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 saphenous vein reflux, followed by sclerotherapy for tributary veins and conservative measures for patients who cannot undergo or decline intervention. 1

Initial Diagnostic Workup

Before any treatment, venous duplex ultrasonography is mandatory 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

Treatment Algorithm

Conservative Management (First-Line for Specific Populations)

Required before interventional treatment for most patients: minimum 3-month trial including 1:

• Medical-grade gradient compression stockings (20-30 mmHg minimum pressure) 1
• Leg elevation 1
• Weight loss and lifestyle modifications 1
• Phlebotonics (venoactive drugs) 1

Exceptions where conservative trial can be bypassed 1:

• Recurrent superficial thrombophlebitis
• Severe and persistent pain/swelling interfering with activities of daily living
• Skin changes indicating CEAP C4 disease or higher (ulceration)
• Documented severe reflux with significant functional impairment

Important caveat: Insurance companies typically require documented conservative management failure before approving interventional treatments, even though clinical guidelines support immediate intervention for severe disease 1. Recent evidence shows compression therapy alone does not prevent progression of venous disease when significant reflux is present 1.

First-Line Interventional Treatment: Endovenous Thermal Ablation

Indications 1:

• Symptomatic varicose veins with documented valvular reflux ≥500ms
• Great saphenous vein diameter ≥4.5mm (for radiofrequency ablation specifically) 1
• Failed conservative management (in most cases)

Types of thermal ablation 1:

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

Advantages 1:

• 90-100% success rate at 1 year 1
• Performed under local anesthesia 1
• Immediate walking after procedure 1
• Quick return to work and normal activities 1
• Superior long-term outcomes compared to sclerotherapy alone at 1-, 5-, and 8-year follow-ups 1

Risks 1:

• Approximately 7% risk of surrounding nerve damage from thermal injury 1
• Deep vein thrombosis in 0.3% of cases 1
• Pulmonary embolism in 0.1% of cases 1
• Thrombophlebitis, hematoma, infection (rare) 1

Second-Line Treatment: Sclerotherapy

Indications 1:

• Small to medium-sized varicose veins (2.5-4.5mm diameter) 1
• Adjunctive therapy after thermal ablation for tributary veins 1
• Recurrent varicose veins 1
• Residual refluxing segments post-ablation 1

Common sclerosing agents 1:

• Hypertonic saline
• Sodium tetradecyl
• Polidocanol (Varithena for foam sclerotherapy) 1

Efficacy: 72-89% occlusion rates at 1 year 1

Critical treatment principle: Sclerotherapy alone for saphenofemoral junction reflux has inferior outcomes compared to thermal ablation 1. The saphenofemoral junction must be treated with thermal ablation or ligation before or concurrent with tributary sclerotherapy to prevent recurrence 1.

Advantages over thermal ablation 1:

• Fewer complications (no thermal injury risk to skin, nerves, muscles) 1
• No tumescent anesthesia required 1
• Appropriate for smaller vessels where catheter-based ablation is not feasible 1

Minimum vessel size: Vessels <2.0mm have only 16% patency at 3 months; optimal results require ≥2.5mm diameter 1

Alternative Non-Thermal Option: VenaSeal (Cyanoacrylate Adhesive)

Indications 2:

• Symptomatic varicose veins (CEAP class C2-C4b) with documented saphenous vein incompetence 2
• Patients who cannot tolerate tumescent anesthesia 2
• Concerns about thermal damage to surrounding structures 2

Advantages: Minimal discomfort and quick recovery 2

Surgical Options (Third-Line)

Procedures 1:

• Ligation and excision
• Saphenous vein stripping
• Ambulatory phlebectomy (stab phlebectomy)

Current role: Reserved for specific cases where endovenous techniques are not appropriate or feasible 1. Surgical stripping has largely been replaced by endovenous thermal ablation due to similar efficacy with fewer complications and faster recovery 1, 3.

Phlebectomy as adjunctive treatment: Medically necessary for symptomatic varicose tributary veins when performed concurrently with treatment of saphenofemoral junction reflux 1. Bulging varicosities should be treated by phlebectomy at the time of truncal vein ablation 4.

Treatment Sequencing for Optimal Outcomes

The correct sequence is critical 1:

1. Treat main truncal veins first (great saphenous vein, small saphenous vein) with endovenous thermal ablation if diameter ≥4.5mm and reflux ≥500ms 1

2. Treat tributary veins second with sclerotherapy or phlebectomy, either concurrently or after truncal vein treatment 1

3. Treat incompetent perforating veins using transluminal occlusion of perforator (TRLOP) approach if significant 4

Evidence supporting this sequence: Chemical sclerotherapy alone has worse outcomes at 1-, 5-, and 8-year follow-ups compared to thermal ablation or surgery 1. Untreated junctional reflux causes persistent downstream pressure, leading to tributary vein recurrence rates of 20-28% at 5 years even after successful sclerotherapy 1.

Special Populations

Pregnant Women

Conservative measures only 1:

• Compression stockings as first-line therapy 1
• Leg elevation 1
• Interventional treatment deferred until after delivery 1

Patients with Pelvic Vein Reflux

• Investigate with transvaginal duplex ultrasound using Holdstock-Harrison protocol 4
• Treat incompetent pelvic veins with coil embolization if refluxing into symptomatic leg varicose veins 4

Patients with Advanced Disease (CEAP C4-C6)

• Immediate intervention recommended without mandatory conservative trial 1
• C4 disease (skin changes including corona phlebectasia, stasis dermatitis, hyperpigmentation) requires intervention to prevent progression 1
• C5-C6 disease (healed or active ulceration) benefits from endovenous ablation to treat underlying reflux 1

Common Pitfalls to Avoid

1. Treating tributary veins without addressing saphenofemoral junction reflux: This leads to high recurrence rates 1

2. Proceeding to sclerotherapy without recent ultrasound: Duplex ultrasound within past 6 months documenting reflux duration and vein diameter is mandatory 1

3. Treating vessels <2.5mm with sclerotherapy: Poor outcomes with only 16% patency at 3 months 1

4. Using sclerotherapy as sole treatment for large saphenous veins: Thermal ablation has superior long-term outcomes for veins ≥4.5mm 1

5. Bypassing conservative management without documentation: Insurance denial likely without documented 3-month trial of compression therapy, except in severe cases 1

6. Performing lateral calf phlebectomy without avoiding common peroneal nerve: Risk of foot drop from nerve injury 1

Post-Procedure Monitoring

• Early postoperative duplex scans (2-7 days) mandatory to detect endovenous heat-induced thrombosis 1
• Longer-term imaging (3-6 months) needed to assess treatment success and identify residual incompetent segments requiring adjunctive therapy 1
• Participation in venous registry for outcome monitoring should be considered mandatory 4

Expected Outcomes

Thermal ablation 1:

• Technical success: 91-100% occlusion at 1 year 1
• Patient satisfaction: 96% in early studies 1
• Recurrence: Lower than surgery or sclerotherapy alone 1

Sclerotherapy 1:

• Occlusion rates: 72-89% at 1 year 1
• Higher recurrence rates when used alone for truncal veins 1

Overall recurrence: 20-28% at 5 years even with appropriate treatment 1, highlighting the chronic progressive nature of venous disease 4, 5.