Dr. Deyan Lazarov: Varicose Veins – Causes, Symptoms, Diagnosis, and Modern Treatment

What are varicose veins?

It is important to first note that the venous system of the legs consists of two main parts — the deep and superficial venous systems.

The deep veins are located between the muscles and carry most of the blood returning to the heart. The superficial veins are located close to the skin and are the ones we can see when they become enlarged. The two systems are interconnected, and under normal circumstances, blood flows from the superficial to the deep venous system.

To allow blood to travel upward toward the heart despite gravity, the veins contain valves. These valves close after each volume of blood passes through and prevent it from flowing back downward. When these valves become weakened, damaged, or begin to leak, venous reflux occurs — blood flows backward, becomes trapped in the superficial veins, pressure within them increases, and they gradually become enlarged. Over time, discomfort, a feeling of heaviness, pain, and swelling may develop.

Varicose veins are superficial veins in the legs that do not function normally. Patients often say, “I have a few veins that are visible.” However, the problem is usually more widespread, and the visible veins are the external manifestation of a deeper process — venous reflux.

What are the main causes of varicose veins?

Varicose veins develop when the venous wall and valves become weakened and can no longer ensure the normal upward flow of blood. This usually does not happen suddenly but results from a combination of factors that gradually alter the functioning of the venous system.

The most important factor is heredity. If there are people with varicose veins in the family, the likelihood of developing them is greater.

Other common factors include prolonged standing or sitting, being overweight, pregnancy, hormonal changes, and advancing age. Over time, the valves naturally become weaker, while hormonal changes can affect the condition of the venous wall.

All of these factors can lead to venous reflux — the backward flow of blood — and to the development of chronic venous insufficiency, which underlies the formation of varicose veins.

When are varicose veins no longer just a cosmetic problem?

At first, when they are small and isolated, varicose veins are often perceived solely as an aesthetic problem. Over time, however, they can begin to cause genuine symptoms.

Fatigue and a feeling of heaviness in the legs, pain, burning, and tingling may occur. Swelling around the ankles is also typical, developing throughout the day and usually becoming most pronounced in the evening. This may be a sign that the venous system is under strain and is not functioning optimally.

As the disease progresses, skin changes may also develop — darkening, dryness, and eczema. Inflammation of a vein, known as thrombophlebitis, as well as the development of leg ulcers, are more serious complications that require medical evaluation and treatment.

Therefore, it is important not to underestimate the problem. Timely diagnosis and appropriate treatment can limit disease progression and the development of complications.

Which symptoms should not be ignored, and when is it time to consult a specialist?

At first, varicose veins often appear to be a minor problem, but the body clearly indicates when the venous system begins to come under strain.

Heaviness or fatigue in the legs, especially at the end of the day, are among the early warning signs. Many patients also describe burning, throbbing, or a dull ache along the veins, which becomes more pronounced after prolonged standing or sitting, in warm weather, or after a hot shower.

Another characteristic symptom that should not be ignored is swelling around the ankles. If the legs become swollen toward the end of the day and the swelling does not completely subside by morning, this may indicate more advanced venous insufficiency. Nighttime cramps, itching, and dry skin around the varicose veins may also be signs of increased venous pressure.

When the skin begins to darken or thicken, or when eczema develops, this is already a sign of a chronic process.

It is particularly important to seek medical attention if a vein becomes painful, red, or hard, as this may be a sign of inflammation — thrombophlebitis. Sudden pain or rapid swelling of the leg also requires immediate medical evaluation.

Consultation with a vascular surgeon is recommended when symptoms begin to interfere with daily life, when skin changes develop, or when there is a family history of venous ulcers. Timely assessment makes it possible to determine the severity of venous insufficiency and select the appropriate treatment.

How is the diagnosis made, and what role does ultrasound imaging play in choosing the treatment?

The diagnosis of varicose veins begins with a clinical examination and a discussion of symptoms — heaviness, pain, swelling, and cramps. The legs are examined for visible changes in the veins and skin. This provides an initial assessment of the condition of the venous system.

The most accurate examination of the veins, however, is duplex Doppler ultrasound, which is a fundamental diagnostic method in vascular medicine.

Ultrasound makes it possible to assess how the veins function internally — whether the valves close properly, whether there is backward blood flow (reflux), which venous trunks are affected, and how the superficial and deep venous systems are connected.

