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Varicose Veins

Typical recovery: Endovenous laser ablation is usually a day-case procedure. Walking is encouraged early afterwards. Return to work and exercise varies with how much treatment was required, your occupation, symptoms before treatment and individual recovery, so no fixed timeline applies to everyone. Bruising, tightness or tenderness along the treated vein can occur during early recovery, and the treating clinician gives individual advice. Where compression is advised after intervention, NICE advises it is not used for more than 7 days. Recovery after open surgery is generally longer. Individual recovery also varies with whether skin changes or ulceration are present and your general health.

Key points

  • Varicose veins are dilated superficial leg veins caused by failure of the one-way valves, allowing blood to reflux and pool.
  • Thread veins are a cosmetic finding and are not the same as varicose veins.
  • Symptoms such as aching, heaviness, itching, cramps and ankle swelling correlate poorly with how large the veins look.
  • Skin pigmentation, venous eczema, skin hardening and ulceration indicate longer-standing venous hypertension and change the urgency of assessment.
  • NICE advises immediate referral to a vascular service for a bleeding varicose vein (NICE CG168, recommendation 1.2.1).
  • NICE advises referral to a vascular service for symptomatic primary or recurrent varicose veins, venous skin changes, superficial vein thrombosis with suspected venous incompetence, an active venous leg ulcer and a healed venous leg ulcer (NICE CG168, recommendation 1.2.2).
  • A venous leg ulcer is defined by NICE as a break in the skin below the knee that has not healed within two weeks.
  • Duplex ultrasound confirms venous reflux, maps which veins are affected and excludes deep vein thrombosis (NICE CG168, recommendation 1.3.1).
  • NICE advises endothermal ablation first, foam sclerotherapy if unsuitable, and surgery if foam sclerotherapy is also unsuitable (NICE CG168, recommendation 1.3.2).
  • EVLT is the endothermal technique offered in this practice; radiofrequency ablation, foam sclerotherapy and conventional stripping/phlebectomy are described for information only.
  • Where compression is used after an intervention, NICE advises it is not used for more than 7 days (NICE CG168, recommendation 1.3.3).
  • NICE advises that compression hosiery should not be used as treatment for varicose veins unless intervention is unsuitable (NICE CG168, recommendation 1.3.4).
  • In pregnancy, intervention is not usually carried out other than in exceptional circumstances, and compression hosiery may be considered for symptom relief (NICE CG168, recommendations 1.4.1-1.4.3).
  • Recurrence and the development of new varicose veins remain possible after any technique.

Overview

What varicose veins are

Veins in the leg carry blood back towards the heart against gravity, helped by one-way valves and by the pumping action of the calf muscles. When valves in the superficial veins stop working, blood refluxes downwards and pools. The veins under the skin then dilate and become the visible, twisted cords known as varicose veins.

Not all leg veins are varicose veins. Fine red or blue surface vessels — thread veins or spider veins — are a cosmetic finding. Varicose veins and deep vein thrombosis are different conditions: varicose veins involve superficial veins, while DVT is a clot in the deep venous system. Varicose veins are part of a wider spectrum called chronic venous disease, which ranges from visible veins with no consequences at all through to skin damage and ulceration.

Symptoms, and what they do and do not mean

Common symptoms are aching or heaviness, throbbing, itching, cramps and swelling of the ankle, typically worse after long periods standing and better with elevation or walking. Symptoms correlate poorly with how large the veins look: prominent veins can be symptom-free, and modest veins can ache considerably.

The features that matter most are the signs of skin damage: brown pigmentation around the ankle, venous eczema, hardening of the skin and underlying fat, white scarred patches, and ulceration. These indicate that venous hypertension has been present for some time, and they change the urgency of assessment.

Bleeding from a varicose vein — always take seriously

Any episode of bleeding from a varicose vein warrants immediate vascular assessment. NICE advises that bleeding varicose veins are referred to a vascular service immediately (NICE CG168, recommendation 1.2.1).

If a varicose vein is bleeding now: apply firm direct pressure over the site, raise the leg where this is feasible, and get emergency help if the bleeding does not stop with pressure or if you feel faint, dizzy or unwell. Even once bleeding has been controlled, it still needs prompt vascular assessment rather than being left unreviewed.

