What are the recommended management and treatment options for a patient with varicose veins?

Patient Information About Varicose Veins and Management

What Are Varicose Veins?

Varicose veins are enlarged, twisted veins that typically appear in your legs, affecting approximately 25% of women and 15% of men. 1 They occur when the valves inside your veins stop working properly, causing blood to flow backward and pool in the veins rather than returning efficiently to your heart. 2

• Common symptoms include: pain, swelling, heaviness, fatigue, leg cramps, and itching in the affected leg 1, 2
• Visible signs include: bulging, rope-like veins under the skin, skin discoloration (brownish pigmentation), and in advanced cases, skin changes or ulcers 3, 1
• Important distinction: Spider veins (tiny red or blue veins <1mm) are different from varicose veins (≥3mm) and require different treatment approaches 4

What You Can Do: Conservative Management

First-Line Measures (Start Here)

Before considering any procedures, you should try conservative management for at least 3 months. 1 This includes:

• Compression stockings: Wear medical-grade graduated compression stockings (20-30 mmHg pressure) daily 3, 1

  • Put them on first thing in the morning before swelling develops
  • Wear them throughout the day, especially during prolonged standing or sitting
  • Remove them at bedtime

• Leg elevation: Elevate your legs above heart level for 15-30 minutes several times daily 1

• Exercise regularly: Walking, swimming, and cycling help improve calf muscle pump function and venous return 1, 5

• Weight management: Maintain a healthy weight to reduce pressure on leg veins 1, 5

• Avoid prolonged standing or sitting: Take breaks to move around every 30-60 minutes 1

Dietary Considerations

• Consume foods rich in antioxidants: Grapes, blackberries, avocados, ginger, and rosemary may help support vein health 5
• Consider venoactive medications: Flavonoid-based supplements may provide therapeutic benefit for chronic venous disorders, though you should discuss this with your healthcare provider 5

When to Consider Medical Treatment

You should seek medical evaluation if you have:

• Persistent symptoms (pain, swelling, heaviness) that interfere with daily activities despite 3 months of conservative management 3, 1
• Skin changes: Brown discoloration, thickening, or inflammation of the skin around your ankles 3, 1
• Recurrent superficial blood clots (thrombophlebitis) in the varicose veins 1
• Bleeding from varicose veins 2
• Venous ulcers (open sores near the ankle) 3, 1

Medical Treatment Options (If Conservative Measures Fail)

Diagnostic Testing Required First

Before any procedure, you need a venous duplex ultrasound to map your veins and measure blood flow patterns. 1 This test:

• Identifies which veins have faulty valves (reflux >500 milliseconds is abnormal) 1
• Measures vein diameter to determine appropriate treatment 3, 1
• Checks for blood clots in deep veins 1
• Must be performed within 6 months before treatment 3

Treatment Algorithm Based on Vein Size

The treatment you receive depends on your vein diameter and location of reflux:

For Large Veins (≥4.5mm diameter) with Junction Reflux

• Endovenous thermal ablation (radiofrequency or laser) is first-line treatment 3, 1
  • Success rate: 90-100% at 1 year 3, 1
  • Performed under local anesthesia 1
  • Walk immediately after procedure 1
  • Return to work within days 1
  • Risk of temporary nerve damage: approximately 7% 3, 1

For Medium Veins (2.5-4.5mm diameter) or Tributary Veins

• Sclerotherapy (injection therapy) is appropriate 3, 1
  • Success rate: 72-89% at 1 year 3, 1
  • Used for smaller veins or as adjunctive treatment after thermal ablation 3, 1
  • Common side effects: temporary skin discoloration, phlebitis, new spider veins 3

For Spider Veins (<1mm diameter)

• Cosmetic sclerotherapy may be appropriate 4
• Important: If you have symptoms of venous insufficiency, underlying larger vein problems must be treated first 4

Critical Treatment Principle

If you have reflux at the saphenofemoral junction (where the superficial vein meets the deep vein in your groin), this MUST be treated first before addressing smaller tributary veins. 3 Treating only the visible varicose veins without fixing the underlying junction problem leads to recurrence rates of 20-28% at 5 years. 3

What to Expect from Treatment

Success Rates and Outcomes

• Thermal ablation: 91-100% vein closure at 1 year, with significant symptom improvement 3, 1
• Sclerotherapy: 72-89% vein closure at 1 year for appropriately sized veins 3, 1
• Quality of life improvement: Most patients experience significant reduction in pain, swelling, and heaviness 1, 6

Potential Complications

• Thermal ablation risks: Deep vein thrombosis (0.3%), pulmonary embolism (0.1%), temporary nerve damage (7%), skin burns (rare) 3
• Sclerotherapy risks: Skin discoloration, phlebitis, new spider veins, allergic reaction (rare) 3

Common Pitfalls to Avoid

• Don't skip conservative management: Insurance typically requires documented 3-month trial of compression therapy before approving procedures 3, 1
• Don't treat only visible veins: Underlying junction reflux must be addressed to prevent recurrence 3
• Don't expect spider veins to disappear completely: Even with treatment, some cosmetic imperfections may remain 4
• Don't ignore skin changes: Brown discoloration or skin thickening indicates more advanced disease requiring prompt evaluation 3, 1

When Conservative Management Is Sufficient

You may not need procedures if:

• Your symptoms are mild and don't interfere with daily activities 1
• You're pregnant (wait until after delivery; varicose veins often improve postpartum) 1
• Your primary concern is purely cosmetic with no symptoms 4
• You have medical conditions that make procedures high-risk 1

In these cases, continue compression therapy, leg elevation, exercise, and weight management indefinitely. 1

Special Considerations

Pregnancy

• Conservative management only during pregnancy 1
• Compression stockings are first-line therapy 1
• Many varicose veins improve spontaneously after delivery 1
• Delay interventional treatment until at least 3-6 months postpartum 1

Recurrent Varicose Veins

• If varicose veins return after previous treatment, you need repeat ultrasound to identify the source of recurrence 3
• Treatment approach depends on whether new reflux has developed or residual veins were incompletely treated 3

Bottom Line for Patients

Start with 3 months of compression stockings (20-30 mmHg), daily leg elevation, regular exercise, and weight management. 1 If symptoms persist and significantly interfere with your daily activities, seek evaluation with venous duplex ultrasound to determine if you're a candidate for endovenous procedures. 1 Modern minimally invasive treatments have excellent success rates (90%+) with minimal downtime, but proper patient selection and treatment sequencing are critical for long-term success. 3, 1