What are the treatment options for varicose veins?

Varicose Vein Treatment

First-Line Treatment Recommendation

Endovenous thermal ablation (radiofrequency or laser ablation) is the first-line treatment for symptomatic varicose veins with documented saphenous vein reflux ≥500 milliseconds and vein diameter ≥4.5mm. 1, 2 This approach has replaced traditional surgical stripping as the standard of care, offering 90-100% occlusion rates at one year with fewer complications, faster recovery, and immediate return to normal activities. 1, 3

Diagnostic Requirements Before Treatment

Before any interventional therapy, venous duplex ultrasonography is mandatory to assess: 1

• Reflux duration: Pathologic reflux is defined as >500ms in superficial veins, >350ms in perforating veins, and >1,000ms in femoropopliteal veins 1
• Vein diameter: Must be ≥4.5mm for thermal ablation to be medically indicated 1, 2
• Saphenofemoral or saphenopopliteal junction incompetence 1
• Deep venous system patency to exclude thrombosis 1
• Location and size of incompetent perforating veins 1

The ultrasound must be performed within 6 months of planned intervention and document exact anatomic landmarks where measurements were obtained. 2

Conservative Management Requirements

A documented 3-month trial of conservative therapy is required before interventional treatment, except in specific circumstances: 1

• Medical-grade gradient compression stockings (20-30 mmHg minimum) 1
• Leg elevation during rest periods 1
• Weight loss and lifestyle modifications 1

Exceptions where conservative therapy can be bypassed: 1, 4

• Recurrent superficial thrombophlebitis
• Severe persistent pain and swelling interfering with activities of daily living
• Skin changes indicating CEAP C4c or higher (lipodermatosclerosis, corona phlebectasia, stasis dermatitis)
• Active or healed venous ulceration

Treatment Algorithm by Vein Size and Location

Large Truncal Veins (≥4.5mm diameter)

Endovenous thermal ablation (radiofrequency or laser) for great or small saphenous veins with documented junctional reflux: 1, 2

• Success rate: 91-100% occlusion at 1 year 1, 2
• Performed under local anesthesia with immediate walking post-procedure 1
• Return to work: 1-2 days 1
• Complications: ~7% temporary nerve damage from thermal injury, 0.3% deep vein thrombosis, 0.1% pulmonary embolism 1, 2

Medium Veins (2.5-4.4mm diameter)

Foam sclerotherapy (including Varithena/polidocanol) for tributary veins and accessory saphenous veins: 1, 2

• Occlusion rates: 72-89% at 1 year 1, 2
• Used as adjunctive therapy after thermal ablation of main trunks 1, 2
• Should NOT be used alone for saphenofemoral junction reflux—chemical sclerotherapy alone has inferior outcomes at 1-, 5-, and 8-year follow-up compared to thermal ablation 1, 2

Small Veins (<2.5mm diameter)

**Avoid sclerotherapy for veins <2.0mm**—only 16% primary patency at 3 months compared to 76% for veins >2.0mm 2

For spider veins and small reticular veins, laser therapy or sclerotherapy is appropriate. 4

Bulging Varicosities

Ambulatory phlebectomy (stab phlebectomy) should be performed concurrently with thermal ablation of the main truncal vein: 1, 2

• Critical anatomic consideration: Avoid the common peroneal nerve near the fibular head during lateral calf phlebectomy to prevent foot drop 2
• Most common complication: Skin blistering from dressing abrasions 2

Critical Treatment Sequencing

The sequence of treatment is essential for long-term success: 1, 2

1. First: Treat saphenofemoral or saphenopopliteal junction reflux with thermal ablation 1, 2
2. Second: Treat tributary veins with sclerotherapy or phlebectomy 1, 2
3. Third: Surgery (ligation and stripping) only if endovenous techniques are not feasible 1, 3

Untreated junctional reflux causes persistent downstream pressure, leading to tributary vein recurrence rates of 20-28% at 5 years even after successful sclerotherapy. 2 Multiple studies demonstrate that treating junctional reflux is mandatory before tributary sclerotherapy to prevent recurrence. 2

Special Populations

Pregnant Women

Conservative management only: 1

• Compression stockings
• Leg elevation
• Lifestyle modifications
• Defer interventional treatment until after delivery 1

Patients Not Candidates for Intervention

Conservative measures are recommended for patients who: 1

• Are not surgical candidates due to comorbidities
• Do not desire intervention
• Have contraindications to endovenous procedures

Post-Procedure Monitoring

Early postoperative duplex ultrasound (2-7 days) is mandatory to detect endovenous heat-induced thrombosis. 2 Longer-term imaging at 3-6 months assesses treatment success and identifies residual incompetent segments requiring adjunctive therapy. 2

Common Pitfalls to Avoid

• Do not perform sclerotherapy alone for saphenofemoral junction reflux—this has significantly worse long-term outcomes 1, 2
• Do not treat tributary veins without addressing junctional reflux first—this leads to high recurrence rates 2
• Do not treat veins <2.0mm with sclerotherapy—poor outcomes with only 16% patency 2
• Do not proceed without recent ultrasound documentation—vein diameter and reflux duration directly predict treatment outcomes 2
• Do not skip the 3-month compression trial unless patient has qualifying conditions (ulceration, recurrent thrombophlebitis, severe functional impairment) 1

Insurance Considerations

Most insurance companies require documentation of: 1, 2

• Failed 3-month trial of medical-grade compression stockings
• Duplex ultrasound within 6 months showing reflux ≥500ms and appropriate vein diameter
• Symptoms interfering with activities of daily living
• Treatment of junctional reflux when performing tributary procedures

Evidence Quality

The recommendations are based on: 1, 2

• Level A evidence from American Academy of Family Physicians guidelines (2019) for endovenous thermal ablation as first-line treatment
• Level A evidence from American College of Radiology Appropriateness Criteria (2023) for treatment sequencing and diagnostic requirements
• Multiple meta-analyses confirming 91-100% technical success rates for thermal ablation 1, 3, 5