Who manages a patient with superficial venous reflux in the greater saphenous vein (GSV)?

Management of Superficial Venous Reflux in the Greater Saphenous Vein

Patients with superficial venous reflux in the greater saphenous vein should be referred to a vascular specialist for endovenous ablation therapy, which is the first-line treatment with high success rates (91-100% at 1 year). 1

Diagnostic Evaluation and Specialist Referral

• Initial evaluation should include:

  • Assessment of symptom severity (pain, swelling, skin changes)
  • Evaluation for signs of chronic venous insufficiency (hyperpigmentation, lipodermatosclerosis, ulcers)
  • Venous Doppler ultrasound to confirm reflux and measure:
    • Reflux duration (≥500ms indicates significant reflux)
    • Vein diameter (≥4.5mm typically requires intervention)

• Appropriate specialists for management include:

  • Vascular surgeons
  • Interventional radiologists
  • Phlebologists (vein specialists)

Treatment Options

First-Line Treatments

1. Endovenous Thermal Ablation:

   • Endovenous laser ablation (EVLA) - recommended for most cases of GSV reflux 1
   • Radiofrequency ablation (RFA) - particularly effective for veins >4.5mm in diameter 1
   • Both techniques have comparable long-term outcomes to surgical intervention with fewer complications 1

2. Sclerotherapy:

   • Indicated for smaller veins (≤3mm) and telangiectasias
   • Often used as adjunctive therapy after endovenous ablation 1

Surgical Options

• Microphlebectomy/stab phlebectomy for tributary veins exceeding 2.5mm
• Traditional surgical ligation and stripping - less commonly used now due to higher complication rates 1

Special Considerations

• Below-knee GSV reflux: Can be safely treated with endovenous ablation with minimal complications (4% transient paresthesia) 2

• Combined deep and superficial venous reflux:

  • Saphenous vein ablation can improve deep venous reflux in approximately one-third of patients 3
  • Patients with deep venous reflux velocities <10 cm/sec typically show better outcomes after saphenous ablation 4

• Advanced venous disease:

  • For patients with severe post-thrombotic syndrome or venous ulcers, more complex interventions may be needed 5
  • Endovascular or surgical approaches may be considered for iliocaval/iliofemoral obstruction 5

Post-Procedure Care

• Compression therapy (20-30 mmHg) to promote vein closure
• Walking for 15-20 minutes immediately after the procedure
• Follow-up ultrasound to confirm successful vein closure
• Monitor for potential complications:
  • Phlebitis
  • Residual pigmentation
  • Nerve damage (approximately 7%)
  • DVT risk (0.3-0.7%) 1

Conservative Management

While awaiting specialist evaluation, patients should be advised to:

• Elevate legs when possible
• Wear compression stockings (20-30 mmHg)
• Avoid prolonged standing
• Lose weight if obese
• Avoid restrictive clothing 1

The American Academy of Family Physicians and American College of Radiology guidelines strongly support endovenous ablation as the treatment of choice for saphenous vein reflux, with excellent outcomes and favorable safety profiles compared to traditional surgical approaches 1.