What is the recommended initial assessment and management for a patient with varicose veins?

Management of Varicose Veins

Begin with medical-grade gradient compression stockings (20–30 mmHg) as first-line therapy for all symptomatic varicose veins, combined with lifestyle modifications including leg elevation, regular calf-pump exercise, and avoidance of prolonged standing. 1

Initial Conservative Management

• Prescribe medical-grade gradient compression stockings delivering 20–30 mmHg pressure for a documented 3-month trial before considering any interventional procedures. 2, 1
• Advise specific lifestyle modifications: avoid prolonged standing or sitting, perform regular calf-pump-enhancing exercise, elevate legs when resting, and pursue weight loss if overweight. 2, 3
• Document symptom persistence with a symptom diary during the compression trial, as insurance policies typically require this documentation before approval for interventional treatment. 2, 1

Important caveat: Compression stockings alone have no proven benefit in preventing post-thrombotic syndrome or treating established venous insufficiency when significant reflux is present, and recent randomized trials show compression therapy does not prevent disease progression. 1 However, the 3-month trial remains a practical requirement for insurance authorization.

Diagnostic Evaluation

Order venous duplex ultrasound when symptoms persist despite conservative management or when interventional therapy is being considered. 2, 1

The ultrasound must document:

• Reflux duration at the saphenofemoral or saphenopopliteal junction (pathologic reflux defined as ≥500 milliseconds). 2, 1, 4
• Vein diameter measured at specific anatomic landmarks (≥4.5 mm for main saphenous trunks, ≥2.5 mm for tributary veins). 2, 1, 4
• Deep venous system patency to exclude deep vein thrombosis. 2
• Location and extent of all refluxing segments with exact anatomic landmarks. 2, 4

The ultrasound should be performed within 6 months of any planned intervention and ideally by a specialist trained in ultrasonography who is not the treating physician. 2, 5

Indications for Interventional Treatment

Refer for endovenous thermal ablation when any of the following criteria are met:

Absolute Indications (No Compression Trial Required)

• Active or healed venous ulceration (CEAP C5-C6): Existing evidence suggests compression therapy trials are not warranted before referral for endovenous thermal ablation in these patients. 1, 4
• Skin changes (CEAP C4) including hemosiderosis, stasis dermatitis, or corona phlebectasia—these patients require intervention to prevent progression even without severe pain. 2, 1

Relative Indications (After Failed Conservative Management)

• Severe and persistent symptoms (pain, swelling, heaviness, aching, cramping) interfering with activities of daily living despite 3-month trial of compression stockings. 2, 1, 4
• Documented reflux ≥500 milliseconds at saphenofemoral or saphenopopliteal junction. 2, 1, 4
• Vein diameter ≥4.5 mm for main saphenous trunks or ≥2.5 mm for tributary veins. 2, 1, 4

Treatment Algorithm Based on Vein Size and Location

First-Line: Endovenous Thermal Ablation

Endovenous thermal ablation (radiofrequency or laser) is the first-line treatment for saphenofemoral or saphenopopliteal junction reflux when vein diameter is ≥4.5 mm with documented reflux ≥500 ms. 2, 1, 4

• Technical success rates: 91–100% occlusion at 1 year. 2, 4
• Advantages over surgery: similar efficacy with fewer complications (reduced bleeding, hematoma, wound infection, paresthesia), improved early quality of life, and reduced hospital recovery time. 2, 4
• Can be performed under local anesthesia with same-day discharge. 4

Critical principle: Treating junctional reflux with thermal ablation is essential before or concurrent with tributary treatment to prevent recurrence—untreated junctional reflux causes persistent downstream pressure leading to tributary vein recurrence rates of 20–28% at 5 years. 2, 1

Second-Line: Foam Sclerotherapy

Foam sclerotherapy is appropriate for tributary veins (2.5–4.5 mm diameter) or as adjunctive treatment following thermal ablation of main trunks. 2, 1