This is important because the varicose veins visible on the skin are usually only part of the problem. The examination helps identify the underlying cause and develop a comprehensive treatment strategy — for example, whether laser ablation, stripping, sclerotherapy, miniphlebectomy, or a combination of methods is appropriate.

Ultrasound examination is also important for ruling out more serious conditions, such as deep vein thrombosis.

Ultimately, the clinical examination and ultrasound complement each other and provide a comprehensive picture of the condition and functioning of the venous system. This forms the basis for selecting the appropriate treatment.

What is ultrasound-guided sclerotherapy, and which patients is it suitable for?

Ultrasound-guided sclerotherapy is a minimally invasive treatment for varicose veins in which the problematic vein is excluded from the circulation using a specialized medication.

The difference compared with standard sclerotherapy is that the procedure is performed with the assistance of ultrasound. This allows the physician to see exactly where the vein is located, determine its diameter, and monitor how the medication is distributed. The method is particularly useful for veins that are not clearly visible on the surface or are located deeper within the tissues.

During the procedure, a sclerosing agent — a liquid or foam — is injected into the affected vein, causing controlled closure of the venous wall. The vein then gradually closes over the following weeks and months. Ultrasound allows the distribution of the medication within the vein to be monitored in real time.

The method may be suitable for certain patients for whom another treatment, such as laser ablation, is not necessary or cannot be performed. It is often used for smaller venous trunks, residual veins following previous procedures, recurrent varicose veins, or veins that are difficult to access without ultrasound guidance.

The advantage is that the procedure is gentle and does not require incisions. However, the specific treatment method should be selected following an examination and ultrasound assessment of the venous system.

When is surgical removal of varicose veins necessary, and how do you choose the most appropriate method for an individual patient?

Surgical or minimally invasive treatment of varicose veins is considered when the condition causes significant symptoms or there is evidence of progressive venous insufficiency. This may manifest as persistent heaviness, pain, swelling, or skin changes around the ankles.

Sometimes varicose veins may appear large but cause no symptoms. In such cases, surgical treatment is not always necessary. The important thing is to assess how the veins and their valves are functioning, which is determined through ultrasound examination.

When the valves of the main venous trunks are not functioning properly and there is significant reflux, endovenous methods such as laser or radiofrequency ablation may be appropriate. These techniques allow the affected vein to be treated with minimal trauma and without conventional incisions.

For problems involving smaller branches or residual veins following previous procedures, sclerotherapy or miniphlebectomy may be used. In more complex anatomical cases or recurrent disease, a combined approach may sometimes be necessary.

The choice of treatment should not be based solely on the appearance of the veins. It is determined following an examination and ultrasound assessment, which shows where the reflux originates, which veins are affected, and how the superficial and deep systems are interconnected.

The goal is to tailor the treatment to the patient’s specific anatomy and symptoms, achieve a good outcome, and limit the progression of venous disease.

What should patients know about recovery, and can varicose veins recur after treatment?

Recovery after treatment for varicose veins is generally easier than most patients expect. Modern methods — laser ablation, radiofrequency ablation, sclerotherapy, and miniphlebectomy — are minimally invasive and, in many cases, allow patients to return quickly to their normal daily activities.

In most cases, patients can start walking on the day of the procedure. Over the following days, they gradually return to their usual activities. Mild discomfort, a feeling of tightness, or tenderness along the treated vein may occur and usually subsides gradually.

In some cases, wearing a compression stocking for a specified period is recommended to support recovery and may help reduce swelling.

Movement is an important part of recovery. Walking promotes venous return, while strenuous physical activity is usually restricted for a short period, depending on the specific procedure and the patient’s condition. The skin and tissues recover gradually, and the final result is assessed over a longer period.

As for the recurrence of varicose veins, it is important to understand that venous insufficiency is a chronic condition. Treatment removes or excludes non-functioning veins from the circulation, but it does not alter the genetic predisposition or the way the venous system as a whole functions.

After treatment, blood continues to return to the heart through other functioning veins. In people with an inherited predisposition to venous insufficiency, new varicose veins may develop over time. This does not necessarily mean that the previous treatment was unsuccessful — the disease may continue to progress in other areas of the venous system.

With timely follow-up and periodic Doppler ultrasound assessment, these changes can be detected at an earlier stage and treated when necessary.

Ultimately, recovery following modern treatment is generally rapid, while long-term management of venous disease is important for maintaining good results. Physical activity, maintaining a healthy weight, appropriate compression when necessary, and periodic medical examinations can help manage the condition.