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Varicose veins in the lower limbs

OVERVIEW

What is varicose veins in the lower limbs?

Varicose veins in the lower limbs refer to the abnormal dilation of superficial veins in the legs, manifesting as thickened, tortuous, and clustered veins resembling earthworms. It is one of the common diseases in vascular surgery [1].

The venous system in the lower limbs can be divided into deep veins and superficial veins. Deep veins are located deep within the muscles, while superficial veins lie in the subcutaneous tissue. Numerous "perforating veins" connect the deep and superficial veins. Generally, varicose veins in the lower limbs refer to superficial vein dilation, including the great saphenous vein, small saphenous vein, and their branches.

Individuals who stand or sit for prolonged periods, suffer from habitual constipation, chronic cough, or are pregnant are more prone to developing varicose veins. Additionally, certain conditions such as deep vein thrombosis, arteriovenous fistulas, Klippel-Trenaunay syndrome, and Budd-Chiari syndrome can also lead to varicose veins.

For mild cases or pregnant women, compression stockings or bandages are the first-line treatment. Severe cases may require surgical intervention. However, if the underlying causes (e.g., prolonged standing, obesity) are not addressed, recurrence is possible post-surgery [1].

How common are varicose veins in the lower limbs?

Varicose veins are a prevalent condition. International studies indicate an incidence rate of approximately 10%–40%, meaning 10 to 40 out of 100 people may develop this condition [2]. In China, the adult prevalence is around 10%, equating to roughly 10 out of 100 adults [3].

What are the types of varicose veins in the lower limbs?

Classification by cause:

  1. Primary varicose veins: A standalone condition not caused by other diseases.
  2. Secondary varicose veins: Result from other underlying conditions, such as post-thrombotic syndrome, May-Thurner syndrome, or Budd-Chiari syndrome [4].

Which department should I visit for varicose veins?

  1. Consult vascular surgery for varicose veins. If an underlying condition is identified, referral to a relevant department may be necessary.
  2. If vascular surgery is unavailable, general surgery can provide care.

SYMPTOMS

What are the symptoms of varicose veins in the lower limbs?

Initially, patients may experience dilated, tortuous, and clustered superficial veins in the lower limbs, particularly in the calves, resembling earthworms. They may also feel heaviness, fatigue, or even soreness and discomfort in the legs. These are signs of mild varicose veins.

Patients with severe varicose veins in the lower limbs may develop mild ankle swelling, which is typically less noticeable in the morning and worsens in the afternoon. The swelling is often asymmetrical between the two legs.

Other symptoms include darkening or blackening of the skin on the lower calves and feet, itching, rashes, and, in later stages, skin that is prone to breaking and slow to heal [1]. This condition is colloquially known as "chronic leg ulcers." Varicose veins in the lower limbs develop gradually, with progression rates varying among individuals—some may develop "chronic leg ulcers" in as little as five to six years, while others may take 20 to 30 years.

What complications can occur in patients with varicose veins in the lower limbs?

In advanced stages, varicose veins in the lower limbs can lead to several complications:

  1. Superficial thrombophlebitis: This occurs when blood clots form in the superficial veins, causing poor blood flow and hard nodules. Symptoms often include swelling, pain, redness, and increased skin temperature in the affected area.
  2. Ulcer formation: As the condition progresses, local ulcers may develop, known as "chronic leg ulcers." These typically appear as easily broken skin on the lower calves or ankles that is slow to heal, often recurring repeatedly.
  3. Rupture and bleeding of varicose veins: Due to the thinner walls of varicose veins, excessive local pressure or minor abrasions can cause bleeding. This may manifest as subcutaneous bleeding (bruising) or external bleeding, which is difficult to stop on its own [1].

CAUSES

What are the causes of lower limb varicose veins?

  1. Primary lower limb varicose veins: Mostly caused by dysfunction of the femoral-saphenous or great saphenous vein valves, leading to venous reflux and dilation/tortuosity of superficial veins. Common causes include [4]:
    • Congenital factors: Abnormal development (e.g., defective venous valves or weak venous walls) related to genetic predisposition.
    • Acquired factors: Increased abdominal pressure due to heavy labor, prolonged standing, pregnancy, obesity, chronic cough, or habitual constipation, overloading venous valves and causing varicose veins.
  2. Secondary lower limb varicose veins: Caused by other conditions like deep vein thrombosis, arteriovenous fistula, Klippel-Trenaunay syndrome, or Budd-Chiari syndrome.

Who is more likely to develop primary lower limb varicose veins?

