What are the treatment options for varicose veins?

Treatment Options for Varicose Veins

Endovenous thermal ablation (radiofrequency or laser) is the recommended first-line treatment for saphenous vein reflux due to its higher efficacy, lower complication rates, faster recovery times, and better patient outcomes. 1

Diagnosis and Assessment

• Symptomatic varicose veins typically present with:
  • Pain, heaviness, and leg fatigue
  • Symptoms worsen with prolonged standing or walking
  • Physical examination confirms large varicose vein chains that interfere with daily activities 1
• Duplex ultrasound is the gold standard for evaluating venous reflux
  • Diagnostic criteria include valve closure times exceeding 500 milliseconds 1

Treatment Algorithm

First-Line Treatments

1. Endovenous Thermal Ablation

   • Radiofrequency or laser ablation for saphenous vein reflux
   • Higher efficacy and lower complication rates compared to traditional surgery 1
   • Faster recovery times and better patient outcomes

2. Ultrasound-Guided Foam Sclerotherapy

   • Effective as adjunctive treatment for tributary veins and varicosities
   • Can be combined with thermal ablation for higher primary closure rates 1
   • Less invasive than surgical options 2

3. Microphlebectomy/Phlebectomy

   • Recommended for visible varicosities
   • Can be performed as part of the same procedure with other treatments 1
   • Note: Combined RFA with stab phlebectomy may increase risk of endovenous heat-induced thrombosis (EHIT) 1

4. Compression Therapy

   • 30-40 mmHg thigh-high compression stockings
   • Used both as initial treatment and post-procedure care 1
   • Particularly effective for symptom management, though evidence for use as sole treatment is limited 3, 4

Traditional Surgical Options

• Saphenous vein stripping and ligation of saphenofemoral junction
  • Effective but associated with higher complication rates
  • Longer recovery time compared to endovenous procedures 2
  • Generally reserved for cases where endovenous options are not suitable

Post-Procedure Care

• Early follow-up ultrasound within 1-2 weeks to:
  • Confirm successful closure
  • Rule out complications like endovenous heat-induced thrombosis (EHIT) 1
• Continue compression therapy with 30-40 mmHg thigh-high compression stockings 1
• Monitor for potential complications:
  • Deep vein thrombosis (reported in up to 16% of RFA cases)
  • Risk factors for more rapid progression include positive D-dimer, extensive thrombosis, multiple vein involvement, and larger vein diameter 1

Lifestyle Modifications and Long-Term Management

• Weight management
• Regular exercise
• Leg elevation when possible
• Non-restrictive clothing 1
• Regular follow-up to monitor disease progression and adjust treatment plans

Special Considerations

• Compression therapy has shown high-level evidence for healing venous ulcers and preventing recurrence 5
• The efficacy of compression stockings as the sole initial treatment for varicose veins without ulceration remains unclear due to limited high-quality evidence 3, 4
• Patient compliance with compression therapy varies significantly and can impact treatment outcomes 3

Common Pitfalls to Avoid

• Failing to perform early post-procedure ultrasound, which is critical for detecting EHIT
• Neglecting compression therapy after interventional procedures
• Overlooking pelvic origin of varicose veins, which requires specific diagnostic approaches 1
• Treating only visible varicosities without addressing underlying venous reflux, which may lead to recurrence