What is the initial workup and treatment for varicose veins in the legs?

Initial Workup and Treatment for Varicose Veins in the Legs

Venous duplex ultrasonography is the recommended initial diagnostic test for varicose veins when interventional therapy is being considered, followed by endovenous thermal ablation as the first-line treatment for symptomatic varicose veins with documented valvular reflux. 1

Diagnostic Workup

• Venous duplex ultrasonography is the modality of choice when venous disease is severe or interventional therapy is being considered 1
• Ultrasonography assesses the anatomy and physiology of the lower extremity venous system, identifying:
  • Incompetent saphenous junctions
  • Diameter of junctions
  • Extent of reflux
  • Location and size of incompetent perforating veins
  • Presence of deep venous thrombosis or superficial thrombophlebitis 1
• Reflux is defined as retrograde flow duration of:

  • 350 milliseconds in perforating veins

  • 500 milliseconds in superficial and deep calf veins

  • 1,000 milliseconds in femoropopliteal veins 1

• Other imaging modalities (CT, MRI, venography, plethysmography) are used only if ultrasonography is inconclusive or for complex surgical situations 1

Treatment Algorithm

First-Line Treatment for Symptomatic Varicose Veins

• Endovenous thermal ablation is recommended as first-line treatment for symptomatic varicose veins with documented valvular reflux 1, 2
• Types of thermal ablation:
  • Endovenous laser ablation
  • Radiofrequency ablation
  • Both are effective for larger vessels, including the great saphenous vein 1
• Benefits of endovenous thermal ablation:
  • Can be performed under local anesthesia
  • Patients can walk immediately after the procedure
  • Quick return to work and normal activities
  • Success rate of 90% at 1 year 2
• Potential risk: Approximately 7% risk of surrounding nerve damage, though most is temporary 1

Second-Line Treatment

• Endovenous sclerotherapy is recommended for:
  • Small to medium-sized varicose veins (1-5 mm) 3
  • As adjunctive therapy after thermal ablation 2
  • Recurrent varicose veins 3
• Common sclerosing agents include:
  • Hypertonic saline
  • Sodium tetradecyl (Sotradecol)
  • Polidocanol (Varithena) 1, 3
• Occlusion rates range from 72% to 89% at 1 year 2

Third-Line Treatment

• Surgery (ligation and stripping or phlebectomy) is considered third-line treatment 3
• Modern surgical techniques use small incisions to reduce scarring and blood loss 1
• May be performed under local or regional anesthesia 1

Conservative Measures

• Conservative measures are recommended for patients who:

  • Are not candidates for endovenous or surgical management
  • Do not desire intervention
  • Are pregnant 1

• These measures include:

  • Compression stockings (20-30 mmHg gradient) 1
  • Elevation of the affected leg 1
  • Lifestyle modifications (avoiding prolonged standing, exercise, wearing nonrestrictive clothing) 1
  • Weight loss for obese patients 1
  • Phlebotonics (e.g., horse chestnut seed extract) 1

Important Considerations and Caveats

• The 2013 National Institute for Health and Care Excellence guidelines recommend offering external compression only if interventional treatment is ineffective, and as first-line therapy only in pregnant women 1
• Insurance companies may require a trial of external compression before approving interventional treatments 1
• The treatment sequence is important for long-term success, with studies showing that chemical sclerotherapy alone has worse outcomes compared to thermal ablation or surgery 2
• For radiofrequency ablation to be medically indicated, the great saphenous vein diameter should be at least 4.5mm 2
• After treatment with sclerotherapy, compression therapy is suggested to improve outcomes, though the optimal duration is not established 4
• In patients with mixed arterial and venous disease, compression should be limited to those with ankle-brachial index exceeding 0.5 or absolute ankle pressure >60 mmHg 4