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 valvular reflux, offering 90-100% success rates at one year with minimal recovery time. 1

Diagnostic Requirements Before Treatment

Before any interventional therapy, venous duplex ultrasonography must be performed to assess 1:

• Incompetent saphenous junctions and their diameter
• Extent and duration of reflux (pathologic reflux defined as >500ms in superficial veins, >1000ms 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 intervention and document specific vein diameters and reflux durations. 1

Treatment Algorithm

Conservative Management (First-Line for Specific Populations)

Conservative measures are recommended for 1:

• Patients who are not candidates for endovenous or surgical management
• Patients who do not desire intervention
• Pregnant women 1

A documented 3-month trial of medical-grade gradient compression stockings (20-30 mmHg minimum) is typically required by insurance before approving interventional treatments. 1 This trial should include 1:

• Compression stockings worn daily
• Elevation of affected legs
• Lifestyle modifications and weight loss
• Regular exercise 2

Interventional Treatment Hierarchy

First-Line: Endovenous Thermal Ablation

For larger vessels (≥4.5mm diameter) with documented reflux ≥500ms, endovenous thermal ablation is the gold standard. 1 This includes 1:

• Radiofrequency ablation (RFA)
• Endovenous laser ablation (EVLA)

Key advantages 1:

• Performed under local anesthesia
• Immediate walking after procedure
• Quick return to work and normal activities
• 90-100% success rate at 1 year 1
• Fewer complications than traditional surgery 1

Important caveat: Approximately 7% risk of surrounding nerve damage from thermal injury. 1

Second-Line: Sclerotherapy

Endovenous sclerotherapy is recommended for 1:

• Small to medium-sized varicose veins (2.5-4.5mm diameter) 1
• Adjunctive therapy after thermal ablation 1
• Recurrent varicose veins 1
• Tributary veins following treatment of main saphenous trunks 1

Common sclerosing agents include hypertonic saline, sodium tetradecyl, and polidocanol (Varithena), with occlusion rates of 72-89% at 1 year. 1

Critical principle: Chemical sclerotherapy alone has worse long-term outcomes compared to thermal ablation or surgery at 1-, 5-, and 8-year follow-ups. 1 Treatment of saphenofemoral junction reflux with thermal ablation must precede tributary sclerotherapy to prevent recurrence. 1

Third-Line: Surgical Intervention

Conventional open vein surgery (ligation and stripping) is reserved for 1, 3:

• Cases where endovenous techniques are not feasible
• Specific complicated vein anatomy 3
• Patient preference after discussion of alternatives 1

Surgery is associated with the best long-term results but has more postoperative complications and longer recovery compared to endovenous techniques. 3

Adjunctive Procedures

Ambulatory phlebectomy (stab phlebectomy) is medically necessary for 1:

• Varicose tributary veins that persist after treatment of main saphenous trunk
• Bulging varicosities treated concurrently with truncal vein ablation 4

Treatment Sequence for Optimal Outcomes

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

1. Treat saphenofemoral or saphenopopliteal junction reflux first with thermal ablation if vein diameter ≥4.5mm and reflux ≥500ms 1
2. Address tributary veins with sclerotherapy or phlebectomy as adjunctive therapy 1
3. Treat perforating veins if significant incompetence is documented 4

Treating tributaries alone without addressing junctional reflux leads to recurrence rates of 20-28% at 5 years. 1

Special Considerations

When Conservative Management Can Be Bypassed

Immediate intervention without a 3-month compression trial is appropriate for 1:

• Recurrent superficial thrombophlebitis
• Severe and persistent pain/swelling interfering with activities of daily living
• Advanced CEAP stages (C4-C6) with skin changes or ulceration 1

Vein Size Criteria

Specific diameter thresholds determine appropriate treatment 1:

• ≥4.5mm: Thermal ablation indicated 1
• 2.5-4.5mm: Sclerotherapy appropriate 1
• <2.5mm: Poor outcomes with sclerotherapy (only 16% patency at 3 months) 1

Pelvic Vein Reflux

In patients with pelvic vein reflux contributing to leg varicosities, transvaginal duplex ultrasound should be performed, and incompetent pelvic veins should be treated with coil embolization. 4

Common Pitfalls to Avoid

1. Never perform sclerotherapy on tributary veins without first treating saphenofemoral junction reflux - this leads to high recurrence rates 1
2. Do not treat veins <2.5mm diameter - outcomes are poor with only 16% patency 1
3. Ensure ultrasound is performed within 6 months of planned intervention with specific measurements documented 1
4. Verify deep venous system patency before any superficial vein ablation 1

Expected Complications

Thermal ablation risks 1:

• Deep vein thrombosis: 0.3% of cases
• Pulmonary embolism: 0.1% of cases
• Nerve damage: ~7% (usually temporary)
• Thrombophlebitis, hematoma, infection: rare 1

Early postoperative duplex scans (2-7 days) are mandatory to detect endovenous heat-induced thrombosis. 1

Monitoring and Follow-Up

Participation in a venous registry for outcome monitoring should be considered mandatory for quality assurance. 4 Long-term follow-up ultrasound at 3-6 months assesses treatment success and identifies residual incompetent segments requiring adjunctive therapy. 1