What treatment options are available for large, inflamed varicose veins that are sore and worsening over time, unresponsive to painkillers such as ibuprofen (nonsteroidal anti-inflammatory drug) or acetaminophen (paracetamol)?

Treatment of Large, Inflamed, Symptomatic Varicose Veins

For Nathan's large, inflamed varicose veins that are sore, worsening, and unresponsive to painkillers, endovenous thermal ablation (radiofrequency or laser ablation) is the first-line definitive treatment, followed by sclerotherapy or phlebectomy for any remaining tributary veins. 1

Initial Diagnostic Evaluation Required

Before any treatment, Nathan must undergo duplex ultrasound examination to document:

• Vein diameter measurements (treatment requires veins ≥4.5mm for thermal ablation or ≥2.5mm for sclerotherapy) 1
• Reflux duration at the saphenofemoral or saphenopopliteal junction (must be ≥500 milliseconds) 1
• Specific anatomic location of incompetent veins and refluxing segments 1
• Deep venous system patency to rule out deep vein thrombosis 1

The ultrasound should be performed in the standing position by a specialist trained in venous ultrasonography, ideally not the treating physician. 2

Evidence-Based Treatment Algorithm

First-Line: Endovenous Thermal Ablation

Endovenous thermal ablation (radiofrequency ablation or endovenous laser ablation) should be performed for the main saphenous trunks when veins exceed 4.5mm diameter with documented reflux >500ms at the saphenofemoral or saphenopopliteal junction. 1

This approach offers:

• 91-100% occlusion rates at 1-year post-treatment 1
• Superior long-term outcomes compared to sclerotherapy alone at 1-, 5-, and 8-year follow-ups 1
• Fewer complications than traditional surgery, including reduced bleeding, hematoma, wound infection, and nerve injury 1
• Faster recovery and improved early quality of life compared to surgical stripping 1

A critical pitfall to avoid: Treating tributary veins with sclerotherapy alone without addressing saphenofemoral or saphenopopliteal junction reflux leads to significantly worse long-term outcomes and higher recurrence rates. 1

Second-Line: Sclerotherapy for Tributary Veins

Foam sclerotherapy (such as Varithena/polidocanol) should be used as adjunctive treatment for tributary veins measuring 2.5-4.5mm in diameter with documented reflux. 1, 3

Sclerotherapy achieves:

• 72-89% occlusion rates at 1 year for appropriately sized veins 1
• Effective treatment for small to medium-sized varicose veins (1-5mm) 3
• Lower complication risk than thermal ablation, with reduced risk of thermal injury to surrounding structures 1

Important caveat: Veins smaller than 2.5mm have only 16% patency at 3 months with sclerotherapy, compared to 76% for veins >2.5mm, making treatment of undersized veins futile. 1

Third-Line: Ambulatory Phlebectomy

Microphlebectomy (stab phlebectomy) is appropriate for bulging varicosities that persist after treatment of the main saphenous trunks, particularly for larger tributary veins >4mm. 1

This procedure:

• Should be performed simultaneously with endovenous thermal ablation for comprehensive treatment 1
• Addresses symptomatic varicose branches that often persist after truncal vein treatment 1
• Uses updated surgical techniques that reduce scarring, blood loss, and complications 1

Conservative Management Is Insufficient

Nathan has already tried painkillers without relief, indicating his symptoms are beyond what conservative management can address. The guidelines are clear:

• Endovenous thermal ablation need not be delayed for a trial of compression therapy when symptoms are present and documented reflux exists 1
• Conservative therapy alone (compression stockings, leg elevation, NSAIDs) is inadequate for patients with lifestyle-limiting symptoms and documented venous insufficiency 1
• Patients with symptoms have significant advantage with interventional treatment over conservative management with compression stockings alone 2

Expected Outcomes and Complications

Nathan should be counseled about:

• High success rates: 91-100% technical success with thermal ablation 1
• Low major complication rates: Deep vein thrombosis in 0.3% of cases, pulmonary embolism in 0.1% 1
• Common minor complications: Temporary nerve damage in approximately 7% (usually resolves), phlebitis, skin discoloration, residual pigmentation 1
• Recurrence rates: 20-28% at 5 years even with appropriate treatment, though significantly lower than with sclerotherapy alone 1, 3

Post-Procedure Monitoring

Early postoperative duplex ultrasound (2-7 days) is mandatory to detect endovenous heat-induced thrombosis and ensure proper vein closure. 1

Why This Sequence Matters

The treatment sequence is critical because multiple studies demonstrate that chemical sclerotherapy alone has worse outcomes at 1-, 5-, and 8-year follow-ups compared to thermal ablation or surgery. 1 Treating the saphenofemoral junction with thermal ablation provides 85% success at 2 years, while foam sclerotherapy alone shows significantly higher recurrence rates. 1