A twist in the vein

Spider veins can be small and very few – or they can be quite visible, turning your legs into a web of purple, blue or red lines. Untreated varicose veins can lead to chronic venous insufficiency, characterised by limb swelling, skin changes, and, in severe cases, non-healing ulcers, writes Dr Naveen Chandrashekar

Dr Naveen Chandrashekar

Varicose veins are described as dilated, tortuous, and bluish-to-reddish veins visible to the naked eye, particularly in the lower limbs. This condition usually develops secondary to weakened valves which lose their function of regulating blood flow between the two vein systems in the legs, ultimately resulting in reversal or opposite blood flow leading to varicose veins.

Stage I of varicose veins shows the presence of spider veins or very thin reddish to bluish-looking clusters of veins seen just beneath the skin in the calf or inner aspect of the leg or thigh. Stage II is where veins are swollen, and tortuous with either a reddish or bluish appearance. Stage III is when along with stage II there are skin changes with swelling, pigmentation, redness and muscle loss. Stage IV is when there is an ulcer or wound along the previous varicose vein site with or without bleeding. In early cases, cosmetic concerns aside, we encounter a broad spectrum of presentations in clinical practice, ranging from asymptomatic to advanced stages like venous ulcers.

Common symptoms include visibly swollen veins (spider veins) under the skin, especially in fair-skinned individuals, along with heaviness in the leg, calf pain, leg fatigue, and skin changes such as redness, darkening (pigmented skin), dryness, itching, and occasional bleeding. In advanced cases, there may be uncontrolled or continuous bleeding leading to ulcer formation. Some patients may also present with secondary inflammation known as cellulitis.

Over time, many patients with varicose veins experience reduced quality of life, especially in work environments that involve prolonged standing or sitting. This often results in increased absenteeism, job changes, and diminished job performance.

Untreated varicose veins can lead to chronic venous insufficiency, characterised by limb swelling, skin changes, and, in severe cases, non-healing ulcers. Managing these ulcers requires extensive time, costs, and frequent outpatient visits. Some studies suggest an increased risk of congestive heart failure in patients with varicose veins, although data remains limited.

Certain professions, such as police officers, teachers, doctors, nurses, and IT professionals, are at risk of developing varicose veins due to prolonged periods of standing or sitting. In both groups, the pooling of blood in the lower limb veins is the underlying cause of the condition. Varicose veins often run in families, indicating a significant role of hereditary factors and genetics in their development. During pregnancy, high levels of estrogen and progesterone dilate veins, and weaken vein walls and valves, causing blood to flow in both directions and leading to pooling and varicose vein formation. A 2009 Croatian study from the Vein Clinics of Cleveland found that women with higher progesterone levels during pregnancy had a greater risk of developing varicose veins. Progesterone levels during pregnancy affect water retention and weight gain, increasing pressure on veins and contributing to vein issues.

The growing uterus during pregnancy compresses larger veins in the lower abdomen, exacerbating blood pooling in the lower limbs and increasing the risk of varicose veins. This compression also contributes to the common occurrence of deep vein thrombosis (DVT) in pregnancy.

Treatment for varicose veins depends on the stage of presentation, Doppler ultrasound findings, impact on quality of life (QOL), and the need to prevent associated complications.

Stage I and II varicose veins are typically managed with compression stockings, which are specially designed to apply external pressure on dilated veins in the legs. These stockings prevent reverse blood flow and promote circulation towards the heart, reducing pooling in the veins. They are pressure graded, meaning the pressure varies at different points on the leg (thigh, knee, calf), optimising venous blood flow. It’s important to consult with an intervention radiologist before using these stockings. In addition to stockings, venotonic drugs may be prescribed in the early stages to improve vein wall health, enhancing vein elasticity and contraction to prevent pooling. Modern compression stockings are made from high-quality, breathable, non-allergenic fabric that is washable for ease of use. Any minor discomfort or skin reactions such as itching or sweating are rare and can be managed with emollients. Stockings are recommended during periods of activity and can be removed at bedtime. For stages II (not responding to conservative management), III, and IV of varicose veins, minimally invasive treatments like Endovascular Laser Treatment (EVLT), radiofrequency ablation, and microwave ablation are options. These techniques use heat-based methods to destroy abnormal veins such as the great saphenous vein, short saphenous vein, and perforator veins. By eliminating these veins, blood stasis is reduced, treating varicose veins and preventing venous ulcers. These procedures also promote ulcer healing and improve quality of life by reducing the need for hospital visits related to wound care. They are outpatient procedures done under local anaesthesia, allowing patients to return home the same day with no recovery time. Certain exercises have been recommended to prevent varicose veins and enhance circulation in lower limb veins, such as yoga, walking, swimming, cycling, calf exercises, wall leg raises, and squats.

Here are some common myths about varicose veins

Myth: It is seen only in females.
Fact: It is seen in both males and females.
Myth: Prolonged standing can cause veins to overwork.
Fact: Prolonged sitting also increases risk due to blood stasis in the lower limb veins.
Myth: Spider veins/reticular veins do not cause future risk of venous disease.
Fact: They end up with chronic venous problems if not addressed.
Myth: Varicose veins are not hereditary.
Fact: Varicose veins run in families and hence genetics is involved.
Myth: Varicose veins do not pose a risk for heart problems.
Fact: Varicose veins pose an increased risk of cardiovascular diseases.
Myth: Varicose veins are typically treated by a major surgery.
Fact: It is a straightforward, outpatient, non-invasive treatment without incisions.
Myth: Varicose veins can recur after treatment.
Fact: Recanalisation rates are minimal with proper treatment and patient compliance.

How to ease the varicose vein pain
Some low-impact activities like walking, swimming, and cycling can help improve circulation and alleviate the discomfort associated with varicose veins. Stretching and yoga also help ease the pain:

 Adho Mukha Svanasana or downward-facing dog: Helps to align the body and improve circulation.

 Warrior 2: A standing pose that opens the hips and strengthens the legs, this pose helps in compressing and releasing the veins.

 Setu Bandha Sarvangasana or bridge pose: This pose helps to strengthen the glutes and spine.

 Baddha Konasana or butterfly pose: This pose is great for relaxing and stretching the hips and thighs and also boosts circulation in the legs.

 Viparita Karani or legs up on the wall: This posture relieves swelling in the legs, calves and ankles.

(The author is a consultant interventional radiologist.)