What is the treatment for great saphenous vein insufficiency?

Treatment for Great Saphenous Vein Insufficiency

Radiofrequency ablation (RFA) is recommended as first-line treatment for great saphenous vein insufficiency, particularly for vein diameters >4.5mm, due to its high success rates and favorable safety profile. 1

Diagnostic Evaluation

• Confirm diagnosis with duplex ultrasound evaluation of:
  • Deep venous system
  • Great saphenous vein (GSV)
  • Small saphenous vein (SSV)
  • Accessory saphenous veins
  • Document presence, location, and duration of reflux (abnormal reflux defined as retrograde venous flow >500 ms) 1

Treatment Algorithm

First-line Treatments

1. Endovenous Thermal Ablation

   • Radiofrequency ablation (RFA) - preferred for veins >4.5mm in diameter 1
   • Endovenous laser ablation (EVLA) - alternative thermal ablation method with similar efficacy to RFA 2
   • Both show higher success rates (88% for EVLA) compared to sclerotherapy (34%) at 5-year follow-up 3

2. Compression Therapy

   • Medical-grade compression stockings:
     • 20-30 mmHg for mild to moderate disease
     • 30-40 mmHg for severe disease 1
   • Continue compression therapy with graduated stockings for at least 2 years, and longer if symptoms persist 1

Alternative Treatments

1. Ultrasound-guided foam sclerotherapy (UGFS)

   • Consider for smaller veins (<4.5mm) 1
   • Lower long-term success rates (34%) compared to thermal ablation (88%) 3

2. Surgical Options

   • High ligation and stripping (HL+S) - traditional surgical approach
   • Shows comparable long-term outcomes to thermal ablation 2
   • Consider when endovenous treatments are contraindicated or failed

3. Newer Techniques

   • Mechanochemical ablation (MOCA)
   • Cyanoacrylate glue
   • Endovenous steam ablation 2

Treatment Selection Based on Vein Diameter

• Veins >7.2mm: Total abolishment of saphenous reflux recommended due to correlation with severe disease and poor prognosis 4
• Veins 4.5-7.2mm: RFA or EVLA preferred 1
• Veins <4.5mm: Consider sclerotherapy 1

Combined Approaches

• Combined EVLA and foam sclerotherapy shows high occlusion rates (93% primary closure) with infrequent complications 5
• Consider adjunctive phlebectomy for tributary varicosities to improve quality of life outcomes 6

Follow-up Care

• Ultrasound follow-up within 1-2 weeks to confirm successful vein closure and rule out deep venous thrombosis 1
• Continue compression therapy with 20-30 mmHg graduated compression stockings for at least 2 years 1
• Monitor for potential complications:
  • Paresthesia
  • Thrombophlebitis
  • Nerve damage
  • DVT risk (0.3-0.7%)
  • Thrombus extension into the common femoral vein 1

Lifestyle Modifications

• Elevation of the affected leg
• Avoidance of prolonged standing and straining
• Regular exercise to activate calf muscle pumps
• Wearing non-restrictive clothing
• Decreased sodium intake
• Weight loss
• Skin care with emollients 1

Treatment Efficacy Considerations

• RFA and EVLA show similar technical success rates up to 5 years 2
• RFA may have better long-term outcomes compared to EVLA or HL/S after 5 years 2
• Standalone ablation of anterior accessory great saphenous veins without treating associated tributaries may result in suboptimal quality of life outcomes 6

The treatment approach should be guided by vein diameter, patient factors, and availability of expertise, with thermal ablation (particularly RFA) being the preferred first-line treatment for most patients with great saphenous vein insufficiency.