From Clinic to Recovery · First Edition
Chapter 16 — Varicose Veins
Dr. Tamer Rushdy Elalfy · 14 min read
In this chapter
Varicose veins are common, especially in people who stand for long periods at work, and in women after pregnancy. Some patients are troubled by aching, heaviness, and swelling; others by appearance; a smaller number develop skin damage, ulcers, or bleeding. Treatment has changed from open stripping under general anesthesia to walk-in, walk-out procedures under local anesthesia, and most patients can return to normal activity within days. The consultation needs to separate symptoms from cosmetic concerns, explain what treatment can and cannot achieve, and be honest that new varicose veins may appear over time.
Learning objectives After reading this chapter you should be able to:
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Table 16.1. Varicose veins at a glance.
| At a glance | |
|---|---|
| Main treatments | Endothermal ablation (radiofrequency or laser); non-thermal ablation; ultrasound-guided foam sclerotherapy; surgery |
| Anesthesia | Usually local anesthesia, as a walk-in, walk-out procedure |
| Back to work | Usually within 1 to 3 days after endovenous treatment |
| Risks every patient should hear | Bruising and tenderness, clots, numbness, skin staining, and new varicose veins in the future |
| The key counseling message | “Treatment relieves symptoms and protects the skin. It does not stop new veins forming in the future.” |
STEP 1 Explaining the condition and the treatment
16.1 Who benefits from treatment
Varicose veins are caused by faulty valves in the superficial veins of the leg, which allow blood to flow backward and pool. Treatment is recommended for people with symptoms that affect their quality of life, swelling, skin changes, superficial thrombophlebitis, healed or active venous ulcers, or bleeding [1, 2]. Spider and thread veins are cosmetic and carry no health risk. Varicose veins without symptoms or skin changes rarely cause harm, and many patients are reassured to learn this. Figure 16.1 summarizes the stages in a form that can be shown to patients.
[Figure — diagram omitted in this text edition; see the figure caption below and the Word chapter file for the image]
Figure 16.1. Stages of venous disease and the usual plan, for use with patients.
Every patient considered for treatment needs a duplex ultrasound scan to map which veins are faulty and to check the deep veins [1]. Treatment is planned on the scan, not on the visible veins alone.
16.2 Treatment options
Endothermal ablation, using radiofrequency or laser energy delivered through a catheter under local anesthesia, is recommended as the first treatment for incompetent truncal veins; foam sclerotherapy and surgery are alternatives when ablation is unsuitable [1, 2]. Non-thermal methods, such as cyanoacrylate glue, avoid the need for tumescent anesthesia and are increasingly used. In a randomized trial followed for 5 years, quality of life was better after laser ablation or surgery than after foam sclerotherapy, and laser ablation was the most cost-effective option [3]. Visible tributary veins can be removed at the same time through tiny incisions (phlebectomy) or treated with foam. Table 16.2 compares the options for patients.
Table 16.2. Treatments for varicose veins, for use with patients.
| Treatment | What happens | Recovery | Points to discuss |
|---|---|---|---|
| Endothermal ablation (radiofrequency or laser) | A thin catheter seals the vein from inside, under local anesthesia | Walk at once; light work in 1 to 2 days | Bruising and a tight cord along the thigh for a week or two |
| Non-thermal ablation (for example, glue) | The vein is sealed with medical glue; fewer injections | Very quick | Occasional skin reaction along the vein |
| Foam sclerotherapy | A foam medicine is injected under ultrasound to close the vein | Walk at once; may need repeat sessions | Brown staining of the skin; more often needs repeating |
| Surgery (ligation and stripping) | The vein is tied and removed through cuts in the groin or behind the knee | Usually 1 to 2 weeks | Used when other methods are unsuitable |
| Compression stockings | Support stockings squeeze the leg | Relieve symptoms while worn | Do not cure; for those who cannot or do not want treatment |
Script: explaining varicose vein treatment What is wrong. “The veins in your leg have one-way valves that stop blood falling back down. In the surface veins of your leg, some valves have failed, so blood pools and the veins stretch. The deep veins, which carry most of the blood, are working, so we can safely close the faulty surface veins.” The treatment. “We numb the leg and pass a thin tube into the vein using the ultrasound. Heat seals it closed. You walk out afterward, and most people are back at light work within a day or two.” What to expect. “Your symptoms should improve and the bulging veins become smaller or disappear. Veins can form again over the years, because the tendency is part of you, so some people need further treatment later.” |
16.3 Venous ulcers
Compression is the foundation of venous ulcer treatment. In addition, early endovenous ablation of the superficial veins speeds ulcer healing and reduces the time the ulcer remains open, compared with delaying treatment until the ulcer has healed [4]. Patients with an ulcer should be referred promptly for duplex assessment, and those with poor arterial circulation need assessment before compression is used.
