What are the treatment options for varicose veins?

Varicose Vein Treatment

First-Line Treatment: Endovenous Thermal Ablation

For symptomatic varicose veins with documented valvular reflux, endovenous thermal ablation (radiofrequency or laser) is the first-line treatment and should be offered without requiring a trial of compression therapy when symptoms are present. 1

When Thermal Ablation is Indicated:

• Great saphenous vein diameter ≥4.5mm with reflux duration ≥500 milliseconds at the saphenofemoral junction 1, 2
• Small saphenous vein diameter ≥4.5mm with reflux duration ≥500 milliseconds at the saphenopopliteal junction 1
• Symptomatic disease causing pain, heaviness, swelling, or functional impairment 1, 3
• Skin changes including hyperpigmentation, lipodermatosclerosis, or venous ulceration (CEAP C4-C6) 1, 2

Expected Outcomes:

• Success rate of 90-100% at 1 year with occlusion of treated veins 1, 3
• Performed under local anesthesia with same-day discharge 1, 3
• Quick return to work and normal activities 1
• Approximately 7% risk of temporary nerve damage from thermal injury 1, 3
• Deep vein thrombosis in 0.3% and pulmonary embolism in 0.1% of cases 1

Second-Line Treatment: Sclerotherapy

Foam sclerotherapy (including agents like polidocanol/Varithena, sodium tetradecyl, or hypertonic saline) is recommended for small to medium-sized varicose veins (2.5-4.5mm diameter), as adjunctive therapy after thermal ablation for tributary veins, and for recurrent varicose veins. 1, 2

When Sclerotherapy is Indicated:

• Vein diameter ≥2.5mm but <4.5mm with documented reflux ≥500 milliseconds 1, 2
• Tributary veins after primary saphenous trunk ablation 1, 2
• Veins too small or tortuous for catheter-based ablation 2

Expected Outcomes:

• Occlusion rates of 72-89% at 1 year 1, 2
• Inferior long-term outcomes compared to thermal ablation when used alone for saphenous trunks, with higher recurrence rates at 1-, 5-, and 8-year follow-ups 1, 2
• Common side effects include phlebitis, new telangiectasias, and residual pigmentation 2

Critical Pitfall:

Chemical sclerotherapy alone for saphenofemoral or saphenopopliteal junction reflux has worse long-term outcomes than thermal ablation or surgery. The treatment sequence matters: treat the main saphenous trunks with thermal ablation first, then use sclerotherapy for tributaries. 1, 2

Conservative Management

Conservative measures are recommended ONLY for patients who are not candidates for intervention, do not desire intervention, or are pregnant. 1

Components of Conservative Management:

• Medical-grade graduated compression stockings (20-30 mmHg) 1
• Leg elevation 1
• Weight loss and lifestyle modifications 1
• Phlebotonics (medications) 1

Important Caveat:

There is insufficient high-certainty evidence that compression stockings are effective as sole treatment for varicose veins. 4, 5 The National Institute for Health and Care Excellence recommends offering external compression only if interventional treatment is ineffective, and as first-line therapy only in pregnant women. 1 However, many insurance companies require a documented 3-month trial of compression therapy before approving interventional treatments. 1

Diagnostic Requirements Before Treatment

Venous duplex ultrasonography is mandatory before any interventional therapy to assess: 1

• Incompetent saphenous junctions and their diameter 1
• Reflux duration (must be >500 milliseconds in superficial veins, >1000 milliseconds in femoropopliteal veins) 1
• Location and size of incompetent perforating veins 1
• Presence of deep venous thrombosis or superficial thrombophlebitis 1

Treatment Algorithm

1. Confirm diagnosis with duplex ultrasound showing reflux ≥500ms and vein diameter measurements 1, 3

2. For veins ≥4.5mm with saphenofemoral/saphenopopliteal junction reflux: Endovenous thermal ablation (radiofrequency or laser) 1, 2

3. For tributary veins 2.5-4.5mm or residual veins after ablation: Foam sclerotherapy 1, 2

4. For veins <2.5mm: Sclerotherapy has only 16% success at 3 months; outcomes are poor 2

5. Surgical ligation and stripping: Reserved only for cases where endovenous techniques are not feasible 2

When Conservative Management is NOT Required

Endovenous thermal ablation need not be delayed for a trial of external compression when: 1, 3

• Recurrent superficial thrombophlebitis is present 1
• Severe and persistent pain/swelling interferes with activities of daily living 1
• Venous ulceration is present (CEAP C5-C6) 1, 3

The presence of these conditions represents more severe disease states warranting immediate intervention rather than prolonged conservative trials. 1, 3