What is the best treatment approach for a patient with varicose veins?

Best Treatment for Varicose Veins

Endovenous thermal ablation (radiofrequency or laser) is the first-line treatment for symptomatic varicose veins with documented saphenofemoral or saphenopopliteal junction reflux ≥500 milliseconds and vein diameter ≥4.5mm, achieving 91-100% occlusion rates at 1 year. 1, 2

Diagnostic Requirements Before Treatment

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

• Reflux duration at saphenofemoral/saphenopopliteal junctions (pathologic if ≥500 milliseconds) 1, 2
• Exact vein diameter at specific anatomic landmarks (minimum 4.5mm for thermal ablation, 2.5mm for sclerotherapy) 1, 2
• Deep venous system patency to exclude thrombosis 2
• Location and extent of incompetent perforating veins 2

The ultrasound must be performed within the past 6 months and should be done with the patient in the erect position. 1, 3

Conservative Management Requirements

A documented 3-month trial of medical-grade gradient compression stockings (20-30 mmHg minimum pressure) with symptom persistence is required before interventional treatment, unless the patient has: 1, 2

• Recurrent superficial thrombophlebitis 2
• Severe and persistent pain/swelling interfering with activities of daily living 2
• Skin changes (CEAP C4 or higher) indicating moderate-to-severe venous disease 1
• Venous ulceration (CEAP C5-C6) 1

Important caveat: The National Institute for Health and Care Excellence guidelines recommend compression therapy only if interventional treatment is ineffective, and as first-line therapy only in pregnant women. However, insurance companies typically require this trial before approval. 2

Evidence-Based Treatment Algorithm

Step 1: Treat Main Truncal Veins First (Saphenofemoral/Saphenopopliteal Junction Reflux)

Endovenous thermal ablation (radiofrequency ablation or endovenous laser ablation) for: 1, 2

• Great or small saphenous veins with diameter ≥4.5mm 1
• Documented reflux ≥500 milliseconds at junctions 1, 2
• Technical success: 91-100% occlusion at 1 year 1
• Benefits: Performed under local anesthesia, immediate walking post-procedure, quick return to activities, 90% success rate at 1 year 2
• Risks: ~7% temporary nerve damage from thermal injury, 0.3% deep vein thrombosis, 0.1% pulmonary embolism 1

Critical principle: Treating junctional reflux is mandatory before or concurrent with tributary vein treatment. Chemical sclerotherapy alone has worse outcomes at 1-, 5-, and 8-year follow-ups compared to thermal ablation, with recurrence rates of 20-28% at 5 years. 1, 4

Step 2: Treat Tributary and Accessory Veins

Foam sclerotherapy (including Varithena/polidocanol) for: 1, 2

• Tributary veins with diameter 2.5-4.5mm 1
• Residual refluxing segments after thermal ablation 1
• Accessory saphenous veins 1
• Occlusion rates: 72-89% at 1 year 1, 2
• Common side effects: Phlebitis, new telangiectasias, residual pigmentation, transient colic-like pain 1

Important: Vessels <2.0mm have only 16% primary patency at 3 months compared to 76% for veins >2.0mm, so optimal results require vein diameter ≥2.5mm. 1

Step 3: Remove Bulging Varicosities

Ambulatory phlebectomy (stab phlebectomy) for: 1, 3

• Symptomatic varicose tributary veins that persist after junctional treatment 1
• Larger tributary veins (>4mm) where sclerotherapy may be less effective 1
• Should be performed concurrently with thermal ablation of main trunks 1
• Critical anatomic consideration: Avoid the common peroneal nerve near the fibular head during lateral calf phlebectomy to prevent foot drop 1

Special Populations and Scenarios

Spider Veins (<1mm diameter)

Spider veins are distinct from varicose veins and require different management. 5 If purely cosmetic without venous insufficiency symptoms, conservative management is not required before treatment. 5 However, duplex ultrasound is mandatory if underlying saphenofemoral/saphenopopliteal junction reflux is suspected, and this must be treated first. 5

Pregnant Women

Conservative measures (compression stockings, leg elevation, lifestyle modifications) are recommended as first-line therapy. 2 Interventional treatment should be deferred until after delivery unless there are severe complications. 2

Patients with Venous Ulceration

Endovenous thermal ablation should not be delayed for a trial of compression therapy when ulceration is present, as the presence of ulceration represents severe disease (CEAP C5-C6) that warrants immediate intervention to treat the underlying reflux contributing to poor wound healing. 1

Common Pitfalls to Avoid

1. Treating tributary veins without addressing junctional reflux: This leads to recurrence rates of 20-28% at 5 years due to persistent downstream pressure. 1

2. Treating veins <2.5mm with sclerotherapy: Results in poor outcomes with only 16% patency at 3 months. 1

3. Proceeding to intervention without proper ultrasound documentation: Exact vein diameter measurements and reflux duration are mandatory to avoid inappropriate treatment selection. 1

4. Using sclerotherapy alone for main saphenous trunks: Chemical sclerotherapy has inferior long-term outcomes compared to thermal ablation for junctional reflux. 1

Strength of Evidence

The American Academy of Family Physicians guidelines (2019) provide Level A evidence that endovenous thermal ablation is first-line treatment for symptomatic varicose veins with documented valvular reflux. 1, 2 The American College of Radiology Appropriateness Criteria (2023) provide Level A evidence for the treatment sequencing algorithm requiring junctional treatment before tributary sclerotherapy. 1