What are the treatment options for varicose veins based on their severity?

Varicose Vein Grading and Treatment Options

The treatment of varicose veins should follow a stepwise approach based on severity, with endovenous thermal ablation as first-line treatment for symptomatic varicose veins with documented valvular reflux, followed by sclerotherapy for smaller veins, and surgery as a third-line option. 1

Classification of Varicose Veins

• Varicose veins are classified using the CEAP (Clinical-Etiology-Anatomy-Pathophysiology) system, which ranges from C0 (no visible signs) to C6 (active venous ulceration) 1, 2
• Reflux is defined as retrograde flow duration of >350 milliseconds in perforating veins, >500 milliseconds in superficial and deep calf veins, and >1,000 milliseconds in femoropopliteal veins 1
• Venous duplex ultrasonography is the initial diagnostic test of choice when interventional therapy is being considered, to assess anatomy and physiology of the venous system 1

Treatment Algorithm Based on Severity

Conservative Management (First Step for All Patients)

• Conservative measures include compression stockings, elevation of the affected leg, lifestyle modifications, weight loss, and phlebotonics 1
• A documented trial of conservative management for at least 3 months is typically required before proceeding to interventional treatments 1
• Compression therapy should be offered if interventional treatment is ineffective or as first-line therapy only in pregnant women 1

First-Line Interventional Treatment

• Endovenous thermal ablation (laser or radiofrequency) is recommended as first-line treatment for symptomatic varicose veins with documented valvular reflux 1, 3
• For radiofrequency ablation to be medically indicated, the great saphenous vein diameter should be at least 4.5mm 2
• Benefits include ability to be performed under local anesthesia, immediate walking after the procedure, quick return to work, and a success rate of 90% at 1 year 1, 3
• Potential risk includes approximately 7% surrounding nerve damage, usually temporary 1, 3

Second-Line Treatment

• Endovenous sclerotherapy (including foam sclerotherapy with agents like Varithena/polidocanol) is recommended for: 1, 2
  • Small to medium-sized varicose veins (2.5-4.5mm diameter)
  • Adjunctive therapy after thermal ablation
  • Recurrent varicose veins
• Occlusion rates range from 72% to 89% at 1 year 1, 2
• Foam sclerotherapy has lower long-term success rates compared to thermal ablation, with higher rates of recurrent reflux 2

Third-Line Treatment

• Surgical procedures such as ligation and stripping are considered when other interventions are not appropriate 1
• Traditional surgical treatment has a five-year recurrence rate of 20% to 28% 2
• Stab phlebectomy is often used as an adjunctive procedure to address varicose tributary veins that persist after treatment of the main saphenous trunk 2

Treatment Considerations Based on Vein Size

• Veins ≥4.5mm with reflux: Endovenous thermal ablation (radiofrequency or laser) 1, 2, 3
• Veins 2.5-4.5mm with reflux: Foam sclerotherapy (including Varithena) 2
• Veins <2.5mm: Traditional sclerotherapy or conservative management 2
• Vessels <2.0mm treated with sclerotherapy had only 16% primary patency at 3 months compared with 76% for veins >2.0mm 2

Special Considerations

• The treatment sequence is critical for long-term success; chemical sclerotherapy alone has worse outcomes compared to thermal ablation or surgery 1, 2
• Treating the saphenofemoral and saphenopopliteal junctions is essential for long-term success 2, 3
• Recurrent superficial thrombophlebitis, severe and persistent pain, and swelling that interferes with activities of daily living may qualify for immediate intervention without conservative management trial 1
• Post-procedure compression therapy is essential to optimize outcomes and reduce complications 3

Potential Complications

• Deep vein thrombosis (0.3% of cases) and pulmonary embolism (0.1% of cases) are rare but serious potential complications 2, 3
• Other complications include thrombophlebitis, hematoma, infection, and skin discoloration 3
• Nerve damage occurs in approximately 7% of thermal ablation cases, though most is temporary 1, 3

By following this evidence-based treatment algorithm, clinicians can effectively manage varicose veins based on their severity, improving patient outcomes and quality of life.