What is the best treatment for tender varicose veins?

Treatment for Tender Varicose Veins

Endovenous thermal ablation (radiofrequency or laser) is the first-line treatment for tender varicose veins with documented reflux, followed by foam sclerotherapy for tributary veins, and surgery as a third-line option. 1, 2

First-Line Treatment: Endovenous Thermal Ablation

• Endovenous thermal ablation (radiofrequency or laser) is recommended as the primary treatment for symptomatic varicose veins with documented valvular reflux, particularly for veins ≥4.5mm in diameter 1, 2
• This procedure has largely replaced surgical ligation and stripping due to similar efficacy with fewer complications and faster recovery time 2
• Technical success rates for radiofrequency ablation range from 91% to 100% within 1-year post-treatment 2
• Treatment of the saphenofemoral and saphenopopliteal junctions is critical for long-term success 1

Second-Line Treatment: Foam Sclerotherapy

• Foam sclerotherapy, including Varithena (polidocanol), is recommended for tributary veins or as an adjunct to primary treatment of the saphenofemoral junction 1
• Occlusion rates for foam sclerotherapy range from 72% to 89% at 1 year 1
• Foam sclerotherapy is particularly appropriate for veins with a diameter of at least 2.5mm with documented reflux 1
• Common side effects include phlebitis, new telangiectasias, and residual pigmentation, while deep vein thrombosis is exceedingly rare 1

Third-Line Treatment: Surgery

• Traditional surgical treatment has a five-year recurrence rate of 20% to 28%, making it less preferable than endovenous techniques 1
• Surgery may be considered when endovenous thermal ablation and sclerotherapy are not suitable or have failed 1

Conservative Management

• Compression stockings are often used as initial treatment but have insufficient high-quality evidence to support their effectiveness as the sole treatment for varicose veins 3, 4
• A Cochrane review concluded that there is insufficient evidence to determine whether compression stockings are effective as the sole and initial treatment of varicose veins 3
• Post-treatment compression therapy is essential to optimize outcomes and reduce complications following any interventional procedure 2

Treatment Algorithm Based on Vein Characteristics

1. For main saphenous trunks with reflux and diameter ≥4.5mm:

   • Endovenous thermal ablation (radiofrequency or laser) 1, 2

2. For tributary veins or veins 2.5-4.5mm with reflux:

   • Foam sclerotherapy (including Varithena) 1

3. For veins <2.5mm:

   • Consider conservative management or sclerotherapy 1
   • Note: Vessels less than 2.0mm treated with sclerotherapy had only 16% primary patency at 3 months compared with 76% for veins greater than 2.0mm 1

Post-Treatment Care

• Post-procedure compression therapy is recommended to optimize outcomes and reduce complications 2
• Higher levels of compression are more effective than lower levels in moderating post-procedure pain and complications 5
• Strong compression can be achieved by inelastic bandaging or by eccentric compression systems 5

Common Pitfalls to Avoid

• Treating veins smaller than 2.5mm with sclerotherapy may result in poor outcomes with lower patency rates 1
• Using foam sclerotherapy alone for saphenofemoral junction reflux leads to worse outcomes at 1-, 5-, and 8-year follow-ups compared to thermal ablation or surgery 1
• Failing to treat the saphenofemoral junction with thermal ablation or ligation when indicated can lead to recurrence 1
• Inadequate post-procedure compression can increase the risk of complications and suboptimal outcomes 2, 5