What can I do for a suspected varicose vein?

Management of Suspected Varicose Veins

For suspected varicose veins, the recommended first-line diagnostic approach is venous duplex ultrasonography to assess the anatomy and physiology of the lower extremity venous system, followed by a staged treatment approach starting with conservative measures and progressing to endovenous thermal ablation for symptomatic cases with documented reflux. 1

Diagnostic Approach

• Venous duplex ultrasonography is the initial diagnostic test of choice when interventional therapy is being considered, to assess the anatomy and physiology of the lower extremity venous system 1
• The ultrasound should evaluate:
  • Which saphenous junctions are incompetent
  • Diameter of the junctions
  • Extent of reflux (defined as retrograde flow duration of >500 milliseconds in superficial veins)
  • Location and size of incompetent perforating veins 1
• A focused medical history and complete physical examination, including digital rectal examination, should be performed to rule out other causes of symptoms 2

Treatment Algorithm

First-Line: Conservative Management

• Begin with conservative measures for at least 3 months before considering interventional treatments 1
• Conservative management includes:
  • Medical-grade gradient compression stockings
  • Elevation of the affected leg
  • Weight loss if applicable
  • Regular exercise
  • Avoiding prolonged standing 1, 3
• Compression therapy may provide symptomatic relief but has limited evidence for long-term effectiveness as sole treatment 4

Second-Line: Interventional Treatment

For symptomatic varicose veins with documented valvular reflux:

1. Endovenous thermal ablation (first-line interventional treatment):

   • Recommended for larger vessels with reflux, particularly the great saphenous vein 1, 5
   • Types include endovenous laser ablation and radiofrequency ablation 1
   • Success rate of approximately 90% at 1 year 1
   • Can be performed under local anesthesia with immediate walking after procedure 1, 5

2. Endovenous sclerotherapy (second-line or adjunctive treatment):

   • Recommended for small to medium-sized varicose veins 1, 6
   • Often used as adjunctive therapy after thermal ablation 1
   • Occlusion rates ranging from 72% to 89% at 1 year 1
   • Common sclerosing agents include hypertonic saline, sodium tetradecyl, and polidocanol 1

3. Surgical procedures (third-line treatment):

   • Traditional surgical ligation and stripping now less common 1, 7
   • Reserved for specific cases where other interventions are not appropriate 1
   • Five-year recurrence rate of 20% to 28% 8

Important Considerations and Caveats

• Treatment sequence is important for long-term success - chemical sclerotherapy alone has worse outcomes compared to thermal ablation or surgery 1, 6
• For radiofrequency ablation to be medically indicated, the great saphenous vein diameter should be at least 4.5mm 1
• Potential complications of thermal ablation include risk of surrounding nerve damage (approximately 7%), which is usually temporary 1, 5
• Varicose veins are not merely a cosmetic concern - they can significantly impact quality of life and may be associated with chronic venous ulceration, venous thromboembolism, and hemorrhage from rupture 9
• Pregnant women should be offered compression therapy as first-line treatment 1
• Insurance companies may require documentation of a trial of external compression before approving interventional treatments 1

By following this evidence-based approach to diagnosis and treatment, you can effectively manage suspected varicose veins and improve patient outcomes and quality of life.