What are the treatment guidelines for varicose veins?

Treatment Guidelines for Varicose Veins

First-Line Treatment Algorithm

Endovenous thermal ablation (radiofrequency or laser) is the first-line treatment for symptomatic varicose veins with documented valvular reflux, having largely replaced surgical stripping due to similar efficacy with fewer complications and faster recovery. 1, 2

Step 1: Diagnostic Workup

• Venous duplex ultrasonography is mandatory before any interventional therapy to assess anatomy, physiology, and determine treatment eligibility 2
• Document reflux duration: >500 milliseconds in superficial veins (great saphenous vein/small saphenous vein) and >1,000 milliseconds in femoropopliteal veins 2
• Measure exact vein diameter at specific anatomic landmarks, particularly at saphenofemoral or saphenopopliteal junctions 1
• Assess deep venous system patency and exclude deep venous thrombosis 2
• Ultrasound must be performed within 6 months of planned intervention 1

Step 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
• Additional conservative measures include leg elevation, exercise, weight loss if applicable, and avoidance of prolonged standing 1, 2
• Exception: Patients with venous ulceration (CEAP C5-C6), recurrent superficial thrombophlebitis, or severe skin changes (CEAP C4) may proceed directly to intervention without compression trial 1, 2

Step 3: Treatment Selection Based on Vein Size and Location

For Main Saphenous Trunks (GSV/SSV):

• Endovenous thermal ablation (radiofrequency or laser) when vein diameter ≥4.5mm with documented reflux ≥500ms at saphenofemoral or saphenopopliteal junction 1, 2
• Technical success rates: 91-100% occlusion at 1 year 1
• Benefits: Performed under local anesthesia, immediate ambulation, quick return to activities, 90% success rate at 1 year 2
• Risks: Approximately 7% risk of temporary nerve damage from thermal injury, 0.3% deep vein thrombosis, 0.1% pulmonary embolism 1

For Tributary and Accessory Veins:

• Foam sclerotherapy (including polidocanol/Varithena) for veins 2.5-4.5mm diameter with documented reflux 1, 2
• Occlusion rates: 72-89% at 1 year 1
• Common side effects: Phlebitis, new telangiectasias, residual pigmentation 1
• Ambulatory phlebectomy for larger tributary veins (>4mm) or when sclerotherapy is contraindicated 1

For Small Veins (<2.5mm):

• Liquid or foam sclerotherapy, though vessels <2.0mm have only 16% primary patency at 3 months compared to 76% for veins >2.0mm 1

Critical Treatment Sequencing

Treating saphenofemoral or saphenopopliteal junction reflux is mandatory before or concurrent with tributary vein treatment to prevent recurrence. 1, 3

• Chemical sclerotherapy or phlebectomy alone without junctional treatment has 20-28% recurrence rates at 5 years and worse outcomes at 1-, 5-, and 8-year follow-ups compared to thermal ablation 1, 3
• The American College of Radiology explicitly states that junctional reflux must be treated concurrently for tributary procedures to meet medical necessity criteria 1, 3

Treatment Algorithm by CEAP Classification

• CEAP C2 (varicose veins without skin changes): Conservative management first, then thermal ablation if symptomatic despite compression 1
• CEAP C3 (edema): Thermal ablation for documented reflux with diameter criteria met 1
• CEAP C4 (skin changes including pigmentation, eczema, lipodermatosclerosis): Intervention required to prevent progression, even without severe pain 1
• CEAP C5-C6 (healed or active ulceration): Immediate intervention without compression trial; endovenous ablation improves wound healing by treating underlying reflux 1, 2

Important Clinical Caveats

When Conservative Management Can Be Bypassed:

• Documented recurrent superficial thrombophlebitis 2
• Severe and persistent pain/swelling interfering with activities of daily living 2
• Active or healed venous ulceration 1
• Advanced skin changes (CEAP C4c with corona phlebectasia) 1

Common Pitfalls to Avoid:

• Do not treat tributary veins with sclerotherapy or phlebectomy without addressing junctional reflux—this leads to high recurrence rates 1, 3
• Do not use thermal ablation for veins <4.5mm diameter—sclerotherapy is more appropriate 1
• Do not treat veins <2.5mm with sclerotherapy—poor outcomes with only 16% patency at 3 months 1
• Avoid lateral calf phlebectomy near the fibular head to prevent common peroneal nerve injury and foot drop 1

Post-Procedure Monitoring:

• Early postoperative duplex scan (2-7 days) is mandatory to detect endovenous heat-induced thrombosis 1
• Longer-term imaging (3-6 months) assesses treatment success and identifies residual incompetent segments requiring adjunctive therapy 1

Special Populations

• Pregnant women: Conservative management with compression stockings only; defer interventional treatment until postpartum 2
• Patients with prior ablation and recurrence: Serial ultrasound required to document new abnormalities or untreated segments; foam sclerotherapy appropriate for residual refluxing segments ≥2.5mm 1

Surgical Options (Third-Line)

• Surgical ligation and stripping reserved for cases where endovenous techniques are not feasible or have failed 1, 2
• Higher complication rates including bleeding, hematoma, wound infection, and paresthesia compared to endovenous techniques 1, 4