What is the treatment for venous insufficiency in the Great Saphenous Vein (GSV)?

Treatment for Venous Insufficiency in the Great Saphenous Vein

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

Diagnostic Evaluation

• Duplex ultrasound is the gold standard for evaluating venous reflux in the GSV
• Diagnostic criteria include valve closure times exceeding 500 milliseconds
• Complete assessment should evaluate the entire venous system from the inguinal ligament to the ankle

Treatment Algorithm

First-Line Interventional Options:

1. Endovenous Thermal Ablation
   • Radiofrequency ablation (RFA)
   • Endovenous laser ablation (EVLA)
   • Both techniques show comparable technical success rates up to 5 years 2
   • RFA may offer better long-term results with lower recurrence rates at 5 years 2

Alternative Interventional Options:

1. Ultrasound-Guided Foam Sclerotherapy (UGFS)

   • Less effective than thermal ablation for technical success 2
   • Can be used as adjunctive treatment for tributary veins and varicosities 1
   • Consider for patients who cannot undergo thermal ablation

2. High Ligation and Stripping (HL/S)

   • Traditional surgical approach
   • May have better technical success compared to UGFS 2
   • Similar recurrence rates to EVLA but with longer recovery time 2

3. Newer Techniques

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

Adjunctive Treatments:

1. Compression Therapy

   • Essential component of all treatment plans
   • Use 30-40 mmHg thigh-high compression stockings after procedures 1
   • Higher compression over the calf (rather than graduated compression) may be more effective in enhancing venous pump function 3
   • Caution: When applying stockings after sclerotherapy, be aware that pulling up the stocking can cause significant hemodynamic changes that might flush sclerosant into deeper veins 4

2. Phlebectomy/Microphlebectomy

   • For visible varicosities
   • Can be performed concurrently with primary treatment 1

Special Considerations

Superficial Vein Thrombosis (SVT) in GSV

Factors that favor anticoagulant therapy in SVT involving the GSV include:

• Extensive SVT
• Involvement above the knee, particularly if close to the saphenofemoral junction
• Severe symptoms
• History of VTE or SVT
• Active cancer
• Recent surgery 5

Follow-up Protocol

• Early follow-up ultrasound within 1-2 weeks to confirm successful closure and rule out complications like endovenous heat-induced thrombosis (EHIT) 1
• Regular follow-up to monitor disease progression and adjust treatment plans

Lifestyle Modifications

• Weight management
• Regular exercise
• Leg elevation
• Non-restrictive clothing
• These modifications are important but should complement rather than replace definitive treatment 1

Potential Complications

• Deep vein thrombosis (reported in up to 16% of RFA cases)
• Superficial vein thrombosis (9.6% in external valvuloplasty) 6
• Recurrence (varies by procedure)
• Skin burns, nerve injury, and hyperpigmentation

The choice between treatment options should be guided by the specific anatomical pattern of venous insufficiency, patient factors, and available expertise, with endovenous thermal ablation techniques offering the best balance of efficacy and safety for most patients with GSV insufficiency.