Treatment of Small Varicose and Spider Veins
Primary Treatment Recommendation
For small varicose veins (1-3 mm) and spider veins (≤1 mm), sclerotherapy is the method of choice and should be your first-line treatment. 1, 2
Treatment Algorithm by Vein Size
Spider Veins (≤1 mm diameter)
- Use polidocanol 0.5% solution with 0.1-0.3 mL per injection, maximum 10 mL per session 3
- Inject using a fine needle (26- or 30-gauge) inserted tangentially into the vein 3
- Apply compression stockings for 2-3 days post-treatment 3
- Expected outcomes: effective thrombosis and elimination when performed properly 4
Reticular Veins (1-3 mm diameter)
- Use polidocanol 1% solution with 0.1-0.3 mL per injection, maximum 10 mL per session 3
- Apply compression stockings for 5-7 days post-treatment 3
- Sclerotherapy demonstrates 72-89% occlusion rates at 1 year for appropriately selected veins 2, 5
Medium Varicose Veins (3-5 mm diameter)
- Foam sclerotherapy is appropriate as second-line treatment after endovenous thermal ablation but before surgery 2
- Ultrasound guidance is essential for safe and effective treatment of these larger vessels 5
- Minimum vein diameter of 2.5 mm is required for optimal outcomes; vessels <2.0 mm have only 16% patency at 3 months compared to 76% for veins >2.0 mm 5
Critical Pre-Treatment Requirements
Documentation Needed
- Recent duplex ultrasound (within 6 months) documenting vein diameter and reflux duration if considering treatment beyond simple cosmetic spider veins 2, 5
- For symptomatic varicose veins requiring insurance coverage: documented 3-month trial of conservative management including medical-grade compression stockings (20-30 mmHg) 1, 5
Conservative Management Components
- Leg elevation, exercise, weight loss if applicable 1
- Avoidance of prolonged standing and straining 1
- Wearing nonrestrictive clothing 1
- Medical-grade gradient compression stockings (20-30 mmHg minimum) 5
Post-Treatment Protocol
Immediate Post-Procedure Care
- Have patient walk for 15-20 minutes immediately after injection 3
- Keep patient under observation during this period to detect anaphylactic or allergic reactions 3
- Apply compression with stocking or bandage immediately after needle removal 3
Compression Duration
- Spider veins: 2-3 days 3
- Reticular veins: 5-7 days 3
- Extensive varicosities: longer compression with higher compression class stockings 3
Treatment Sequencing for Complex Cases
When treating larger varicose veins with associated smaller vessels, always treat from proximal to distal and largest to smallest vein. 6
- First-line: Endovenous thermal ablation for main saphenous trunks with reflux (veins ≥4.5 mm) 1, 2
- Second-line: Sclerotherapy for tributary and smaller veins (1-5 mm) 2
- Third-line: Surgery only when endovenous techniques are not feasible 2
Common Pitfalls to Avoid
Critical Safety Considerations
- Never inject intra-arterially - this causes severe necrosis, ischemia, or gangrene; if this occurs, consult vascular surgery immediately 3
- Minimize volume to reduce anaphylaxis risk - severe reactions are more frequent with volumes >3 mL 3
- Avoid foaming with room air (high nitrogen concentration) as this increases risk of stroke, TIA, and MI 3
- Use smallest effective volume at each injection site to prevent extravasation and tissue necrosis 3
Patient Selection Cautions
- Patients with reduced mobility, history of DVT/PE, or recent major surgery are at increased risk for thrombosis 3
- Post-treatment compression is mandatory to reduce DVT risk 3
- Polidocanol (Asclera) has not been studied in varicose veins >3 mm diameter 3
Expected Complications and Management
Common Side Effects
- Phlebitis, new telangiectasias, residual pigmentation at treatment sites 5
- Allergic skin reactions as allergic dermatitis, contact urticaria, or erythema 4
- Transient migraine headaches (more frequent with foam than liquid sclerotherapy) 4
Rare but Serious Complications
- Anaphylaxis (rare but can be fatal) - be prepared to treat appropriately 3, 4
- Deep vein thrombosis (approximately 0.3%) 5
- Pulmonary embolism (exceedingly rare) 5