What are the treatment options for superficial varicose veins?

Treatment Options for Superficial Varicose Veins

Endovenous thermal ablation is the recommended first-line treatment for symptomatic varicose veins with documented valvular reflux in non-pregnant patients, and should not be delayed for a trial of compression therapy. 1

Diagnostic Approach

Before determining treatment, proper assessment is essential:

• Duplex ultrasound is the gold standard for evaluation
• Assess for:
  • Incompetent saphenous junctions
  • Extent of reflux (retrograde flow >500 milliseconds in superficial veins)
  • Diameter of affected veins
  • Presence of deep venous thrombosis

Treatment Algorithm Based on Patient Characteristics

1. Conservative Management

Appropriate for:

• Pregnant women
• Patients who decline interventional procedures
• Patients with contraindications to procedures
• Patients with mild symptoms (CEAP class C1-C2)

Conservative options include:

• Compression therapy:

  • Despite historical use, evidence for compression stockings in uncomplicated varicose veins is limited 1, 2
  • When used, 20-30 mmHg gradient compression stockings are recommended 1
  • More effective for advanced disease (C5-C6) with healed or active ulcers than for uncomplicated varicose veins 1
  • Note: Compression stockings may not effectively compress leg veins in standing position 3

• Lifestyle modifications:

  • Avoiding prolonged standing/sitting
  • Regular exercise
  • Leg elevation
  • Weight loss if overweight
  • Wearing non-restrictive clothing

2. Interventional Treatments (in order of preference)

a. Endovenous Thermal Ablation

• First-line treatment for symptomatic varicose veins with documented reflux 1
• Types:
  • External laser ablation (for telangiectasias/spider veins)
  • Endovenous laser ablation (EVLA)
  • Radiofrequency ablation (RFA)
• Advantages:
  • Minimally invasive, performed under local anesthesia
  • Same-day discharge
  • Quick return to normal activities
  • Lower complication rates than surgery
  • Better tolerated than sclerotherapy and surgery 1
• Potential complication: Temporary nerve damage (7% risk) 1

b. Endovenous Sclerotherapy

• Second-line treatment or for specific vein types 1
• Best for:
  • Small (1-3 mm) and medium (3-5 mm) veins
  • Recurrent varicose veins after surgery
• Technique: Injection of sclerosing agent (often as foam) into the vein
• Common agents: Hypertonic saline, sodium tetradecyl, polidocanol
• No evidence that any agent is superior 1

c. Surgery

• Third-line treatment after thermal ablation and sclerotherapy 1
• Modern techniques:
  • Ligation and stripping (typically from groin to knee)
  • Phlebectomy for smaller veins
• Higher recurrence rates (20-28% at 5 years) compared to newer techniques 1
• More invasive, longer recovery time

Special Considerations

For Pregnant Women

• Compression stockings are first-line therapy 1
• Defer interventional treatments until after pregnancy

For Patients with Insurance Restrictions

• May require trial of compression therapy before approval of interventional treatments 1
• Typical requirement: 20-30 mmHg gradient compression stockings

For Patients with Venous Ulcers (C5-C6)

• Compression therapy has proven benefit for ulcer healing and prevention of recurrence 1
• 30-40 mmHg inelastic compression is better than elastic bandaging 1

Pitfalls and Caveats

1. Don't delay referral for interventional treatment in symptomatic patients with documented reflux 1
2. Don't assume compression stockings are effective for uncomplicated varicose veins - evidence is limited 1, 2, 4
3. Be cautious with compression in patients with arterial disease - use reduced pressure (20-30 mmHg) when ankle-brachial index is between 0.6-0.9, and avoid when <0.6 1
4. Consider patient compliance with compression therapy - proper fitting and education are essential 1
5. A randomized controlled trial showed that surgical treatment was significantly more effective than compression therapy alone in improving symptoms and quality of life at 2 years 5