Peripheral venous disease is a group of conditions in which the veins of the legs (and sometimes the arms) can’t return blood to the heart efficiently. The most common form is chronic venous insufficiency, where small one-way valves inside the veins stop working properly, allowing blood to flow backward and pool in the lower legs. About 19% of adults develop varicose veins, the most visible sign of the disease, and roughly 1 in 200 will eventually develop a venous leg ulcer.
How Healthy Veins Work, and What Goes Wrong
Veins carry blood back toward the heart against gravity. Two systems keep that upward flow moving: tiny flap-like valves inside the veins that open to let blood through and snap shut to prevent backflow, and the calf muscles, which squeeze veins during walking and push blood upward. In a healthy leg, calf muscle contractions reduce venous pressure by about 70%.
In peripheral venous disease, one or both of those systems fail. The most common scenario starts with vein walls that are naturally weaker than average. Under everyday pressures, these walls stretch and widen until the valve flaps can no longer meet in the middle of the vein. Blood leaks backward through the gap, raising pressure in the veins below. That increased pressure stretches more veins, damages more valves, and creates a cascade of worsening insufficiency. In diseased veins, walking reduces venous pressure by only about 20%, a fraction of what a healthy system achieves.
Other triggers can set off the same chain of events. A deep vein blood clot (DVT) can destroy valves directly. Pregnancy hormones make vein walls more elastic, which is why varicose veins often appear or worsen during pregnancy. Superficial vein inflammation (phlebitis) or direct injury to a vein can also cause primary valve failure.
How It Differs From Peripheral Artery Disease
People often confuse peripheral venous disease with peripheral artery disease (PAD), but they affect opposite sides of the circulatory loop. PAD involves arteries, where fatty plaque builds up inside vessel walls and narrows the channel carrying oxygen-rich blood away from the heart. Its hallmark symptom is leg pain during walking that stops when you rest. Peripheral venous disease involves veins, where failed valves let blood fall backward toward the feet. Its hallmark symptoms are swelling, heaviness, and visible vein changes that worsen with prolonged standing and improve with elevation. Both can cause leg ulcers, but the ulcers look different, appear in different locations, and require different treatments.
Symptoms and How They Progress
Peripheral venous disease develops gradually, and early symptoms are easy to dismiss. The progression typically looks like this:
- Early stage: Spider veins or small varicose veins appear. Legs feel heavy, achy, or fatigued after long periods of standing. Mild swelling around the ankles develops by the end of the day and resolves overnight.
- Moderate stage: Varicose veins become more prominent and painful. Swelling persists longer. The skin around the ankles may start to darken or take on a reddish-brown discoloration as red blood cells leak from pressurized veins and break down in the tissue.
- Advanced stage: The skin becomes thickened, hardened, or itchy. Fat beneath the skin may break down, creating a tight, woody texture. At its worst, the stressed skin breaks down into an open wound, a venous ulcer, typically on the inner ankle.
Not everyone progresses through all stages. Many people live with varicose veins for decades without developing ulcers. But the disease rarely reverses on its own, and earlier intervention tends to produce better outcomes.
Who Gets It
Peripheral venous disease is one of the most common vascular conditions. Epidemiological data from the United Kingdom found that about 2.5% of adults have symptomatic varicose veins requiring medical attention in any given year, with a smaller but significant number developing venous ulcers. The condition is more common in women, people over 50, those with a family history of varicose veins, and anyone whose job involves prolonged standing. Obesity, prior DVT, and multiple pregnancies all raise risk substantially.
How It’s Diagnosed
Diagnosis starts with a physical exam in the standing position, since veins fill and bulge under gravity. Your doctor will look for visible varicose veins, swelling, skin changes, and ulcers. The key diagnostic tool is a duplex ultrasound, a painless scan that shows both the structure of your veins and the direction of blood flow in real time. The ultrasound can pinpoint exactly which valves are leaking, how far the reflux extends, and whether a blood clot is contributing to the problem. It’s non-invasive and takes about 30 to 45 minutes.
Compression Therapy and Lifestyle Changes
Compression stockings are the foundation of conservative treatment. They work by applying graduated pressure, tightest at the ankle and looser toward the knee, to help push blood upward and support weakened vein walls. For mild symptoms like minor swelling and achiness, stockings in the 15 to 20 mmHg range are typically sufficient. Moderate to severe disease, including active ulcers, calls for medical-grade compression in the 30 to 40 mmHg range. These higher-pressure stockings usually require a prescription and proper fitting.
Exercise plays a surprisingly powerful role. A randomized trial published in the Journal of Vascular Surgery found that a structured calf-strengthening program restored calf pump function to normal range after six months. The exercise group showed significant improvements in how effectively their muscles squeezed blood out of the leg, while a control group wearing compression stockings alone did not improve. The program used standard physical therapy exercises focused on calf strength and ankle flexibility, nothing exotic. Walking, calf raises, and ankle circles are the typical starting points.
Other practical changes that reduce symptoms include elevating your legs above heart level for 15 to 30 minutes several times a day, avoiding prolonged standing or sitting, maintaining a healthy weight, and staying well hydrated.
Procedures to Treat Damaged Veins
When compression and lifestyle changes aren’t enough, several minimally invasive procedures can close off or remove the damaged veins. Blood reroutes through healthy veins nearby.
The two most common options are thermal ablation procedures done through a tiny catheter inserted into the vein. Radiofrequency ablation uses heat from radio waves, while laser ablation uses laser energy. Both are performed under local anesthesia, usually in an outpatient setting, and you walk out the same day. At one month, both techniques close the treated vein more than 98% of the time. At one year, closure rates remain above 93%. A meta-analysis comparing the two found that radiofrequency ablation had a slightly lower recurrence rate at one year (about 5% versus 7% for laser), a gap that widened at five years (19% versus 39% in one follow-up study, though other studies found no significant difference).
Traditional surgical stripping, where the damaged vein is physically removed through small incisions, produces similar long-term results but involves more pain and a longer recovery. It’s still used in certain situations, such as very large or unusually shaped veins, but thermal ablation has largely replaced it as the first-line procedure. For smaller varicose veins and spider veins, sclerotherapy (injecting a solution that collapses the vein) or surface laser treatments are common options.
Current clinical guidelines recommend that anyone who has had a vein procedure should have at least one follow-up visit after healing, and that recurrent varicose veins should be evaluated with a standing exam and ultrasound to determine whether the original vein has reopened or a new source of reflux has developed.
Venous Ulcers: The Most Serious Complication
Venous ulcers are the end result of long-standing, untreated venous disease. They’re open wounds, usually on the inner ankle, that form when chronically high venous pressure damages the skin and underlying tissue beyond its ability to repair itself. These ulcers are notoriously slow to heal. With consistent compression therapy, 30 to 60% of venous ulcers heal within 24 weeks, and 70 to 85% heal within a year. But they often recur, and some remain open for years.
The complications of an open venous ulcer go beyond the wound itself. Skin infection (cellulitis) is common and can spread rapidly. In rare cases, chronic ulcers can lead to bone infection or even malignant changes in the wound tissue. The impact on quality of life is substantial: chronic pain, wound care routines, limited mobility, and social isolation are all well-documented consequences.