What are the management options for varicose veins?

Management Options for Varicose Veins

Endovenous thermal ablation is the first-line treatment for symptomatic varicose veins with documented valvular reflux, with radiofrequency ablation (RFA) particularly recommended for saphenous vein incompetence with vein diameters >4.5mm. 1

Diagnostic Evaluation

• Duplex ultrasonography is essential before initiating treatment to:
  • Assess saphenous junction incompetence
  • Measure junction diameter
  • Determine reflux extent (abnormal reflux defined as retrograde venous flow >500 ms)
  • Locate incompetent perforating veins 1

Treatment Algorithm Based on Disease Severity

Conservative Management

1. Compression Therapy

   • Mild to moderate disease: 20-30 mmHg medical-grade compression stockings
   • Severe disease: 30-40 mmHg compression stockings
   • Contraindicated when ankle-brachial index <0.6 due to risk of arterial compromise 1

2. Lifestyle Modifications

   • Elevation of 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

3. Pharmacological Options

   • Horse chestnut seed extract may provide symptomatic relief (available as over-the-counter supplement) 1
   • Antioxidant medications from flavonoid groups may help reduce complications 2

Interventional Procedures

1. Endovenous Thermal Ablation

   • First-line for symptomatic varicose veins with documented reflux
   • Radiofrequency ablation (RFA) preferred for saphenous vein incompetence with vein diameter >4.5mm 1
   • Potential complications include paresthesia, thrombophlebitis, nerve damage, and DVT risk (0.3-0.7%) 1

2. Sclerotherapy

   • Recommended for:
     • Spider veins (≤1 mm)
     • Reticular veins (1-3 mm)
     • Telangiectasias
     • Veins <4.5mm in diameter
   • Agents include polidocanol, sodium tetradecyl, and hypertonic saline 1

3. Surgical Procedures

   • Indicated for severe cases or when endovenous procedures are not suitable
   • Surgical or endovenous procedures recommended to correct central post-thrombotic venous occlusion or infrainguinal valvular incompetence for patients with severe superficial vein thrombosis 1

Special Populations

• Pregnancy: External compression is the only first-line treatment recommended during pregnancy 1
• Patients with DVT: The American College of Chest Physicians recommends anticoagulation for 3 months with direct oral anticoagulants (DOACs) over vitamin K antagonists 1

Follow-up Care

• Ultrasound follow-up within 1-2 weeks after interventional procedures to:
  • Confirm successful vein closure
  • Rule out deep venous thrombosis 1
• Continue compression therapy with 20-30 mmHg graduated compression stockings for at least 2 years, and longer if symptoms persist 1
• Patient education about signs of serious complications requiring urgent attention (e.g., deep vein thrombosis) 1

Treatment Selection Based on Vein Characteristics

• Saphenous veins >4.5mm: Radiofrequency ablation
• Veins <4.5mm: Sclerotherapy
• Spider/reticular veins: Sclerotherapy
• Visible bulging varicosities: Phlebectomy (often performed at the time of truncal vein ablation) 1, 3

Common Pitfalls to Avoid

• Failing to perform proper diagnostic imaging before treatment selection
• Using compression therapy in patients with arterial insufficiency (ankle-brachial index <0.6)
• Neglecting to treat underlying reflux when addressing visible varicosities
• Inadequate follow-up after interventional procedures
• Discontinuing compression therapy too early after treatment

The evidence strongly supports a systematic approach to varicose vein management, with endovenous thermal ablation emerging as the preferred first-line treatment for most symptomatic patients with documented reflux 1, 3. While older studies advocated for surgical removal as the most effective management 4, more recent evidence favors less invasive approaches with comparable efficacy and fewer complications.