What are the management options for varicose veins?

Management of Varicose Veins: A Comprehensive Approach for Interventional Radiologists

Endovenous thermal ablation should be considered the first-line treatment for symptomatic varicose veins with documented valvular reflux, with sclerotherapy as second-line therapy and surgery as third-line. 1

Diagnostic Evaluation

• Venous duplex ultrasonography is the initial diagnostic test of choice when interventional therapy is being considered, providing essential information about:

  • Anatomy and physiology of the lower extremity venous system
  • Incompetent saphenous junctions and their diameters
  • 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

Treatment Algorithm

First-Line Treatment: Endovenous Thermal Ablation

• Endovenous thermal ablation techniques include:

  • Endovenous laser ablation (EVLA)
  • Radiofrequency ablation (RFA) 1, 2

• Key advantages of thermal ablation:

  • Can be performed under local anesthesia
  • Allows immediate ambulation post-procedure
  • Quick return to work and normal activities
  • Success rate of 90% at 1 year 1
  • Fewer complications compared to surgery 3, 4

• Considerations:

  • For RFA to be medically indicated, the great saphenous vein diameter should be at least 4.5mm 5
  • Risk of surrounding nerve damage is approximately 7% 1

Second-Line Treatment: Sclerotherapy

• Endovenous sclerotherapy is recommended for:

  • Small to medium-sized varicose veins
  • Adjunctive therapy after thermal ablation
  • Recurrent varicose veins 1, 5

• Common sclerosing agents:

  • Hypertonic saline
  • Sodium tetradecyl
  • Polidocanol (Varithena) 1, 5

• Efficacy:

  • Occlusion rates ranging from 72% to 89% at 1 year 1
  • Foam sclerotherapy has better outcomes than liquid sclerotherapy 5

• Considerations:

  • Minimum vein diameter of 2.5mm is recommended for foam sclerotherapy to be considered medically necessary 5
  • Lower long-term success rates compared to thermal ablation 5

Third-Line Treatment: Surgical Intervention

• Surgical options include:

  • Ligation and stripping
  • Ambulatory phlebectomy 3, 6

• Considerations:

  • Higher complication rates and longer recovery time compared to endovenous therapies 3
  • Five-year recurrence rate of 20% to 28% 5
  • May be appropriate for specific anatomical situations where endovenous approaches are not suitable 6

Conservative Management

• Conservative measures are recommended for:

  • Patients who are not candidates for endovenous or surgical management
  • Patients who do not desire intervention
  • Pregnant women 1

• Options include:

  • Compression stockings
  • Elevation of the affected leg
  • Lifestyle modifications
  • Weight loss
  • Phlebotonics (e.g., diosmin) 1, 7

• Limitations:

  • National Institute for Health and Care Excellence (NICE) guidelines recommend offering external compression only if interventional treatment is ineffective 1
  • Insurance companies may require a trial of external compression before approving interventional treatments 1

Special Considerations for Interventional Radiologists

• Treatment sequence is critical for long-term success:

  • Chemical sclerotherapy alone has worse outcomes compared to thermal ablation or surgery at 1-, 5-, and 8-year follow-ups 5
  • Treating the saphenofemoral junction with thermal ablation or ligation provides better long-term outcomes than foam sclerotherapy alone 5

• Ultrasound guidance is essential for:

  • Safe and effective performance of endovenous procedures
  • Accurate visualization of the vein and surrounding structures
  • Confirmation of proper treatment 5

• Combined approach for comprehensive treatment:

  • Endovenous thermal ablation for main saphenous trunks
  • Sclerotherapy for tributary veins 5

Pharmacological Management

• Diosmin can be used as an adjunctive therapy for:

  • Reducing symptoms of discomfort, swelling, and inflammation
  • Managing edema by increasing lymphatic drainage
  • Modulating venous tone and capillary resistance 7

• Mechanism of action:

  • Enhances venous tone by prolonging post-synaptic response to norepinephrine
  • Increases sensitivity of vascular smooth muscle to norepinephrine and calcium
  • Acts as a scavenger of reactive oxygen species
  • Inhibits inflammatory factors 7

• Clinical efficacy:

  • Significant reduction in CEAP class, edema, and quality of life score after 6 months
  • 79% of subjects and 83% of investigators rated effectiveness as good or excellent 7

Emerging Trends and Considerations

• Endovenous treatments have largely replaced surgical ligation and stripping as the main treatment method due to:

  • Similar efficacy
  • Improved early quality of life
  • Reduced recovery time 8

• Comprehensive management should address:

  • Truncal vein incompetence (best treated with endovenous thermal ablation)
  • Incompetent perforating veins (treated by thermal ablation using transluminal occlusion of perforator approach)
  • Incompetent pelvic veins (treated by coil embolization when appropriate)
  • Bulging varicosities (treated by phlebectomy at the time of truncal vein ablation) 8

• Patient selection and treatment should be guided by:

  • Vein diameter
  • Extent of reflux
  • Symptom severity
  • Patient preferences and comorbidities 6