What are the treatment options for varicose vein pain?

Treatment of Varicose Vein Pain

For varicose vein pain, endovenous thermal ablation (radiofrequency or laser) is recommended as first-line treatment for symptomatic varicose veins with documented valvular reflux, followed by foam sclerotherapy for tributary veins, and surgery as a third option. 1, 2

Initial Conservative Management

• Compression stockings are often used as first-line conservative treatment, though evidence for their effectiveness as sole therapy is insufficient and of low certainty 3, 4
• Conservative measures include leg elevation, exercise, weight loss, and avoiding prolonged standing or sitting 1
• A trial of conservative management with compression stockings for at least 3 months is typically recommended before proceeding to invasive treatments 1, 5
• Compression therapy after invasive treatments may help reduce postoperative pain, with pressures >20 mmHg providing the greatest benefit 6

Endovenous Thermal Ablation

• Radiofrequency ablation (RFA) or endovenous laser treatment (EVLT) is recommended as first-line treatment for great saphenous vein reflux 1, 2
• These procedures have largely replaced surgical ligation and stripping due to:
  • Similar efficacy with fewer complications 2
  • Improved early quality of life 2
  • Reduced recovery time 2
  • Occlusion rates of 90% at 1 year 1
• Procedures can be performed under local anesthesia with same-day discharge 2
• Potential complications include a 7% risk of surrounding nerve damage, though most is temporary 2

Foam Sclerotherapy

• Foam sclerotherapy, including Varithena (polidocanol), is recommended as second-line treatment for tributary veins or as an adjunct to primary treatment of the saphenofemoral junction 1
• Occlusion rates range from 72% to 89% at 1 year 1
• Typically indicated for small and medium-sized veins 1
• Medical necessity criteria for sclerotherapy include:
  • Vein diameter ≥2.5mm measured by ultrasound 1
  • Documented reflux duration ≥500 milliseconds 1
  • Failed conservative management 1

Surgical Options

• Surgery is considered third-line treatment after endovenous thermal ablation and sclerotherapy 1, 5
• Surgical techniques include:
  • Ligation and stripping of the saphenous vein 1
  • Ambulatory phlebectomy for removal of tributary veins 5
• Traditional surgical treatment has a five-year recurrence rate of 20-28% 5

Treatment Algorithm Based on Vein Characteristics

• For great saphenous vein with reflux and diameter ≥4.5mm: Endovenous thermal ablation 1, 2
• For tributary veins and veins with diameter 2.5-4.5mm: Foam sclerotherapy 1
• For visible bulging varicosities: Phlebectomy, often performed at the time of trunk vein ablation 7
• For perforator veins: Thermal ablation using transluminal occlusion of perforator (TRLOP) approach 7

Important Clinical Considerations

• Treatment sequence is critical for long-term success, as chemical sclerotherapy alone has worse outcomes at 1-, 5-, and 8-year follow-ups compared to thermal ablation or surgery 1
• Ultrasound guidance is essential for the safe and effective performance of endovenous procedures 5
• Treating the saphenofemoral junction with thermal ablation or ligation provides better long-term outcomes than foam sclerotherapy alone 1
• Patients with skin changes indicating CEAP C4c venous disease are considered to have moderate-to-severe venous insufficiency and benefit from intervention 1

Monitoring and Follow-up

• Regular follow-up is recommended to monitor for potential complications and recurrence 5
• Duplex ultrasonography is the modality of choice for evaluation before and after treatment 1