What are the treatment options for an adult patient with varicose veins?

Treatment Options for Varicose Veins

For adults with symptomatic varicose veins, endovenous thermal ablation (radiofrequency or laser) is the first-line treatment when documented reflux ≥500 milliseconds and vein diameter ≥4.5mm are present, following a 3-month trial of medical-grade compression stockings (20-30 mmHg). 1, 2

Initial Diagnostic Workup

Before any treatment decision, obtain venous duplex ultrasonography to document:

• Reflux duration at saphenofemoral or saphenopopliteal junction (pathologic if ≥500 milliseconds) 1, 2
• Exact vein diameter at specific anatomic landmarks (minimum 4.5mm for thermal ablation, 2.5mm for sclerotherapy) 1
• Deep venous system patency to rule out deep vein thrombosis 2
• Location and extent of refluxing segments 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

Treatment Algorithm Based on Clinical Presentation

Step 1: Conservative Management (Required First-Line for Most Patients)

A documented 3-month trial of conservative therapy is mandatory before interventional treatment, unless the patient has recurrent superficial thrombophlebitis or severe functional impairment. 1, 2

Conservative measures include:

• Medical-grade gradient compression stockings (20-30 mmHg minimum pressure) 1, 2
• Leg elevation during rest periods 2
• Regular exercise and weight loss if applicable 2
• Avoidance of prolonged standing 2

Important caveat: While compression stockings are required by insurance policies, recent evidence shows they do not prevent progression of venous disease when significant reflux is present. 1 However, this trial must still be documented with symptom persistence before approval for interventional treatment. 1

Step 2: Interventional Treatment Selection (After Conservative Failure)

For Main Truncal Veins (Great or Small Saphenous Veins)

Endovenous thermal ablation (radiofrequency or laser) when:

• Vein diameter ≥4.5mm 1, 2
• Documented reflux ≥500 milliseconds at saphenofemoral or saphenopopliteal junction 1, 2
• Symptomatic presentation (pain, heaviness, swelling interfering with daily activities) 1, 2

Expected outcomes:

• 91-100% occlusion rates at 1 year 1
• 90% success rate at 1 year 2
• Approximately 7% risk of temporary nerve damage from thermal injury 1, 2
• 0.3% risk of deep vein thrombosis, 0.1% risk of pulmonary embolism 1

Advantages over surgery: Similar efficacy with fewer complications (reduced bleeding, hematoma, wound infection, paresthesia), improved early quality of life, and faster recovery. 1, 2

For Tributary Veins and Smaller Vessels

Foam sclerotherapy (including Varithena/polidocanol) when:

• Vein diameter 2.5-4.5mm 1
• Used as adjunctive therapy after or concurrent with thermal ablation of main trunks 1, 2
• For residual refluxing segments or tributary veins 1

Critical requirement: Treating saphenofemoral or saphenopopliteal junction reflux with thermal ablation is mandatory before or concurrent with tributary sclerotherapy to prevent recurrence. Chemical sclerotherapy alone has worse outcomes at 1-, 5-, and 8-year follow-ups compared to thermal ablation. 1

Expected outcomes:

• 72-89% occlusion rates at 1 year 1, 2
• Common side effects: phlebitis, new telangiectasias, residual pigmentation 1
• Rare complications: deep vein thrombosis (0.3%), systemic sclerosant dispersion 1

Important pitfall: Vessels <2.0mm diameter have only 16% patency at 3 months with sclerotherapy, so avoid treating veins smaller than 2.5mm. 1

For Bulging Varicosities

Ambulatory phlebectomy (stab phlebectomy):

• Performed concurrently with thermal ablation of main trunks 1
• Addresses symptomatic varicose tributary veins that persist after saphenous trunk treatment 1
• Critical anatomic consideration: Avoid the common peroneal nerve near the fibular head during lateral calf phlebectomy to prevent foot drop 1

Step 3: Combined Approach (Recommended for Comprehensive Treatment)

The optimal strategy combines:

1. Endovenous thermal ablation for main saphenous trunks with junctional reflux 1, 2
2. Foam sclerotherapy for tributary veins and accessory saphenous veins 1, 2
3. Phlebectomy for bulging varicosities performed simultaneously 1

This combined approach addresses both the underlying reflux and visible varicosities in a single treatment session. 1

Special Clinical Scenarios

Pregnant Women

• Conservative management only during pregnancy 2
• Compression stockings as first-line therapy 2
• Defer interventional treatment until after delivery 2

Advanced Venous Disease (CEAP C4-C6)

• Patients with skin changes (hemosiderosis, stasis dermatitis, lipodermatosclerosis) or ulceration require intervention to prevent progression, even without severe pain 1
• Do not delay treatment for compression therapy trial when ulceration is present 1
• Endovenous thermal ablation addresses underlying reflux contributing to poor wound healing 1

Clotted Varicose Veins (Superficial Thrombophlebitis)

• Anticoagulant therapy is first-line treatment to prevent extension and recurrence 4
• Low molecular weight heparin or fondaparinux preferred over unfractionated heparin 4
• Duration: 4-6 weeks for isolated superficial thrombophlebitis without deep vein extension 4
• Direct oral anticoagulants (apixaban, rivaroxaban, dabigatran, edoxaban) preferred over warfarin 4
• After acute phase (3-6 months), evaluate for definitive treatment with endovenous thermal ablation to prevent recurrence 4

Recurrent Varicose Veins After Prior Treatment

• Obtain new duplex ultrasound to document new abnormalities or untreated segments 1
• Foam sclerotherapy appropriate for residual refluxing segments after prior ablation 1
• Repeat thermal ablation if new junctional reflux has developed 1

Common Pitfalls to Avoid

1. Treating tributary veins without addressing junctional reflux: This leads to 20-28% recurrence rates at 5 years. Always treat saphenofemoral or saphenopopliteal junction reflux first or concurrently. 1

2. Inadequate documentation: Insurance requires documented 3-month compression stocking trial with symptom diary, recent ultrasound (<6 months) with exact measurements, and specific identification of veins to be treated. 1

3. Treating veins too small: Vessels <2.5mm have poor outcomes with sclerotherapy (only 16% patency at 3 months for veins <2.0mm). 1

4. Bypassing conservative management inappropriately: Unless recurrent superficial thrombophlebitis or severe functional impairment is documented, the 3-month compression trial is required. 2

5. Performing sclerotherapy alone for main trunk reflux: This has inferior long-term outcomes compared to thermal ablation. Sclerotherapy should be reserved for tributary veins or used as adjunctive therapy. 1

Post-Procedure Management

• Early ambulation is recommended over bed rest 4
• Compression stockings (20-30 mmHg) after procedures help reduce pain and swelling 4, 5
• 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

Expected Long-Term Outcomes

• Recurrence rates: 20-28% at 5 years even with appropriate treatment 1
• Patient satisfaction: 96% in early studies of radiofrequency ablation 1
• Quality of life: Improved early quality of life compared to surgical stripping 1