What are the treatment options for leg varicose veins?

Treatment Options for Leg Varicose Veins

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

Diagnostic Evaluation

Before initiating treatment, venous duplex ultrasonography should be performed when considering interventional therapy. This imaging:

• Assesses anatomy and physiology of the lower extremity venous system
• Identifies incompetent saphenous junctions and their diameter
• Measures extent of reflux and locates incompetent perforating veins
• Rules out deep venous thrombosis and superficial thrombophlebitis

Reflux is defined as retrograde flow lasting:

• 350 milliseconds in perforating veins

• 500 milliseconds in superficial and deep calf veins

• 1000 milliseconds in femoropopliteal veins

Treatment Algorithm

1. Conservative Management

Appropriate for:

• Pregnant women (first-line)
• Patients who are not candidates for interventional procedures
• Patients who decline interventional treatment

Options include:

• Compression therapy: 20-30 mmHg elastic compression stockings with gradient pressure (distal to proximal)
• Lifestyle modifications:
  • Avoiding prolonged standing/straining
  • Regular exercise
  • Wearing non-restrictive clothing
  • Managing cardiovascular risk factors
  • Reducing peripheral edema
• Leg elevation: May improve symptoms in some patients
• Weight loss: For obese patients
• Phlebotonics: Horse chestnut seed extract may provide symptomatic relief (limited long-term data)

2. Interventional Treatments

For symptomatic patients with documented venous reflux:

a. Thermal Ablation (First-line)

• External laser thermal ablation: Best for telangiectasias (spider veins)
• Endovenous thermal ablation: For larger vessels including great saphenous vein
  • Types: Endovenous laser ablation or radiofrequency ablation
  • Procedure: Under ultrasound guidance, laser fiber/radiofrequency catheter inserted into vein
  • Advantages: Same-day procedure, quick return to activities
  • Potential complication: Temporary nerve damage (7% risk) 1

b. Endovenous Sclerotherapy (Second-line)

• Best for small (1-3mm) and medium (3-5mm) veins or recurrent varicosities
• Procedure: Sclerosing agent injected into vein under ultrasound guidance
• Agents: Hypertonic saline, sodium tetradecyl (Sotradecol), polidocanol (Varithena)
• Creates inflammation of endothelium, resulting in fibrosis and vein occlusion

c. Surgery (Third-line)

• Ligation and stripping of great or small saphenous vein
• Phlebectomy for smaller veins (removal through small incisions)
• Modern techniques use smaller incisions to reduce scarring and complications
• Limited to removal of superficial axial veins from groin to knee

Treatment Selection Considerations

• Patient symptoms and preferences
• Vein characteristics (size, location)
• Presence/absence of deep venous insufficiency
• Cost and insurance coverage
• Provider expertise
• Potential complications

Important Clinical Pearls

1. Evidence has evolved: Recent guidelines no longer recommend compression stockings as mandatory initial therapy for varicose veins before interventional treatment 1, 2.

2. Compression therapy limitations: Insufficient evidence supports compression stockings' effectiveness for varicose veins without active/healed ulcers 1, 3.

3. Treatment efficacy: Endovenous thermal ablation, radiofrequency ablation, and foam sclerotherapy are as effective as traditional surgery with fewer complications 1.

4. Mandatory imaging: Venous duplex ultrasound should be performed before any interventional treatment, even for small varicosities, as most have underlying venous reflux 2.

5. Post-procedure compression: After interventional treatment, compression therapy may help reduce pain, bruising and ecchymosis 4.

6. Recurrence risk: Varicose veins commonly recur after treatment, requiring ongoing management in many cases 5.

7. Pregnancy considerations: Compression therapy is the only first-line treatment recommended during pregnancy 1.

AI-generated content review: This response provides a structured approach to varicose vein treatment based on the most recent guidelines, prioritizing interventions that improve morbidity, mortality and quality of life.