  1. Family history: Genetic predisposition increases risk if parents have the condition.
  2. Prolonged standing: Teachers, police officers, chefs, waitstaff, etc., due to occupational strain on venous valves.
  3. Sedentary office workers: Prolonged sitting with legs下垂 impairs venous return, stressing valves.
  4. Heavy manual laborers: Porters or construction workers face excessive pressure, hindering venous flow.
  5. Obesity: Excess weight obstructs femoral vein return, and thicker blood raises inflammation risk.
  6. Chronic cough/habitual constipation: Repeated straining elevates abdominal pressure, burdening venous valves.
  7. Pregnant women: Uterine expansion impedes venous return.

Are lower limb varicose veins hereditary?

They often show familial clustering due to genetic predisposition, likely from inherently weak venous walls/valves. Later factors like prolonged standing or overloading further damage valves, accelerating their development [3].

DIAGNOSIS

What tests are needed for varicose veins in the lower limbs?

The symptoms and signs of varicose veins in the lower limbs are relatively straightforward. Diagnosis can be confirmed through physical examination, simple physical tests, and imaging studies (such as ultrasound, CT venography, MR venography, or angiography).

  1. Vascular Ultrasound: The most commonly used diagnostic method, which is non-invasive, painless, and radiation-free.
    • If the ultrasound shows widening of the superficial veins, superficial venous valve insufficiency, or blood reflux (positive Valsalva test), and excludes deep venous obstruction, valve insufficiency, or arteriovenous fistula, primary varicose veins can be diagnosed.
    • If complex conditions cannot be ruled out by ultrasound, further confirmation can be made through venography or CT venography.
  2. Angiography: A minimally invasive procedure involving contrast injection into the lower limb veins. It helps determine the nature, extent, and severity of the condition and is the most reliable diagnostic method for lower limb venous diseases.
  3. Other Tests: CT venography or MR venography can assess venous patency and detect congenital venous abnormalities, though their accuracy is lower than that of venography [1].

Which diseases can varicose veins in the lower limbs be easily confused with?

Conditions such as primary deep venous valve insufficiency, post-thrombotic syndrome, and arteriovenous fistula may mimic varicose veins. Specialists typically differentiate them through medical history, physical examination, and imaging (ultrasound or angiography).

  1. Primary Deep Venous Valve Insufficiency: May also present with worm-like varicose veins, but additional features include limb thickening, elongation, and large purplish-red vascular nevi on the skin [1], which are absent in typical varicose veins.
  2. Post-Thrombotic Syndrome: Can also show similar varicose veins but is often preceded by sudden limb swelling [1], whereas swelling in varicose veins usually occurs later. Imaging can confirm the diagnosis.
  3. Arteriovenous Fistula: May resemble varicose veins but is characterized by localized skin warmth, distal limb coldness due to ischemia, and incomplete blood drainage upon limb elevation [1]. Varicose veins lack these features and typically show complete drainage when elevated.

TREATMENT

How to Treat Varicose Veins in the Lower Limbs?

Currently, there are three methods for treating varicose veins in the lower limbs, briefly introduced here for reference:

  1. Wearing medical compression stockings or using elastic bandages: Simple, non-invasive, and painless, though the pressure from the stockings may cause a tight sensation.
  2. Sclerotherapy: Injecting a sclerosing agent (e.g., foam sclerosant, hypertonic saline) into the varicose veins, followed by compression bandaging to close them.
  3. Surgical treatment: Provides a permanent solution. Options include traditional high ligation and stripping of the great/small saphenous vein, as well as minimally invasive procedures like laser closure and radiofrequency ablation. The choice depends on the condition [1].

To decide which treatment to choose, click the corresponding link or scroll down for details, and consult your doctor for personalized advice.

Additionally, for secondary varicose veins, treating the underlying condition is key. Once resolved, the varicose veins often improve or disappear naturally.

Who Should Wear Medical Compression Stockings or Use Elastic Bandages?

  1. Patients with mild varicose veins;
  2. Pregnant women (varicose veins may resolve postpartum);
  3. Patients unwilling or unable to undergo surgery [1].

Consistent use of compression stockings may help mild cases recover. Even if not fully cured, it can slow progression and prevent complications.

How to Properly Use Compression Stockings or Elastic Bandages?

  1. Compression stockings: Wear like regular socks, ideally in the morning and remove at night. Alternatively, elevate the legs to drain blood before wearing. Choose the right type (length, pressure, thickness) based on medical advice.
  2. Elastic bandages: Wrap from the bottom up, ensuring snug but comfortable pressure that doesn’t restrict movement or arterial pulse [5].

Who Is Suitable for Sclerotherapy?

Sclerotherapy is mainly recommended for:

  1. Localized treatment: Telangiectasia, reticular veins, or isolated varicose veins;
  2. Residual or recurrent veins after surgery;
  3. Patients unsuitable for surgery [1].