When referral to a vascular service is advised

Beyond active bleeding, NICE advises referral to a vascular service for symptomatic primary or symptomatic recurrent varicose veins; for lower-limb skin changes such as pigmentation or eczema thought to be caused by chronic venous insufficiency; for superficial vein thrombosis with suspected venous incompetence; for an active venous leg ulcer, defined as a break in the skin below the knee that has not healed within two weeks; and for a healed venous leg ulcer (NICE CG168, recommendation 1.2.2).

Assessment

Assessment begins with history and examination of both legs, including the arterial circulation, because leg ulceration is not always venous and compression can be harmful in significant arterial disease.

Duplex ultrasound is the key investigation, used to confirm the diagnosis, define the pattern of truncal reflux and plan treatment (NICE CG168, recommendation 1.3.1). It distinguishes superficial from deep venous disease and excludes deep vein thrombosis, which is why treatment is not decided from appearance alone.

Self-help and conservative measures

Regular walking and other light-to-moderate physical activity can help calf-muscle pumping and may reduce symptoms. If overweight, weight reduction can be beneficial for overall venous health. Avoiding long uninterrupted periods of standing or sitting and elevating the legs when symptoms are troublesome may help some people. These measures can improve symptoms but do not repair established venous reflux and are not a mandatory trial before appropriate specialist assessment or intervention.

Treatment

For confirmed truncal reflux, NICE sets out a clear order of preference: endothermal ablation is offered first; if endothermal ablation is unsuitable, ultrasound-guided foam sclerotherapy is offered; and if foam sclerotherapy is also unsuitable, surgery is offered (NICE CG168, recommendation 1.3.2).

EVLT is the endothermal technique offered in this practice. Radiofrequency ablation, foam sclerotherapy and conventional stripping/phlebectomy are described for understanding of the treatment pathway and are information-only unless separately confirmed. Endovenous laser ablation closes the refluxing vein from within using laser energy delivered through a fine catheter, under ultrasound guidance and usually with local anaesthetic infiltration around the vein.

Compression has a defined and limited place. NICE advises that when compression hosiery or bandaging is used after an intervention for varicose veins, it should not be used for more than 7 days (NICE CG168, recommendation 1.3.3). NICE also advises that compression hosiery should not be used as treatment for varicose veins unless interventional treatment is unsuitable for that person (NICE CG168, recommendation 1.3.4); compression retains an important role in relieving symptoms when intervention is not suitable and in the management of venous ulceration.

Varicose veins and pregnancy

Varicose veins are common in pregnancy and often improve after delivery. NICE advises that pregnant women are given information about varicose veins in pregnancy (NICE CG168, recommendation 1.4.1). Intervention is not usually carried out during pregnancy other than in exceptional circumstances (NICE CG168, recommendation 1.4.2), and compression hosiery may be considered for symptom relief during pregnancy (NICE CG168, recommendation 1.4.3). Definitive treatment, where needed, is generally considered after delivery.

EVLT: what to expect and recovery

Treating significant superficial venous reflux can improve venous symptoms, but it does not remove the underlying tendency to venous disease. In people with an active venous leg ulcer and suitable superficial reflux, early endovenous treatment in addition to compression has been shown to accelerate ulcer healing. Existing pigmentation or other long-standing skin changes may not disappear completely. New varicose veins can develop over time, and recurrence after any technique is recognised. Residual tributaries or recurrent veins may occasionally need further assessment or an additional treatment session. Thread veins may remain after truncal treatment and are a separate, cosmetic issue.

Walking is encouraged from soon after the procedure. Bruising, tightness along the treated vein and temporary discomfort are usual after ablation. Return to work, exercise and other activities varies with the extent of vein treated, occupation, symptoms before treatment and individual recovery, so no fixed timeline applies to everyone. No treatment is painless, scarless or a permanent guarantee against future venous disease.

Signs & symptoms

  • Visible dilated, twisted veins in the leg.
  • Aching, heaviness or throbbing in the leg, often worse after standing.
  • Ankle swelling towards the end of the day.
  • Itching over the veins or around the ankle.
  • Night cramps or restless discomfort in the legs.
  • Brown discolouration, eczema or hardened skin around the ankle.
  • A break in the skin below the knee that is not healing.
  • A hard, red, tender segment of vein, suggesting superficial vein thrombosis.

How assessment and treatment are planned

  1. 1

    History covering symptoms, duration, previous vein treatment, previous deep vein thrombosis and family history.

