What are the management options for varicose veins?

Management Options for Varicose Veins

Radiofrequency ablation (RFA) is the first-line treatment for symptomatic varicose veins with saphenous vein incompetence, particularly for vein diameters >4.5mm, due to its high success rates and favorable safety profile. 1

Initial Management Approach

Conservative Management (First Step)

• A 3-month trial of conservative management should be attempted before considering procedural interventions 1:
  • Medical-grade compression stockings (20-30 mmHg)
  • Daily leg elevation
  • Regular exercise to improve calf muscle pump function
  • Weight management for patients with obesity
  • Decreased sodium intake
  • Skin care with emollients

When to Consider Intervention

• Persistent symptoms despite conservative management
• Complications such as bleeding, thrombophlebitis, or skin changes
• Patient preference after discussing risks and benefits

Procedural Treatment Options

Endovenous Thermal Ablation (First-Line)

1. Radiofrequency Ablation (RFA)

   • Recommended for vein diameters >4.5mm 1
   • Benefits:
     • Earlier return to normal activities (median 3 days vs. 12.5 days for surgery)
     • Less postoperative pain than conventional surgery
     • Excellent long-term results with 100% truncal obliteration rates at 7+ years follow-up 1
   • Technique:
     • Ultrasound-guided catheter placement within 1 cm of saphenofemoral junction 1
     • Post-procedure compression therapy (20-30 mmHg) 1

2. Endovenous Laser Ablation (EVLA)

   • Similar efficacy to RFA with comparable safety profile 2
   • Most cost-effective therapeutic option according to recent studies 2

Other Treatment Options

1. Sclerotherapy

   • Best for:
     • Spider veins (≤1 mm)
     • Reticular veins (1-3 mm)
     • Telangiectasias 1
   • Common agents: polidocanol, sodium tetradecyl, hypertonic saline 1
   • Note: Ultrasound-guided foam sclerotherapy has higher recanalization rates (51% at 1 year) 2

2. Surgical Options

   • Now considered third-line after endovenous thermal ablation and sclerotherapy 2
   • High ligation and stripping
   • CHIVA technique (Cure conservatrice et Hemodynamique de l'Insufficience Veineuse en Ambulatoire)
     • May cause more bruising than RFA or EVLA 2

3. Newer Techniques

   • Mechanochemical endovenous ablation (MOCA)
     • Non-thermal, non-tumescent option
     • Lower overall success rate than EVLA or RFA 2
   • Cyanoacrylate embolization
     • Promising but requires more evidence 2

Post-Procedure Care and Follow-up

• Early ambulation recommended post-procedure 1
• Compression therapy (20-30 mmHg) should be continued for at least 2 years, longer if symptoms persist 1
• Follow-up ultrasound within 1-2 weeks to:
  • Confirm successful vein closure
  • Rule out deep venous thrombosis 1

Potential Complications to Monitor

• Post-procedure DVT (up to 16% of cases) 1
• Endovenous heat-induced thrombosis (EHIT) in approximately 9% of cases 1
• Paresthesia, thrombophlebitis, and nerve damage 1
• Thrombotic complications (DVT risk 0.3-0.7%) 1

Special Considerations

• Pre-procedure assessment should confirm absence of significant arterial disease (measure ankle-brachial index if arterial disease is suspected) 1
• For patients with pelvic vein reflux, transvaginal duplex ultrasound and potential coil embolization may be needed 3
• Incompetent perforating veins should be treated by thermal ablation using the transluminal occlusion of perforator (TRLOP) approach 3

Treatment Algorithm

1. Start with 3 months of conservative management (compression, lifestyle modifications)
2. If symptoms persist, obtain venous duplex ultrasound in erect position
3. For saphenous vein incompetence >4.5mm: RFA or EVLA as first-line
4. For spider/reticular veins: Sclerotherapy
5. For recurrent or complex cases: Consider surgical options
6. Maintain compression therapy for at least 2 years post-procedure