What are the treatment options for painful varicose veins?

Treatment Options for Painful Varicose Veins

Endovenous thermal ablation is the recommended first-line treatment for symptomatic varicose veins with documented valvular reflux, offering better outcomes and fewer complications than traditional surgical approaches. 1

Diagnostic Assessment

• Venous duplex ultrasonography is the preferred diagnostic test when considering interventional therapy, as it assesses venous anatomy, incompetent junctions, reflux extent, and rules out thrombosis 2
• Reflux is defined as retrograde flow duration >350 milliseconds in perforating veins, >500 milliseconds in superficial and deep calf veins, and >1,000 milliseconds in femoropopliteal veins 1
• The CEAP (Clinical, Etiologic, Anatomic, Pathophysiologic) classification system helps characterize the severity of venous disease and guide treatment decisions 2

Treatment Options

Conservative Measures

• Conservative treatments are recommended for patients who are not candidates for interventional procedures, don't desire intervention, or are pregnant 2, 1
• These include:
  • Lifestyle modifications: avoiding prolonged standing, exercise, wearing non-restrictive clothing, and cardiovascular risk factor modification 2
  • Elevation of affected legs to reduce venous pressure 2
  • Weight loss for obese patients to improve symptoms 2
  • Phlebotonics (including horse chestnut seed extract) may provide symptomatic relief, though long-term studies are lacking 2

Compression Therapy

• Despite historical recommendations, evidence for compression stockings in treating varicose veins without active or healed ulcers is insufficient 2
• The National Institute for Health and Care Excellence recommends compression only if interventional treatment is ineffective, or as first-line therapy only in pregnant women 2, 1
• When using compression therapy, a minimum pressure of 20-30 mmHg is recommended, with 30-40 mmHg advised for more severe disease 2
• Insurance companies may require a trial of compression before approving interventional treatments 1

Interventional Treatments

1. Endovenous Thermal Ablation (First-Line)

   • Includes endovenous laser ablation and radiofrequency ablation 1
   • Benefits: performed under local anesthesia, immediate walking after procedure, quick return to normal activities, 90% success rate at 1 year 1
   • Potential risk: approximately 7% surrounding nerve damage 1
   • Has largely replaced surgery as the standard of care 2

2. Endovenous Sclerotherapy

   • Recommended for small to medium-sized varicose veins, as adjunctive therapy after thermal ablation, or for recurrent varicose veins 1
   • Common sclerosing agents: hypertonic saline, sodium tetradecyl (Sotradecol), and polidocanol (Varithena) 2
   • Occlusion rates range from 72% to 89% at 1 year 1
   • Chemical sclerotherapy alone has worse outcomes compared to thermal ablation or surgery 1

3. External Laser Thermal Ablation

   • Works best for telangiectasias (spider veins) 2

4. Surgical Options

   • Includes ligation and stripping or phlebectomy with multiple small incisions 2
   • Modern techniques use small incisions to reduce scarring and blood loss 2
   • May be performed under local or regional anesthesia 2
   • Growing evidence suggests surgery is not consistently the best interventional option 2

Treatment Sequence and Considerations

• Treatment sequence is important for long-term success 1
• For radiofrequency ablation to be medically indicated, the great saphenous vein diameter should be at least 4.5mm 1
• Bulging varicosities should be treated by phlebectomy at the time of truncal vein ablation 3
• Treatment decisions should be based on symptoms, patient preferences, cost, potential complications, and physician training 2

Monitoring and Follow-up

• Participation in a venous registry is recommended for monitoring outcomes 3
• Regular follow-up is essential to assess treatment efficacy and detect recurrence