What are the treatment options for varicose veins?

Treatment Options for Varicose Veins

Endovenous thermal ablation (radiofrequency or laser) is the first-line treatment for symptomatic varicose veins with documented saphenous vein reflux, followed by sclerotherapy for smaller tributary veins and conservative management for those who cannot or will not undergo intervention. 1

Diagnostic Requirements Before Treatment

Before proceeding with any interventional therapy, venous duplex ultrasonography in the erect position is mandatory to assess 1:

• Incompetent saphenous junctions and their diameter
• Reflux duration (pathologic if >500 milliseconds in superficial veins, >1,000 milliseconds in femoropopliteal veins) 1
• Location and size of incompetent perforating veins
• Presence of deep venous thrombosis or superficial thrombophlebitis 1

The ultrasound must be performed within 6 months of planned treatment and document specific vein measurements and reflux times 1.

Treatment Algorithm by Clinical Presentation

For Symptomatic Varicose Veins with Truncal Reflux

First-line: Endovenous Thermal Ablation 1

• Indicated when great saphenous vein diameter ≥4.5mm with reflux >500 milliseconds 1
• Options include radiofrequency ablation (RFA) or endovenous laser ablation (EVLA) 1
• Success rate: 90-100% occlusion at 1 year 1, 2
• Performed under local anesthesia with immediate ambulation and quick return to work 1
• Risk of nerve damage approximately 7% due to thermal injury 1

Second-line: Foam Sclerotherapy 1

• Appropriate for veins ≥2.5mm diameter 1
• Used as adjunctive therapy after thermal ablation or for recurrent varicose veins 1
• Occlusion rates 72-89% at 1 year 1
• Common sclerosing agents: hypertonic saline, sodium tetradecyl, polidocanol (Varithena) 1
• Critical caveat: Sclerotherapy alone has significantly worse long-term outcomes compared to thermal ablation, with higher recurrence rates at 1-, 5-, and 8-year follow-ups 1

Third-line: Surgical Ligation and Stripping 1

• Reserved for cases where endovenous techniques are not feasible 1
• Traditional 5-year recurrence rate 20-28% 1

For Small Tributary Veins and Spider Veins

• Sclerotherapy or ambulatory phlebectomy for veins 2.5-4mm diameter 1, 3
• Laser therapy for spider veins and smaller reticular veins 3
• Phlebectomy should be performed at time of truncal vein ablation to address bulging varicosities 1

For Patients Requiring Conservative Management

Conservative measures are appropriate for 1:

• Patients not candidates for endovenous or surgical management
• Those who do not desire intervention
• Pregnant women (first-line in this population) 1

Conservative options include 1:

• Medical-grade gradient compression stockings (20-30 mmHg)
• Leg elevation
• Weight loss and lifestyle modifications
• Phlebotonics (venoactive drugs)

Medical Necessity Criteria

A 3-month trial of conservative management with compression stockings is typically required before insurance approval for interventional treatment, unless the patient has 1:

• Recurrent superficial thrombophlebitis
• Severe and persistent pain/swelling interfering with activities of daily living
• Advanced skin changes (CEAP C4-C6 disease including stasis dermatitis, lipodermatosclerosis, or ulceration) 1
• Venous bleeding 1

Important exception: When symptoms are present with documented reflux, treatment should not be delayed for compression trial, particularly in advanced disease 1, 3.

Treatment Sequence for Optimal Outcomes

The proper sequence is critical for long-term success 1:

1. Treat saphenofemoral or saphenopopliteal junction reflux first with thermal ablation or surgical ligation 1
2. Then address tributary veins with sclerotherapy or phlebectomy 1
3. Avoid sclerotherapy as sole treatment for truncal vein reflux—this leads to poor outcomes 1

Key Clinical Pitfalls to Avoid

• **Do not treat veins <2.5mm with sclerotherapy**—vessels smaller than 2.0mm have only 16% patency at 3 months versus 76% for veins >2.0mm 1
• Do not use foam sclerotherapy alone for saphenofemoral junction reflux—this has significantly higher failure rates than thermal ablation 1
• Do not skip ultrasound evaluation—treating visible varicose veins without assessing underlying truncal reflux leads to recurrence 4
• Ultrasound guidance is mandatory for all endovenous procedures to minimize complications and optimize outcomes 1

Comparative Effectiveness

Endovenous thermal ablation versus surgery 1, 2:

• Similar efficacy for vein occlusion
• Fewer complications (reduced bleeding, hematoma, wound infection, paresthesia)
• Faster recovery and return to normal activities
• Better early quality of life

RFA versus EVLA 2:

• Equivalent safety and occlusion rates
• Similar time to return to normal activity
• Choice based on operator experience and patient anatomy

Foam sclerotherapy limitations 1:

• Lower long-term success than thermal ablation
• Higher rates of recurrent reflux and junction failure
• Best used as adjunctive therapy, not primary treatment for truncal veins

Special Populations

Pregnant women: Conservative management with compression stockings is first-line; interventional treatment deferred until postpartum 1

Patients with venous ulceration: Endovenous thermal ablation should not be delayed for compression trial—immediate referral for definitive treatment is appropriate 1

Patients with CEAP C4-C6 disease: Intervention is indicated to prevent disease progression; compression alone has inadequate evidence for these advanced stages 1