  2. 2

    Examination of both legs for varicosities, oedema, venous skin changes and ulceration.

  3. 3

    Assessment of the arterial circulation before any compression is advised.

  4. 4

    Referral to a vascular service in line with the NICE referral criteria.

  5. 5

    Duplex ultrasound to confirm venous reflux, map the affected veins and exclude deep vein thrombosis.

  6. 6

    Discussion of the NICE treatment order and of what is offered here and what is described for information.

  7. 7

    Endovenous laser ablation performed under ultrasound guidance, usually with local anaesthetic infiltration around the vein.

  8. 8

    Discussion/referral for ultrasound-guided foam sclerotherapy when endothermal treatment is unsuitable; this technique is described on this website for information and is not listed as personally offered.

  9. 9

    Discussion/referral for conventional surgical treatment when appropriate; conventional stripping/phlebectomy is information-only on this website unless separately confirmed.

  10. 10

    Compression and mobilisation after treatment as advised, with planned follow-up including ultrasound where indicated.

Preparation

  • Bring any previous duplex ultrasound reports and details of previous vein treatment.
  • Bring a list of your medicines, including blood thinners, antiplatelet medicines, hormone treatment and the contraceptive pill.
  • Tell the clinician about any previous deep vein thrombosis, pulmonary embolism or clotting disorder.
  • Mention arterial disease, diabetes or previous leg ulceration.
  • Wear or bring loose clothing that allows the whole leg to be examined and scanned.
  • Tell the clinician if you are pregnant or might be pregnant, as this affects timing of treatment.
  • Arrange loose trousers and comfortable shoes for the day of treatment, and plan to walk afterwards.

Recovery and aftercare

  • Walk regularly from the day of treatment rather than resting in bed.
  • Wear compression stockings for the period you are advised to; where compression is used after an intervention, NICE advises it is not used for more than 7 days.
  • Bruising, tightness or tenderness along the treated vein can occur during early recovery; how long these symptoms take to settle varies between patients and with the extent of treatment. Use simple pain relief as advised.
  • Avoid long-haul travel and prolonged immobility in the early period after treatment unless your clinician advises otherwise.
  • Elevate the leg when resting and avoid long periods standing still in the first days.
  • Attend follow-up, including any planned ultrasound check.
  • Continue ulcer care and compression as directed if you have or have had a venous ulcer.

Risks and possible complications

  • Bruising, tightness and discomfort along the treated vein, which are usual after ablation.
  • Skin discolouration or lumpiness along the treated vein, which usually fades but can persist.
  • Temporary numbness or altered sensation from irritation of a nearby sensory nerve.
  • Superficial vein thrombosis in the treated area.
  • Deep vein thrombosis or pulmonary embolism, which are uncommon but serious.
  • Rare thermal injury or skin burn after endovenous laser ablation.
  • Skin staining, visual disturbance or other reactions associated with foam sclerotherapy.
  • Wound infection, bleeding or scarring after open surgery.
  • Failure of the vein to close, residual varicosities, or recurrence over time.
  • Remaining thread veins, which are a separate cosmetic issue and are not corrected by truncal treatment.

When to arrange prompt medical assessment

  • New brown discolouration, eczema or hardening of the skin around the ankle.
  • A break in the skin below the knee that has not healed within two weeks.
  • A hard, red, tender segment of vein suggesting superficial vein thrombosis.
  • Any episode of bleeding from a varicose vein requires immediate or same-day vascular-service assessment even if the vein has bled and then stopped.
  • Sudden new one-sided leg or calf swelling, pain or tenderness — particularly when unexplained — needs urgent same-day assessment for possible deep vein thrombosis.
  • Increasing redness, warmth, swelling, worsening pain or discharge around a leg ulcer should be assessed promptly, especially if accompanied by fever or feeling unwell.

When to go to an emergency department now

  • Bleeding from a varicose vein that does not stop with firm pressure and leg elevation.
  • Bleeding from a varicose vein together with feeling faint, dizzy, unwell or other signs of significant blood loss.
  • Chest pain, breathlessness or coughing up blood, which may indicate a pulmonary embolism.
  • A leg that becomes cold, pale, numb or severely painful.

Myth vs fact

Frequently asked questions

Sources

Medically reviewed by Dr. Shams Alam Mohammed Tahir, MBBS, MS (General Surgery). Last reviewed 2026-08-14.

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