What is the recommended treatment for symptomatic great saphenous vein (GSV) reflux in the legs?

Recommended Treatment for Symptomatic Great Saphenous Vein Reflux

Endovenous thermal ablation (radiofrequency or laser) is the first-line treatment for symptomatic GSV reflux with documented saphenofemoral junction incompetence, achieving 91-100% occlusion rates at 1 year with superior outcomes compared to surgery or sclerotherapy alone. 1

Treatment Algorithm Based on Vein Diameter and Reflux Location

Primary Treatment: Endovenous Thermal Ablation

• Thermal ablation (radiofrequency or laser) is indicated when GSV diameter is ≥4.5mm with documented reflux ≥500 milliseconds at the saphenofemoral junction. 1
• This approach has largely replaced surgical stripping due to similar efficacy with fewer complications, improved quality of life, and faster recovery. 1
• Technical success rates range from 91-100% within 1 year post-treatment, with 96% patient satisfaction. 1

Critical Requirement: Treat the Saphenofemoral Junction

• Treating saphenofemoral junction reflux is mandatory for long-term success—chemical sclerotherapy alone has significantly worse outcomes at 1-, 5-, and 8-year follow-ups compared to thermal ablation. 1
• Studies demonstrate that untreated junctional reflux causes persistent downstream pressure, leading to tributary vein recurrence rates of 20-28% at 5 years. 1

Below-Knee GSV Considerations

• When reflux extends below the knee, concomitant ablation of the below-knee GSV segment should be performed to improve long-term outcomes and reduce residual symptoms. 2, 3
• Leaving below-knee reflux untreated results in residual symptoms and need for reintervention in nearly half of patients. 2
• Below-knee ablation can be performed safely with minimal complications (4% paresthesia rate, resolving within 4 weeks). 2

Adjunctive Treatments

Foam Sclerotherapy for Tributary Veins

• Foam sclerotherapy (including Varithena/polidocanol) is appropriate as secondary treatment for tributary veins ≥2.5mm diameter with documented reflux ≥500 milliseconds. 1
• Occlusion rates for foam sclerotherapy range from 72-89% at 1 year. 1
• Sclerotherapy should only be performed after or concurrent with treatment of saphenofemoral junction reflux—never as standalone therapy for main truncal veins. 1

Ambulatory Phlebectomy

• Stab phlebectomy is indicated as adjunctive treatment for symptomatic varicose tributary veins, particularly those >4mm diameter. 1
• This procedure is typically performed simultaneously with thermal ablation for comprehensive treatment. 1

Pre-Treatment Requirements

Mandatory Diagnostic Documentation

• Duplex ultrasound within the past 6 months documenting: reflux duration ≥500 milliseconds at saphenofemoral junction, exact vein diameter at specific anatomic landmarks, deep venous system patency, and extent of refluxing segments. 1

Conservative Management Trial

• A documented 3-month trial of medical-grade gradient compression stockings (20-30 mmHg minimum) with persistent symptoms is required before interventional treatment. 1
• Exception: Patients with venous ulceration (C5-C6 disease) do not require a trial of compression therapy before referral for endovenous ablation. 1

Complications and Risks

Thermal Ablation Risks

• Deep vein thrombosis occurs in approximately 0.3% of cases. 1
• Pulmonary embolism occurs in 0.1% of cases. 1
• Temporary nerve damage from thermal injury occurs in approximately 7% of cases, though most resolves. 1
• Early postoperative duplex scans (2-7 days) are mandatory to detect endovenous heat-induced thrombosis. 1

Sclerotherapy Risks

• Common side effects include phlebitis, new telangiectasias, and residual pigmentation. 1
• Deep vein thrombosis is exceedingly rare with sclerotherapy. 1

Common Pitfalls to Avoid

• Never perform sclerotherapy alone for main saphenous trunk reflux—this leads to high recurrence rates and poor long-term outcomes. 1
• Do not ignore below-knee GSV reflux when present—this results in residual symptoms requiring additional interventions in up to 89% of patients. 3
• Vessels <2.5mm diameter have poor outcomes with sclerotherapy (only 16% patency at 3 months)—these should not be treated. 1
• Avoid lateral calf phlebectomy near the fibular head to prevent common peroneal nerve injury and foot drop. 1

Evidence Quality

• The recommendation for endovenous thermal ablation as first-line treatment is supported by Level A evidence from the American Family Physician guidelines (2019) and American College of Radiology Appropriateness Criteria (2023). 1
• The requirement for treating saphenofemoral junction reflux before tributary sclerotherapy is supported by multiple meta-analyses demonstrating superior long-term outcomes. 1