Treatment of Leg Varicosities
For symptomatic varicose veins with documented reflux, endovenous thermal ablation (radiofrequency or laser) is the first-line treatment, followed by sclerotherapy for smaller tributary veins, with compression stockings reserved for those who cannot undergo or refuse interventional treatment. 1, 2
Initial Diagnostic Evaluation
Before any treatment, venous duplex ultrasonography is mandatory to assess the anatomy and pathophysiology of the lower extremity venous system 2. The ultrasound must document:
- Reflux duration: >500 milliseconds at the saphenofemoral or saphenopopliteal junction indicates pathologic reflux requiring intervention 1, 2
- Vein diameter: Measurements at specific anatomic landmarks determine which procedure is appropriate 1
- Deep venous system patency: To exclude deep vein thrombosis 2
- Location and extent of incompetent perforating veins 2
The ultrasound should be performed within 6 months of planned treatment and must be done in the erect position by a specialist trained in ultrasonography 1, 3.
Treatment Algorithm Based on Vein Size and Reflux
For Main Truncal Veins (≥4.5mm diameter with reflux ≥500ms)
Endovenous thermal ablation (radiofrequency or laser) is the appropriate first-line treatment for great saphenous vein or small saphenous vein reflux 1, 2, 4. This approach has:
- Technical success rates of 91-100% at 1 year 1, 4
- Similar efficacy to surgery with fewer complications, including reduced bleeding, hematoma, wound infection, and paresthesia 1, 4
- Faster recovery: Can be performed under local anesthesia with same-day discharge and immediate walking 2, 4
Important caveat: There is approximately 7% risk of temporary nerve damage from thermal injury 1, 2. Deep vein thrombosis occurs in 0.3% of cases and pulmonary embolism in 0.1% 1, 4.
For Tributary and Reticular Veins (2.5-4.5mm diameter)
Foam sclerotherapy is the appropriate treatment for tributary veins, either as adjunctive therapy after thermal ablation or as standalone treatment for smaller veins 1, 2. Sclerotherapy achieves:
- Occlusion rates of 72-89% at 1 year 1, 5
- Fewer complications than thermal ablation, including no risk of thermal injury to surrounding structures 1
For veins 1-3mm in diameter, use polidocanol 1% solution; for spider veins ≤1mm, use 0.5% solution 6. Inject 0.1-0.3 mL per injection with a maximum of 10 mL per session 6.
For Spider Veins (<1mm diameter)
Sclerotherapy with polidocanol 0.5% is indicated for cosmetic treatment of spider veins 6, 7.
Critical Treatment Sequence
Treating saphenofemoral or saphenopopliteal junction reflux BEFORE tributary sclerotherapy is essential for long-term success 1. Studies demonstrate that:
- Chemical sclerotherapy alone has worse outcomes at 1-, 5-, and 8-year follow-ups compared to thermal ablation 1
- Untreated junctional reflux causes persistent downstream pressure, leading to tributary vein recurrence rates of 20-28% at 5 years 1, 2
The recommended sequence is: endovenous thermal ablation for main trunks → sclerotherapy for tributaries → ambulatory phlebectomy for larger bulging varicosities (>4mm) 1, 2.
Role of Conservative Management
A 3-month trial of conservative management is typically required before interventional treatment, unless the patient has 2:
- Recurrent superficial thrombophlebitis
- Venous ulceration (CEAP C5-C6)
- Severe skin changes (CEAP C4 with lipodermatosclerosis or corona phlebectasia)
Conservative measures include 2, 8:
- Medical-grade gradient compression stockings (20-30 mmHg minimum) 1, 2
- Leg elevation
- Exercise and weight loss
- Avoidance of prolonged standing
However, for patients with documented reflux and venous ulceration, endovenous thermal ablation should not be delayed for compression therapy trials 4. The evidence shows compression stockings alone have no proven benefit in preventing disease progression when significant reflux is present 1, 9.
Post-Procedure Compression
After sclerotherapy, compression is mandatory 6:
- 2-3 days for spider veins
- 5-7 days for reticular veins
- Longer duration for extensive varicosities with gradient compression stockings 6
After thermal ablation, low compression stockings (15 mmHg) are as effective as high compression (40 mmHg) and more comfortable 10.
Common Pitfalls to Avoid
**Do not perform sclerotherapy on vessels <2.0mm diameter** - these have only 16% patency at 3 months compared to 76% for veins >2.0mm 1
Do not inject sclerosants intra-arterially - this causes tissue ischemia and necrosis 6
Do not treat tributary veins without addressing junctional reflux - this leads to high recurrence rates 1
Do not proceed with intervention without recent duplex ultrasound (within 6 months) documenting specific reflux duration and vein diameters 1, 2
Special Populations
Pregnant women: Compression stockings are first-line therapy; interventional treatment should be deferred until after delivery 2, 9.
Patients with active deep vein thrombosis: Sclerotherapy is contraindicated 6.