What is the treatment for swollen varicose veins?

Treatment of Swollen Varicose Veins

Endovenous thermal ablation (radiofrequency or laser) is the first-line treatment for symptomatic varicose veins with documented saphenofemoral or saphenopopliteal junction reflux ≥500 milliseconds and vein diameter ≥4.5mm, followed by sclerotherapy or phlebectomy for tributary veins. 1

Initial Diagnostic Requirements

Before any treatment, you must obtain:

• Duplex ultrasound within the past 6 months documenting specific measurements: reflux duration at the saphenofemoral junction (SFJ) or saphenopopliteal junction (SPJ), exact vein diameter at specific anatomic landmarks, assessment of deep venous system patency, and location/extent of refluxing segments 1, 2
• The ultrasound should be performed in the erect position by a specialist trained in ultrasonography, ideally not the treating physician 3
• Reflux duration ≥500 milliseconds correlates with clinical manifestations requiring intervention 1, 2

Conservative Management Trial

• A documented 3-month trial of medical-grade gradient compression stockings (20-30 mmHg minimum pressure) is required before interventional treatment 1, 2
• Conservative measures should include leg elevation, exercise, weight loss if applicable, and avoidance of prolonged standing 1
• Important caveat: For patients with venous ulceration (CEAP C5-C6), endovenous thermal ablation need not be delayed for compression therapy trials 1, 2
• The evidence for compression stockings as sole treatment is insufficient and of very low certainty, with no conclusive benefit demonstrated in preventing disease progression 4, 5

Treatment Algorithm Based on Vein Size and Location

For Main Truncal Veins (GSV/SSV with diameter ≥4.5mm and reflux ≥500ms):

• Endovenous thermal ablation (radiofrequency or laser) is first-line treatment with 91-100% occlusion rates at 1 year 1, 2
• This has largely replaced surgical stripping due to similar efficacy, improved early quality of life, reduced hospital recovery, and fewer complications including reduced bleeding, hematoma, wound infection, and paresthesia 1, 2
• The procedure can be performed under local anesthesia with same-day discharge 2
• Critical requirement: Treating saphenofemoral or saphenopopliteal junction reflux is mandatory before tributary treatment, as untreated junctional reflux causes persistent downstream pressure leading to 20-28% recurrence rates at 5 years 1

For Tributary Veins (diameter 2.5-4.4mm):

• Foam sclerotherapy (including Varithena/polidocanol) is appropriate with 72-89% occlusion rates at 1 year 1
• Sclerotherapy should be performed as adjunctive or secondary treatment following thermal ablation of main trunks, not as standalone therapy 1
• Vessels <2.5mm have only 16% primary patency at 3 months with sclerotherapy, making treatment of smaller veins inappropriate 1

For Bulging Varicosities:

• Ambulatory phlebectomy (stab phlebectomy) is medically necessary as adjunctive treatment for symptomatic varicose tributary veins when performed concurrently with treatment of junctional reflux 1, 2
• Phlebectomy is more appropriate than sclerotherapy for larger tributary veins (>4mm) 1

Clinical Staging and Treatment Indications

Treatment is indicated for symptomatic CEAP stages C2s-C6 6:

• C2s: Varicose veins with symptoms (pain, heaviness, cramping, swelling interfering with daily activities) 1
• C3: Edema 1
• C4a: Pigmentation or eczema 1
• C4b: Lipodermatosclerosis or atrophie blanche 1
• C4c: Corona phlebectasia (moderate-to-severe venous insufficiency requiring intervention) 1
• C5-C6: Healed or active venous ulceration 1

Patients with C4 disease (skin changes) require intervention to prevent progression, even when severe pain is not the primary complaint 1

Complications and Risks

• Deep vein thrombosis occurs in 0.3% of cases, pulmonary embolism in 0.1% 1, 2
• Approximately 7% risk of temporary nerve damage from thermal injury 1, 7, 2
• Early postoperative duplex scans (2-7 days) are mandatory to detect endovenous heat-induced thrombosis 1
• Common side effects of sclerotherapy include phlebitis, new telangiectasias, and residual pigmentation 1
• Critical anatomic consideration: The common peroneal nerve near the fibular head must be avoided during lateral calf procedures to prevent foot drop 1

Common Pitfalls to Avoid

• Never perform sclerotherapy alone for saphenofemoral junction reflux - chemical sclerotherapy has inferior long-term outcomes at 1-, 5-, and 8-year follow-ups compared to thermal ablation 1
• Do not treat veins <2.5mm diameter - these have poor outcomes with only 16% patency at 3 months 1
• Do not perform endovenous thermal ablation on veins <4.5mm diameter - sclerotherapy is the appropriate treatment for veins 2.5-4.4mm 1, 7
• Never skip ultrasound documentation - clinical presentation alone cannot determine medical necessity 2
• Avoid treating tributary veins before addressing junctional reflux - this leads to high recurrence rates 1

Post-Procedure Management

• Post-procedure compression therapy is essential to optimize outcomes and reduce complications 2
• Ultrasound guidance is mandatory for safe and effective sclerotherapy administration 1
• Patients can expect quick return to normal activities with minimal downtime 2