What are the treatment options for varicose veins pain?

Treatment of Varicose Veins Pain

For varicose veins causing pain, endovenous thermal ablation (radiofrequency or laser) is the first-line treatment when veins are ≥4.5mm in diameter with documented reflux ≥500 milliseconds at the saphenofemoral or saphenopopliteal junction, achieving 91-100% occlusion rates at one year with superior outcomes compared to conservative management alone. 1, 2

Initial Conservative Management

Before proceeding to interventional treatment, patients should undergo a documented 3-month trial of conservative therapy including: 1, 3

• Medical-grade gradient compression stockings (20-30 mmHg minimum pressure) 1, 3
• Leg elevation during rest periods 3
• Regular exercise to improve venous return 3
• Weight loss if applicable 3

However, for patients with venous ulceration (CEAP C5-C6), endovenous thermal ablation need not be delayed for a trial of external compression, as the presence of ulceration represents severe disease warranting immediate intervention. 2

Diagnostic Requirements Before Treatment

Duplex ultrasound performed within the past 6 months is mandatory before any interventional therapy, documenting: 1, 3

• Reflux duration ≥500 milliseconds at the saphenofemoral or saphenopopliteal junction 1, 3
• Vein diameter measurements at specific anatomic landmarks 1
• Direction of blood flow and assessment for venous obstruction 3
• Condition of the deep venous system to rule out deep vein thrombosis 3
• Extent of refluxing superficial venous pathways 3

Treatment Algorithm Based on Vein Size and Location

For Main Truncal Veins (Great or Small Saphenous Veins)

Endovenous thermal ablation is first-line treatment when: 1, 2

• Vein diameter ≥4.5mm measured by ultrasound 1, 3
• Documented reflux ≥500 milliseconds at junctional sites 1, 3
• Symptoms persist despite conservative management 1, 2

Technical success rates: 91-100% occlusion within one year, with fewer complications than traditional surgery including reduced bleeding, hematoma, wound infection, and paresthesia. 1, 2

For Medium-Sized Veins (2.5-4.4mm)

Foam sclerotherapy (including polidocanol/Varithena) is the appropriate treatment for veins in this size range, achieving 72-89% occlusion rates at one year. 1, 3 This includes:

• Tributary veins 1, 3
• Accessory saphenous veins 3
• Perforating veins 1

For Small Veins (<2.5mm)

Liquid or foam sclerotherapy is appropriate, though vessels <2.0mm have only 16% primary patency at 3 months compared to 76% for veins >2.0mm, indicating poor outcomes with very small vessels. 3

Critical Treatment Sequencing

Treating saphenofemoral or saphenopopliteal junction reflux is mandatory before tributary sclerotherapy. 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. 1, 3

The evidence-based sequence is: 1, 3

1. Endovenous thermal ablation for main saphenous trunks with junctional reflux
2. Sclerotherapy or phlebectomy for tributary veins (often performed concurrently)
3. Surgery reserved for cases where endovenous techniques are not feasible

Adjunctive Procedures

Stab phlebectomy (ambulatory phlebectomy) is medically necessary as an adjunctive procedure to address symptomatic varicose tributary veins ≥2.5mm that persist after treatment of the main saphenous trunk. 1, 3 This should be performed concurrently with thermal ablation of junctional reflux for optimal outcomes. 1

Critical anatomic consideration: The common peroneal nerve near the fibular head must be avoided during lateral calf phlebectomy to prevent foot drop. 3

Comparative Effectiveness

Endovenous thermal ablation has largely replaced surgical ligation and stripping as the standard of care due to: 1, 2, 4

• Similar efficacy (91-100% vs 93-98% long-term success rates) 1
• Improved early quality of life 2, 4
• Reduced hospital recovery time 2, 4
• Lower complication rates 2, 4
• Ability to perform under local anesthesia with same-day discharge 2

Chemical sclerotherapy alone has inferior long-term outcomes compared to thermal ablation, with worse results at 1-, 5-, and 8-year follow-ups. 1, 3 However, as adjunctive therapy for tributaries post-ablation, sclerotherapy represents appropriate care. 3

Risks and Complications

Endovenous thermal ablation carries: 1, 2

• Deep vein thrombosis: 0.3% of cases 1, 2
• Pulmonary embolism: 0.1% of cases 1, 2
• Nerve damage from thermal injury: approximately 7% (usually temporary) 1, 2
• Thrombophlebitis, hematoma, infection: rare 2

Early postoperative duplex scans (2-7 days) are mandatory to detect endovenous heat-induced thrombosis. 3

Foam sclerotherapy has fewer thermal complications but common side effects include phlebitis, new telangiectasias, and residual pigmentation. 3

Post-Procedure Management

Post-procedure compression therapy is essential to optimize outcomes and reduce complications. 2 However, compression stockings alone have no proven benefit in preventing post-thrombotic syndrome or treating established venous insufficiency when significant reflux is present. 3

Common Pitfalls to Avoid

• Do not perform sclerotherapy on veins <2.5mm diameter without understanding the poor outcomes (16% patency at 3 months for vessels <2.0mm) 3
• Do not treat tributary veins without first addressing junctional reflux, as this leads to high recurrence rates 1, 3
• Do not use thermal ablation on veins <4.5mm diameter, as this may lead to suboptimal outcomes and unnecessary procedural risks; use sclerotherapy instead 1
• Do not proceed without recent ultrasound documentation (within 6 months) showing specific reflux duration and vein diameter measurements 1, 3

Symptom Relief and Quality of Life

Varicose veins produce symptoms of pain, swelling, heaviness, fatigue, leg cramps, and pruritus that interfere with activities of daily living and result in lost time from work. 3, 4 Endovenous thermal ablation addresses the underlying pathophysiology of venous reflux, providing symptomatic relief and allowing quick return to work. 2

For patients with advanced disease including skin changes (CEAP C4), lipodermatosclerosis, or ulceration, intervention is necessary to prevent progression and promote healing. 3, 2, 5