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 are not candidates for intervention. 1, 2

First-Line Interventional Treatment: Endovenous Thermal Ablation

For patients with symptomatic varicose veins and documented valvular reflux, endovenous thermal ablation should be performed without requiring a trial of compression therapy first. 2, 3

Indications for Thermal Ablation:

• Great or small saphenous vein diameter ≥4.5mm 2, 4
• Documented reflux duration ≥500 milliseconds at saphenofemoral or saphenopopliteal junction 1, 2
• Symptomatic presentation (aching, pain, heaviness, swelling, cramping) interfering with daily activities 1, 2

Technical Success and Benefits:

• Occlusion rates of 91-100% at 1 year 2, 3
• Performed under local anesthesia with same-day discharge 3
• Immediate walking after procedure with quick return to work 2
• Superior long-term outcomes compared to surgery with fewer complications (reduced bleeding, hematoma, wound infection, paresthesia) 3

Risks:

• Approximately 7% risk of temporary nerve damage from thermal injury 2, 3
• Deep vein thrombosis in 0.3% of cases 2, 3
• Pulmonary embolism in 0.1% of cases 2, 3

Second-Line Treatment: Sclerotherapy

Foam sclerotherapy is appropriate for small to medium-sized varicose veins (2.5-4.5mm diameter), as adjunctive therapy after thermal ablation, and for tributary veins. 1, 2

Sclerosing Agents:

• Hypertonic saline 1
• Sodium tetradecyl (Sotradecol) 1
• Polidocanol (Varithena) 1, 4

Efficacy:

• Occlusion rates of 72-89% at 1 year 2, 4
• Vessels <2.0mm diameter have only 16% primary patency at 3 months, so minimum diameter of 2.5mm is recommended 4

Important Caveat:

Chemical sclerotherapy alone has inferior long-term outcomes compared to thermal ablation, with worse results at 1-, 5-, and 8-year follow-ups. 2, 4 The treatment sequence matters—saphenofemoral junction reflux must be treated with thermal ablation before tributary sclerotherapy to prevent recurrence. 4

Conservative Management

Conservative measures are first-line treatment ONLY in pregnant women; otherwise, they are reserved for patients who decline intervention or are not surgical candidates. 1, 2

Conservative Options Include:

• Medical-grade gradient compression stockings (20-30 mmHg minimum) 1, 2
• Elevation of affected leg 1
• Weight loss in obese patients 1
• Avoidance of prolonged standing and straining 1
• Exercise 1
• Phlebotonics (horse chestnut seed extract may provide symptomatic relief, though long-term studies are lacking) 1

Critical Insurance Requirement:

Most insurance companies require a documented 3-month trial of medical-grade compression stockings before approving interventional treatments, despite guidelines stating this is not medically necessary when reflux is documented. 2

Surgical Treatment: Ligation and Stripping

Surgery has been largely replaced by endovenous thermal ablation as the standard of care and should be reserved for cases where endovenous techniques are not feasible. 1, 3

• Modern techniques use small incisions to reduce scarring and blood loss 1
• May be performed under local or regional anesthesia 1
• Traditional surgery has 20-28% recurrence rate at 5 years 4

External Laser Thermal Ablation

External laser therapy works best for telangiectasias (spider veins) rather than larger varicose veins. 1

Diagnostic Requirements Before Treatment

Venous duplex ultrasonography is mandatory when interventional therapy is being considered. 1, 2

Required Documentation:

• Reflux duration (>500ms in superficial/deep calf veins, >1000ms in femoropopliteal veins) 1, 2
• Vein diameter measurements 2, 4
• Assessment of saphenous junction competence 1
• Location and size of incompetent perforating veins 1
• Exclusion of deep venous thrombosis 1

Treatment Algorithm Summary

1. Document reflux with duplex ultrasound within past 6 months 2, 4
2. For veins ≥4.5mm with reflux ≥500ms: Endovenous thermal ablation 2, 3
3. For tributary veins 2.5-4.5mm: Foam sclerotherapy (after treating main trunk) 2, 4
4. For telangiectasias: External laser or sclerotherapy 1
5. For patients declining intervention or not candidates: Compression stockings and conservative measures 1, 2

Common Pitfalls to Avoid

• Do not perform sclerotherapy on saphenofemoral junction reflux without first treating with thermal ablation—this leads to high recurrence rates 2, 4
• Do not treat vessels <2.5mm with sclerotherapy—poor outcomes with only 16% patency at 3 months 4
• Do not delay thermal ablation for compression stocking trial when symptoms and reflux are documented—guidelines state this is unnecessary 2, 3
• Do not perform interventions without recent duplex ultrasound—vein diameter and reflux duration determine appropriate treatment selection 2, 4