What is the best course of treatment for a 50-year-old male patient with multiple varicosities of the superficial venous structures in the left leg, presenting with recent soreness and wearing bilateral compression socks (Compression Stockings)?

Treatment of Symptomatic Varicose Veins in a 50-Year-Old Male

Endovenous thermal ablation is the recommended first-line treatment for this patient with symptomatic varicose veins and documented superficial venous insufficiency. 1

Assessment of Current Condition

The patient presents with:

• Multiple varicosities of superficial venous structures in left leg (posterior knee and calf)
• Recent soreness for two months
• Hypertrophic vein extending from lateral calf through posterior knee to groin
• Easily palpable vein
• Currently using bilateral compression stockings
• No evidence of deep venous thrombosis (confirmed by ultrasound)

Treatment Algorithm

1. First-line treatment: Endovenous thermal ablation

   • Recommended for symptomatic varicose veins with documented valvular reflux 2, 1
   • Does not need to be delayed for a trial of compression stockings 1
   • Can be performed under local anesthesia with minimal recovery time 2
   • Allows patients to return quickly to work and normal activities 2

2. Adjunctive treatments to consider:

   • Stab phlebectomy for removal of visible varicosities 1
   • Sclerotherapy for smaller tributary veins post-ablation 2, 1

3. Hybrid approach considerations:

   • Combined endovenous laser ablation with phlebectomy and/or sclerotherapy may provide optimal results for complex presentations 3
   • Addresses both the primary source of reflux and visible varicosities 1

Rationale for Recommendation

Current guidelines from the American Family Physician and American College of Radiology strongly support endovenous thermal ablation as first-line therapy for symptomatic varicose veins 2, 1. This recommendation is based on:

• Patient has symptoms (soreness) despite conservative management with compression stockings
• Ultrasound confirms superficial venous varicosities
• The hypertrophic vein likely represents an incompetent saphenous vein
• The patient was previously recommended for intervention ("shoot the vein down") by a specialist

Important Considerations

• Compression therapy limitations: While the patient is already using compression stockings, evidence supporting their effectiveness as primary treatment is lacking 2
• Procedural details: Endovenous thermal ablation involves inserting a laser fiber or radiofrequency catheter into the vein under ultrasound guidance, causing closure of the vein and redirection of blood flow 2
• Risk awareness: There is approximately 7% risk of surrounding nerve damage from thermal injury, though most nerve damage is temporary 2
• Cost considerations: The patient previously declined treatment due to cost; insurance coverage should be verified, as some plans may require documented failure of conservative management (typically 3 months of compression therapy with 20-30 mmHg stockings) 1

Follow-up Recommendations

• Post-procedure ultrasound to confirm successful vein closure
• Continued use of compression stockings for a short period post-procedure
• Assessment for any residual varicosities that may require additional treatment
• Lifestyle modifications including weight management, regular exercise, and avoiding prolonged standing 2