What is the initial workup and management for a patient with bilateral varicose veins and pain?

Initial Workup and Management for Bilateral Varicose Veins with Pain

The initial workup for bilateral lower extremity varicose veins with pain should include duplex ultrasound of the lower extremity to document venous reflux, followed by a treatment algorithm that starts with compression therapy and progresses to endovenous thermal ablation as first-line interventional treatment if symptoms persist. 1

Diagnostic Evaluation

• Duplex ultrasound of the lower extremity is the gold standard initial diagnostic test for varicose veins, which evaluates the deep venous system, great saphenous vein, small saphenous vein, and accessory saphenous veins 1, 2
• Ultrasound should document the presence, absence, and location of reflux, defined as retrograde venous flow lasting >500 milliseconds 2
• Document the CEAP classification to categorize severity (C0: no visible signs, C1: telangiectasias, C2: varicose veins, C3: edema, C4: skin changes, C5: healed ulcer, C6: active ulcer) 1
• Assess for symptoms including pain, burning, itching, heaviness, cramping, throbbing, and swelling, which are often worse at the end of the day or after prolonged standing 1

Initial Management

Conservative Therapy (First-Line)

• Compression therapy with graduated compression stockings (20-30 mmHg for mild disease, 30-40 mmHg for more severe disease) 2
• Lifestyle modifications including:
  • Regular leg elevation above heart level 2
  • Avoidance of prolonged standing or sitting 2
  • Regular exercise to improve calf muscle pump function 2
  • Weight loss if overweight or obese 2
  • Wearing non-restrictive clothing 2
• Horse chestnut seed extract may provide symptomatic relief, though long-term studies are limited 2
• Conservative therapy should be tried for at least 3 months before considering interventional treatment 3, 4

Interventional Treatment

If symptoms persist despite adequate conservative therapy and there is documented valvular reflux:

1. Endovenous thermal ablation (radiofrequency or laser) is the first-line interventional treatment for saphenous vein reflux 1, 3, 4

   • Indicated for veins with documented reflux and diameter ≥4.5mm 3, 4
   • High technical success rates with occlusion rates of 91-100% within 1 year 3
   • Can be performed under local anesthesia with same-day discharge 4

2. Sclerotherapy (including foam sclerotherapy with agents like polidocanol/Varithena) 1, 3

   • Appropriate for smaller tributary veins or as adjunct to primary treatment 3
   • Indicated for veins with diameter of at least 2.5mm with documented reflux 3
   • Occlusion rates range from 72-89% at 1 year 3

3. Surgical options (ligation and stripping, phlebectomy) 1, 2

   • Generally considered third-line therapy after endovenous thermal ablation and sclerotherapy 2
   • May be appropriate for very large varicosities or when other methods have failed 2
   • Bilateral surgery can be performed safely in an ambulatory setting 5

Treatment Algorithm Based on Severity

• C2-C3 (Varicose veins with or without edema): Start with compression therapy for 3 months; if symptoms persist, proceed to endovenous thermal ablation for saphenous reflux, followed by sclerotherapy for residual varicosities 1, 3

• C4-C6 (Skin changes, healed or active ulcers): More aggressive approach warranted; compression therapy with consideration for early endovenous thermal ablation to prevent progression 1, 2

Important Considerations

• Treatment should address the underlying pathophysiology (valvular reflux) rather than just the visible varicosities 6
• Recurrence is common if the source of reflux is not adequately treated 6
• Small varicose veins without symptoms may be treated for cosmetic reasons, but underlying venous reflux should still be investigated 6
• Monitoring outcomes is essential; participation in a venous registry is recommended 6

Potential Complications to Monitor

• Nerve damage from thermal injury (approximately 7% risk, usually temporary) 4
• Wound infection (0.5%) 5
• Hematoma requiring drainage (0.2%) 5
• Transient paresthesia (1.1%) 5
• Superficial thrombophlebitis (0.6%) 5
• Deep vein thrombosis (rare) 5