotherapy are usually carried out under local anaesthetic, where a painkilling medication will be used to numb the area being treated.

After sclerotherapy, your varicose veins should begin to fade after a few weeks as stronger veins take over the role of the damaged vein, which is no longer filled with blood. You may require treatment more than once before the vein fades, and there is a chance the vein may reappear.

Although sclerotherapy has proven to be effective, it's not yet known how effective foam sclerotherapy is in the long term. NICE found, on average, the treatment was effective in 84 out of 100 cases. However, in one study, the varicose veins returned in more than half of those treated.

Sclerotherapy can also cause side effects, including:

blood clots in other leg veins
headaches
lower back pain
changes to skin colour – for example, brown patches over where the treated veins were
fainting
temporary vision problems

You should be able to walk and return to work immediately after having sclerotherapy. You will need to wear compression stockings or bandages for up to a week.

In rare cases, sclerotherapy has been known to have serious potential complications, such as strokes or transient ischaemic attacks.

Surgery

If endothermal ablation treatments and sclerotherapy are unsuitable for you, you'll usually be offered a surgical procedure called ligation and stripping to remove the affected veins.

Varicose vein surgery is usually carried out under general anaesthetic, which means you will be unconscious during the procedure.

You can usually go home the same day, but an overnight stay in hospital is sometimes necessary, particularly if you are having surgery on both legs.

Ligation and stripping

Most surgeons use a technique called ligation and stripping, which involves tying off the vein in the affected leg and then removing it.

Two small incisions are made, approximately 5cm (2in) in diameter. The first cut is made near your groin at the top of the varicose vein. The second cut is made further down your leg, usually around your knee or ankle. The top of the vein (near your groin) is tied up and sealed.

A thin, flexible wire is passed through the bottom of the vein and then carefully pulled out and removed through the lower cut in your leg.

The blood flow in your legs will not be affected by the surgery. This is because the veins situated deep within your legs will take over the role of the damaged veins.

Ligation and stripping can cause pain, bruising and bleeding. More serious complications are rare, but could include nerve damage or deep vein thrombosis, which is where a blood clot forms in one of the deep veins of the body.

After the procedure, you may need up to three weeks to recover before returning to work, although this depends on your general health and the type of work you do. You may need to wear compression stockings for up to a week after surgery.

Transilluminated powered phlebectomy

Transilluminated powered phlebectomy is a relatively new treatment, and there is some uncertainty about its effectiveness and safety.

NICE does not recommend it as part of the normal treatment plan for varicose veins. However, NICE says the treatment may be offered if your doctor thinks it will help and the benefits and risks are explained.

During transilluminated powered phlebectomy, one or two small incisions are made in your leg. Your surgeon will place a special light called an endoscopic transilluminator underneath your skin so they are able to see which veins need to be removed. The affected veins are cut before being removed through the incisions using a suction device.

Transilluminated powered phlebectomy can either be carried out under general anaesthetic or local anaesthetic. You may experience some bruising or bleeding afterwards.