What is the treatment for a varicose vein located at the back?

Treatment of Varicose Veins at the Back

Endovenous thermal ablation (radiofrequency or laser) is the first-line treatment for symptomatic varicose veins located at the back (posterior leg) when documented reflux ≥500 milliseconds and vein diameter ≥4.5mm are present, and compression therapy alone should not delay this intervention. 1, 2

Diagnostic Requirements Before Treatment

Before proceeding with any intervention, you must obtain:

• Duplex ultrasound within the past 6 months documenting exact vein diameter at specific anatomic landmarks, reflux duration at the saphenofemoral or saphenopopliteal junction, assessment of deep venous system patency, and location/extent of refluxing segments 1, 2
• Reflux duration ≥500 milliseconds at the saphenofemoral junction (for great saphenous vein) or saphenopopliteal junction (for small saphenous vein) correlates with clinical manifestations requiring intervention 1, 2, 3
• Vein diameter measurements are mandatory—vessels <2.0mm have only 16% patency at 3 months with sclerotherapy, while veins ≥2.5mm achieve 76% patency 2

Evidence-Based Treatment Algorithm

Step 1: Endovenous Thermal Ablation for Main Truncal Veins

For veins ≥4.5mm diameter with documented reflux ≥500ms:

• Radiofrequency ablation or endovenous laser ablation achieves 91-100% occlusion rates at 1 year 1, 2, 3
• 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, 3
• Performed under local anesthesia with same-day discharge and quick return to work 1, 3
• Approximately 7% risk of temporary nerve damage from thermal injury 1, 2
• Deep vein thrombosis occurs in 0.3% of cases, pulmonary embolism in 0.1% 2, 3

Step 2: Foam Sclerotherapy for Tributary or Smaller Veins

For veins 2.5-4.5mm diameter or tributary veins:

• Foam sclerotherapy (including Varithena/polidocanol) demonstrates 72-89% occlusion rates at 1 year 1, 2
• Appropriate as adjunctive treatment following thermal ablation of main trunks, or as primary treatment for smaller vessels 1, 2
• Fewer potential complications compared to thermal ablation, including reduced risk of thermal injury to skin, nerves, muscles, and non-target blood vessels 2
• Common side effects include phlebitis, new telangiectasias, and residual pigmentation 2

Step 3: Ambulatory Phlebectomy for Large Tributary Veins

For symptomatic tributary veins >4mm:

• Ambulatory phlebectomy may be more appropriate than sclerotherapy for larger tributaries 2
• Medically necessary as adjunctive procedure when performed concurrently with treatment of saphenofemoral junction reflux 2
• Critical anatomic consideration: avoid the common peroneal nerve near the fibular head during lateral calf phlebectomy to prevent foot drop 2

Critical Treatment Sequencing

Treating junctional reflux first is mandatory for long-term success:

• Chemical sclerotherapy alone has worse outcomes at 1-, 5-, and 8-year follow-ups compared to thermal ablation 2
• Untreated saphenofemoral or saphenopopliteal junction reflux causes persistent downstream pressure, leading to tributary vein recurrence rates of 20-28% at 5 years even after successful sclerotherapy 2
• The treatment plan must include treatment of saphenofemoral or saphenopopliteal junction reflux with thermal ablation before or concurrent with tributary treatment 2

Conservative Management (Limited Role)

Compression stockings have insufficient evidence as sole treatment:

• The 2013 National Institute for Health and Care Excellence guidelines recommend offering external compression only if interventional treatment is ineffective, and as first-line therapy only in pregnant women 1
• There is not enough evidence to determine if compression stockings are effective for varicose veins in the absence of active or healed venous ulcers 1, 4, 5
• Compression therapy should not delay endovenous thermal ablation when documented reflux is present 1, 2
• If required by insurance, typical recommendations include 20-30 mmHg elastic compression stockings for 3 months with documented symptom persistence 1, 2

Special Consideration: Clotted Varicose Veins

If the varicose vein at the back is clotted (presenting with pain, redness, warmth, hardening):

• Anticoagulant therapy is the primary treatment to prevent extension and recurrence, reducing risk by 67% (RR 0.33,95% CI 0.11-0.98) 6
• Low molecular weight heparin or fondaparinux preferred over unfractionated heparin 6
• Minimum 3-month treatment phase for acute venous thrombosis, though 4-6 weeks may suffice for clotted varicose veins without deep vein extension 6
• After acute phase (3-6 months), evaluate for definitive treatment with endovenous thermal ablation to prevent recurrence 6

Common Pitfalls to Avoid

• Do not perform sclerotherapy alone for veins with documented saphenofemoral or saphenopopliteal junction reflux—this leads to high recurrence rates 2
• Do not treat veins <2.5mm diameter with sclerotherapy—only 16% patency at 3 months 2
• Do not delay thermal ablation for compression stocking trials when reflux is documented—this represents outdated practice 1, 2
• Ensure ultrasound documents exact reflux times and vein diameters at specific anatomic landmarks—clinical presentation alone cannot determine medical necessity 2, 3