It can serve as an adjunct to surgery or local treatment. However, since it doesn’t address the root cause, recurrence is likely if used alone.

Who Should Consider Surgical Treatment?

Surgery is suitable for moderate-to-severe cases without contraindications.

These are minor procedures with minimal risk, no organ involvement, and short recovery. Patients can walk soon after and typically leave the hospital within days. Traditional surgery costs ~¥2000–5000, while minimally invasive options (e.g., laser, radiofrequency) cost ~¥10,000–15,000.

The main risks are recurrence (depending on the method and lifestyle) and thrombosis. Preventive measures include early mobility, compression stockings/bandages, and anticoagulants [1].

How to Treat Common Complications of Varicose Veins?

  1. Superficial thrombophlebitis: Apply heat and antibiotics (e.g., kanamycin, ceftazidime). Surgery may follow after inflammation subsides.
  2. Ulcers: Clean with moist gauze and elevate legs for healing. Surgery is advised post-healing.
  3. Bleeding from ruptured veins: Elevate the leg and apply pressure. Schedule surgery after bleeding stops [1].

DIET & LIFESTYLE

Do patients with varicose veins need to elevate their legs every night while sleeping?

We know that elevating the feet while lying down can improve blood circulation in the lower limbs. This method is very helpful for people with leg swelling, but patients without swelling do not need to elevate their lower limbs every night while sleeping.

Can patients with varicose veins soak their feet in hot water? Can they take hot springs?

Patients with varicose veins should avoid soaking their feet in hot water or taking hot springs to prevent further dilation of the veins. They can engage in appropriate vascular function exercises, such as alternating between cold and warm water during showers, to stimulate blood vessel contraction and promote vascular function recovery [5].

Should patients with varicose veins exercise more or rest more?

Patients with varicose veins should balance work and rest and engage in regular exercise.

  1. Balance work and rest: Change bad habits and lifestyle, and adjust positions frequently. For example, those who stand for long periods should take breaks; those who sit for long periods should stand up and move for 5–10 minutes every hour, avoiding prolonged crossing of legs or sitting cross-legged [5].
  2. Exercise regularly, at least five times a week, for no less than 30 minutes each time.

What else should patients with varicose veins pay attention to in daily life?

  1. Those with habitual constipation should drink more water, maintain smooth bowel movements, and avoid straining during defecation to prevent worsening varicose veins.
  2. Patients engaged in heavy physical labor should rest adequately, avoid overexertion, and prevent injuries.
  3. Quit smoking.
  4. Patients with hypertension should take antihypertensive medication to maintain normal blood pressure levels.
  5. Patients with high cholesterol should eat a light diet and use medication to control cholesterol if necessary.
  6. Obese individuals should plan weight loss, choose suitable exercises based on their condition, and control their diet.
  7. Trim nails frequently to avoid scratching the skin.

Are there any dietary restrictions for patients with varicose veins?

There are no specific dietary restrictions; a healthy and balanced diet is sufficient.

  1. When cooking, use less salt, less oil, and fewer high-salt seasonings. Avoid pickled vegetables and meats.
  2. Do not rely solely on refined rice and flour for staple foods. Replace some with whole grains, legumes, potatoes, or pumpkin.
  3. Balance meat and vegetables. Choose white meats like chicken, duck, and fish, and eat less fatty meat. Eggs and milk are important sources of protein and other nutrients.
  4. Vegetarians can eat more beans and bean products to supplement protein.
  5. Eat more fruits and vegetables.
  6. Avoid alcohol as much as possible.

PREVENTION

How to Prevent Varicose Veins in the Lower Limbs?

  1. Preventing varicose veins in the lower limbs must start with daily habits, especially for high-risk groups.
    • Those with a family history of the condition: Get regular check-ups and seek medical treatment if necessary.
    • Pregnant women: Elevate the legs when resting, engage in moderate exercise, and avoid blood stagnation in the lower limbs to protect venous valve function.
    • Obese individuals: Start weight loss early, progress gradually, and seek professional help (e.g., fitness trainers) if needed to maintain a healthy weight.
    • People with long-term standing jobs, sedentary lifestyles, or heavy physical labor: Wear medical compression stockings, strengthen lower limb exercises to enhance muscle pump function for blood circulation, and elevate the legs before sleep.
    • Patients with chronic cough or habitual constipation: Seek timely treatment.
    • Avoid smoking and alcohol, reduce greasy and spicy foods, and eat more vitamin-rich foods (e.g., fresh fruits and vegetables) to prevent constipation.
  2. For the general population, avoid prolonged standing, squatting, or sitting to prevent slowed blood return, and engage in appropriate physical exercise.