STEP 2 Preparation, medicines, and recovery
16.4 Before the procedure
- Pregnancy. Treatment is usually deferred until after pregnancy, and ideally until a woman has completed her family, because pregnancy can cause new veins. Veins often improve after delivery.
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Clot risk. Ask about previous clots, family history, and hormonal medicines. Some patients need a short course of blood-thinning injections after treatment, according to the unit protocol.
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Blood thinners. Most endovenous treatments can be done without stopping anticoagulants; follow Chapter 22.
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Marking. Veins to be treated are marked with the patient standing.
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Practical points. Bring loose trousers or a skirt to wear over the bandage and stocking; in hot weather, plan for the stocking.
16.5 After the procedure
Patients walk for about 30 minutes immediately after treatment and every day afterward. A tight, tender cord along the treated vein, with bruising, is common between about the third and the tenth day and is part of the vein closing. Compression stockings are often worn for a short period according to local practice. Long flights increase the risk of clots after treatment and are best avoided for some weeks; if unavoidable, the patient should discuss clot prevention with the team (Figure 16.2).
[Figure — diagram omitted in this text edition; see the figure caption below and the Word chapter file for the image]
Figure 16.2. What to expect after endovenous ablation, for use with patients.
Table 16.3. Typical recovery after varicose vein treatment.
| Activity | After endovenous treatment | After surgery |
|---|---|---|
| Walking | Immediately, and every day | The same day |
| Showering | After removing the bandage, usually day 1 or 2 | Day 2 |
| Driving | Usually the next day, if comfortable | About 1 week |
| Work | Light work in 1 to 2 days | About 1 to 2 weeks |
| Exercise and sport | Gentle at once; strenuous after about 1 to 2 weeks | About 2 weeks |
| Swimming and hot baths | After about 1 week | When the wounds have healed |
| Prayer | As usual | As usual; kneeling may be uncomfortable for a few days |
| Long flights | Avoid for about 4 weeks if possible | Avoid for about 4 weeks if possible |
STEP 3 Questions patients ask
“Are my varicose veins dangerous?”
Usually not. They can cause aching, swelling, and skin problems, and occasionally bleed. They are not a sign of a clot in the deep veins.
“Do I have to have them treated?”
No, unless they cause symptoms, skin changes, an ulcer, or bleeding. If they do not bother you, leaving them is safe.
“Will they come back?”
The treated veins usually stay closed, but new varicose veins can form over the years. Some people need further treatment later.
“Is laser better than surgery or foam?”
Laser or radiofrequency ablation is usually the first choice, with a quick recovery. In a large trial, quality of life was better after laser or surgery than after foam [3]. The best option depends on your scan.
“Will stockings cure my veins?”
No. They relieve symptoms while you wear them, and are useful if you cannot or do not want treatment.
“Can I have treatment before pregnancy?”
It is usually better to wait until after you have completed your family, because pregnancy can cause new veins. Veins often improve after delivery.
“I stand all day at work. What can I do?”
Walk or move your calves often, raise your legs when resting, and wear stockings if they help. Treatment can help if you have symptoms.
“Stockings are hard to wear in the heat. Do I have to?”
After treatment, we may ask you to wear them for a short time. Lighter-weight stockings, putting them on early in the morning, and keeping skin dry help in hot weather.
“What do I do if a vein bleeds?”
Lie down, raise the leg above your heart, and press firmly on the spot with a clean cloth for at least 10 minutes. If it keeps bleeding, call an ambulance. Tell us afterward, because a vein that has bled should be treated.
STEP 4 Risks, warning signs, and consent
16.6 Material risks
Table 16.4. Material risks of varicose vein treatment. Square brackets mark figures to replace with unit data.