• Occlusion rates: 72–89% at 1 year for appropriately selected veins ≥2.5 mm. 2, 1
• Do not treat veins smaller than 2.5 mm—vessels <2.0 mm have only 16% primary patency at 3 months compared to 76% for veins >2.0 mm. 2, 1
• Common side effects: phlebitis, new telangiectasias, residual pigmentation, transient colic-like pain resolving within 5 minutes. 2
• Rare complications: deep vein thrombosis (0.3%), systemic dispersion of sclerosant in high-flow situations. 2

Third-Line: Ambulatory Phlebectomy

Ambulatory phlebectomy is appropriate for larger tributary veins (>4 mm) or bulging varicosities, ideally performed concurrently with thermal ablation of junctional reflux. 2, 1

• More appropriate than sclerotherapy for larger tributaries. 2
• Should be performed at the time of truncal vein ablation to address symptomatic varicose branches comprehensively. 2, 5
• Most common complication: skin blistering from dressing abrasions; rare sensory nerve injury causing temporary anesthesia. 2

Critical anatomic consideration: Avoid the common peroneal nerve near the fibular head during lateral calf phlebectomy to prevent foot drop. 2, 1

Special Clinical Scenarios

Superficial Vein Thrombosis

• Prophylactic-dose fondaparinux or LMWH is recommended over no anticoagulation (Grade 2B), with fondaparinux preferred over LMWH (Grade 2C). 1
• Anticoagulant therapy reduces risk of symptomatic extension or recurrence by 67% (RR 0.33,95% CI 0.11–0.98). 1
• Minimum 3-month treatment phase for acute venous thrombosis; for clotted varicose veins without deep vein extension, a shorter course (4–6 weeks) may be sufficient. 1

Acute Varicose Vein Bleeding

• Apply direct pressure and elevate the leg immediately—this controls bleeding in most cases. 6
• For small-diameter veins (<1 mm), sclerotherapy with 0.2% sodium tetradecyl injection achieves effective thrombosis. 6
• For larger veins, operative removal is required. 6

Pregnancy

• Conservative management with compression stockings is preferred during pregnancy. 3
• Defer interventional treatment until after delivery unless bleeding or severe complications occur. 6

Common Pitfalls to Avoid

1. Never perform sclerotherapy or phlebectomy on tributary veins without treating upstream junctional reflux—this leads to rapid recurrence from persistent downstream venous hypertension with recurrence rates of 20–28% at 5 years. 2, 1

2. Do not treat veins smaller than 2.5 mm with sclerotherapy—vessels <2.0 mm have only 16% primary patency at 3 months. 2, 1

3. Ensure exact vein diameter measurements are documented—vein diameter directly predicts treatment outcomes and determines appropriate procedure selection. 2, 1, 4

4. Do not delay referral for patients with venous ulceration—compression therapy trials are not warranted before endovenous thermal ablation in these patients. 1, 4

Risks and Complications of Endovenous Thermal Ablation

• Nerve damage from thermal injury: approximately 7% of cases, usually temporary. 2, 4
• Deep vein thrombosis: 0.3% of cases. 2, 4
• Pulmonary embolism: 0.1% of cases. 2, 4
• Early postoperative duplex scans (2–7 days) are mandatory to detect endovenous heat-induced thrombosis. 2

Post-Procedure Management

• Post-procedure compression therapy is essential to optimize outcomes and reduce complications. 4
• Patients should be counseled to continue compression stockings for several weeks after the procedure. 4
• Monitor for complications including thrombophlebitis, hematoma, and infection. 4

Risk Factors and Prevention

Risk factors include family history, older age, female sex, pregnancy, obesity, prolonged standing occupations, and history of deep venous thrombosis. 3, 7 Patients with varicose veins have increased risk for deep venous thrombosis and pulmonary embolism, particularly during long-term immobilization, long air travel, or after invasive treatment. 8 Thromboprophylaxis after invasive procedures is recommended in subjects older than 60 years and those with another thrombophilic state. 8