What are the treatment options for varicose veins?

Treatment of Varicose Veins

Endovenous thermal ablation (radiofrequency or laser) is the first-line treatment for symptomatic varicose veins with documented valvular reflux, followed by sclerotherapy for tributary veins and surgery as a third-line option. 1, 2

Diagnostic Requirements Before Treatment

Before any interventional therapy, venous duplex ultrasonography is mandatory to assess: 2

• Reflux duration - pathologic reflux defined as >500 milliseconds in superficial veins and saphenous junctions, >350 milliseconds in perforating veins, and >1,000 milliseconds in femoropopliteal veins 2
• Vein diameter at specific anatomic landmarks - minimum 4.5mm for thermal ablation, minimum 2.5mm for sclerotherapy 1
• Location and extent of incompetent saphenous junctions and refluxing segments 2
• Deep venous system patency to exclude thrombosis 2
• Incompetent perforating veins location and size 2

The ultrasound must be performed within 6 months of planned intervention and should be done in the erect position by a specialist trained in ultrasonography. 1, 3

Conservative Management Requirements

A documented 3-month trial of conservative management is required before interventional treatment, except in cases of recurrent superficial thrombophlebitis, venous ulceration, or severe functional impairment. 2 This trial must include:

• Medical-grade gradient compression stockings (20-30 mmHg minimum pressure) with documented compliance 1, 2
• Leg elevation during rest periods 2
• Exercise and weight loss if applicable 1
• Avoidance of prolonged standing or sitting 2

Important caveat: The National Institute for Health and Care Excellence recommends compression therapy only if interventional treatment is ineffective or as first-line therapy in pregnant women, though many insurance companies still require this trial before approval. 2 For patients with documented valvular reflux and ulceration (C5-C6 disease), endovenous ablation should not be delayed for compression trials. 1

Treatment Algorithm Based on Vein Size and Location

First-Line: Endovenous Thermal Ablation

For great or small saphenous veins with diameter ≥4.5mm and reflux ≥500ms at saphenofemoral or saphenopopliteal junction: 1, 2

• Radiofrequency ablation (RFA) or endovenous laser ablation (EVLA) are equally effective 4
• Success rates: 90-100% occlusion at 1 year 1, 2
• Advantages: Performed under local anesthesia, immediate walking post-procedure, quick return to work, fewer complications than surgery 2, 5
• Risks: Approximately 7% risk of temporary nerve damage from thermal injury, 0.3% deep vein thrombosis, 0.1% pulmonary embolism 1, 2

Critical requirement: Treatment of saphenofemoral or saphenopopliteal junction reflux is mandatory before treating tributary veins, as untreated junctional reflux causes persistent downstream pressure leading to 20-28% recurrence rates at 5 years. 1

Second-Line: Sclerotherapy

For tributary veins, accessory saphenous veins, or veins 2.5-4.5mm in diameter: 1, 2

• Foam sclerotherapy (including Varithena/polidocanol) demonstrates 72-89% occlusion rates at 1 year 1, 2
• Appropriate as adjunctive therapy after thermal ablation of main trunks or for residual refluxing segments 1
• Common side effects: Phlebitis, new telangiectasias, residual pigmentation 1
• Rare complications: Deep vein thrombosis (0.3%), systemic dispersion of sclerosant 1

Critical pitfall: Vessels <2.0mm in diameter have only 16% patency at 3 months with sclerotherapy compared to 76% for veins >2.0mm - treating veins smaller than 2.5mm results in poor outcomes. 1 Additionally, sclerotherapy alone without treating junctional reflux has inferior long-term outcomes at 1-, 5-, and 8-year follow-ups compared to thermal ablation. 1

Third-Line: Surgical Options

Surgery (high ligation and stripping) is reserved for: 2, 4

• Cases where endovenous techniques are not feasible 1
• Patient preference after discussion of higher complication rates 5
• Ambulatory phlebectomy for bulging varicosities, ideally performed concurrently with truncal vein ablation 1, 3

Important anatomic consideration: The common peroneal nerve near the fibular head must be avoided during lateral calf phlebectomy to prevent foot drop. 1

Alternative: Non-Thermal Closure

VenaSeal (cyanoacrylate adhesive) can be considered for patients who: 6

• Cannot tolerate tumescent anesthesia 6
• Have concerns about thermal damage to surrounding structures 6
• Prefer minimal discomfort and quick recovery 6

However, mechanochemical endovenous ablation (MOCA) has lower overall success rates than EVLA, RFA, or stripping and requires more evidence. 4

Treatment Sequence for Comprehensive Management

The optimal approach treats multiple levels simultaneously: 1

1. Endovenous thermal ablation of main saphenous trunks with junctional reflux 1
2. Foam sclerotherapy for tributary veins and accessory saphenous veins 1
3. Ambulatory phlebectomy for bulging varicosities at the same session 1, 3
4. Transluminal occlusion of perforator (TRLOP) for significant incompetent perforating veins 3

This combined approach provides comprehensive treatment and reduces recurrence rates compared to staged procedures. 1

Special Populations

Pregnant women: Conservative management with compression stockings is first-line; interventional treatment should be deferred until after delivery. 2

Patients with pelvic vein reflux: Transvaginal duplex ultrasound using the Holdstock-Harrison protocol is required; treatment involves coil embolization if pelvic veins reflux into symptomatic leg varicosities. 3

Patients with venous ulceration (C5-C6): Endovenous ablation should proceed without delay for compression trials, as treating underlying reflux is critical for wound healing. 1

Post-Procedure Monitoring

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

Cost-Effectiveness

EVLA is the most cost-effective therapeutic option, with RFA being a close second, both superior to surgical stripping or sclerotherapy alone. 4 The combination of lower complication rates, faster recovery, and high success rates makes endovenous thermal ablation the standard of care. 5, 4