| Band | Risk | Typical frequency | Example wording |
|---|---|---|---|
| Common | Bruising, tenderness, and a tight cord along the treated vein | Many patients, for 1 to 2 weeks | “A tender cord along the thigh is normal as the vein closes.” |
| Common | New varicose veins over the years | [unit data] | “New veins can appear in future years.” |
| Less common | Brown staining of the skin after foam | [unit data] | “Some people have brown marks that fade slowly.” |
| Less common | Numbness or tingling from injury to a skin nerve | [unit data] | “A patch of numb skin can occur, usually improving.” |
| Less common | Superficial thrombophlebitis (painful, red, hard vein) | [unit data] | “A treated vein can become inflamed for a while.” |
| Rare but serious | Deep vein thrombosis or pulmonary embolism | [unit data] | “Rarely, a clot forms in a deep vein. Walking helps prevent this.” |
| Rare but serious | Temporary visual disturbance, or very rarely stroke-like symptoms, after foam | [unit data] | “Very rarely, foam causes brief visual changes.” |
| Rare but serious | Skin burn after thermal ablation; infection | [unit data] | “Burns and infection are rare.” |
16.7 Consent checklist
Before the procedure ☐ Symptoms and goals discussed; cosmetic and medical reasons separated. ☐ Duplex scan reviewed and treatment plan based on it. ☐ Options explained: ablation, foam, surgery, compression, or no treatment. ☐ Recurrence and new veins explained. ☐ Risks from Table 16.4 explained, with unit figures where available. ☐ Clot risk assessed; prevention plan agreed; pregnancy plans discussed. ☐ Who will perform the procedure, including trainee involvement under supervision. ☐ Aftercare, stockings, walking, and flights explained; patient guide given. |
16.8 Warning signs
Table 16.5. Green, amber, and red warning signs after varicose vein treatment.
| Level | Signs after varicose vein treatment | What to do |
|---|---|---|
| Green | Bruising and a tender, tight cord along the treated vein Mild aching for 1 to 2 weeks Small lumps under the skin where veins were treated | Expected. Keep walking and follow the guide. |
| Amber | A red, hot, very painful lump along the vein Redness, warmth, or discharge from a small wound A patch of numbness or tingling that is not improving | Call the clinic the same day. |
| Red | Calf pain and swelling, especially if the whole leg swells Sudden breathlessness, chest pain, or coughing blood Bleeding that does not stop after 10 minutes of pressure with the leg raised Sudden weakness, speech or vision problems after foam | Go to the emergency department or call an ambulance now. |
Key points
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STEP 5 Patient education guide
The following pages may be photocopied and given to patients. Tick the treatment, and add your unit’s name, phone numbers, and review date before use.
PATIENT GUIDE Treatment for Varicose Veins For you and your family. Keep it during your recovery. |
The treatment you had
☐ Radiofrequency or laser ablation
☐ Glue treatment
☐ Foam injections
☐ Surgery
☐ Removal of small veins through tiny cuts
1. Walking is part of the treatment
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Walk for 30 minutes after the procedure, and every day after that.
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Avoid standing still or sitting for long periods. Move your feet and calves often.
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Raise your legs when resting.
2. Your leg
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Keep the bandage on for as long as we told you. Then shower normally.
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Wear your stocking for: ______________________
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A tight, tender cord along the thigh between days 3 and 10 is normal. Simple pain medicine helps.
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Bruising fades over 2 to 3 weeks.
3. Getting back to normal
| Activity | Usually from |
|---|---|
| Work | Light work in 1 to 2 days |
| Driving | Usually the next day, if comfortable |
| Exercise | Gentle walking at once; strenuous exercise after 1 to 2 weeks |
| Swimming and hot baths | After about 1 week |
| Prayer | As usual |
| Long flights | Avoid for about 4 weeks. Ask us if you must travel. |
4. If a varicose vein bleeds
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Lie down and raise the leg above your heart.
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Press firmly on the spot with a clean cloth for at least 10 minutes.
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If it keeps bleeding, call an ambulance.
5. Warning signs: when to get help
| Level | What you notice | What to do |
|---|---|---|
| GREEN | Bruising; a tight, tender cord along the vein; mild aching; small lumps under the skin | This is normal. Keep walking. |
| AMBER | A red, hot, very painful lump; redness or discharge from a cut; numbness that is not improving | Call us today. |
| RED | Calf pain and swelling; sudden breathlessness or chest pain; bleeding that will not stop; sudden weakness or vision problems | Go to the emergency department or call an ambulance now. |
My contacts Clinic phone: ______________________ Hours: ______________ Out of hours: ______________________ [Unit name] [Guide version and review date] |
References
1. National Institute for Health and Care Excellence. Varicose veins: diagnosis and management (CG168). London: NICE; 2013.
2. De Maeseneer MG, Kakkos SK, Aherne T, et al. European Society for Vascular Surgery (ESVS) 2022 clinical practice guidelines on the management of chronic venous disease of the lower limbs. Eur J Vasc Endovasc Surg. 2022;63(2):184-267.
3. Brittenden J, Cooper D, Dimitrova M, et al. Five-year outcomes of a randomized trial of treatments for varicose veins. N Engl J Med. 2019;381(10):912-922.
4. Gohel MS, Heatley F, Liu X, et al. A randomized trial of early endovenous ablation in venous ulceration. N Engl J Med. 2018;378(22):2105-2114.
Note: references are numbered within this chapter for the pilot. Items marked in square brackets are collected in the Author Fill-in and Verification Log.