Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ONGOING

symptomatic superficial vein insufficiency, no evidence of peripheral vascular disease or superficial axial truncal insufficiency: tributary insufficiency only

1st line – phlebectomy or foam sclerotherapy

Back
ONGOING
|
symptomatic superficial vein insufficiency, no evidence of peripheral vascular disease or superficial axial truncal insufficiency: tributary insufficiency only
1st line – 

phlebectomy or foam sclerotherapy

Phlebectomy may be achieved by stab avulsion of portions of varicose vein, through small stab incisions not requiring suture closure. Foam sclerotherapy involves injection of a foamed solution such as sodium tetradecyl sulfate or polidocanol into small veins, followed by compression.

Recurrence requires repeat phlebectomies or foam sclerotherapy.

Complications include haematoma, deep venous thrombosis, infection, skin pigmentation, and poor cosmetic outcome. Foam sclerotherapy has had scattered reports of stroke after intervention.[41]

Patients should also be counselled on lifestyle modifications, including weight loss, leg elevation, and exercise.[42]

symptomatic superficial vein insufficiency, no evidence of peripheral vascular disease or superficial tributary insufficiency: truncal axial insufficiency only

1st line – endovenous thermal ablation (radiofrequency or laser)

Back
ONGOING
|
symptomatic superficial vein insufficiency, no evidence of peripheral vascular disease or superficial tributary insufficiency: truncal axial insufficiency only
1st line – 

endovenous thermal ablation (radiofrequency or laser)

Radiofrequency ablation (RFA): generally performed on the great saphenous vein (GSV), anterior accessory saphenous vein (AASV), or small saphenous vein (SSV). Special probes are available for use in perforator veins if needed. The vein is accessed under ultrasound guidance. In the case of the GSV, the RFA probe is passed up to just below the epigastric vein, remaining 2 cm below the saphenofemoral junction (SFJ). It is slowly withdrawn in segments or continuously while energy from radiofrequency causes closure of the vein. Patients may still require phlebectomies for varicosities. Complications include endothermal heat-induced thrombosis (EHIT), phlebitis, thermal skin injury, and paraesthesias. These occur infrequently.

Endovenous laser therapy (EVLT): generally performed on GSV, AASV, or SSV but may be possible in branch varicosities as well. The vein is accessed under ultrasound guidance. In the case of GSV, a laser probe is passed up to just below the epigastric vein, remaining below the SFJ. The fibre is slowly withdrawn while the laser is on, causing thrombosis and destruction of the vein. Patients may still require phlebectomies for varicosities. Complications include EHIT, phlebitis, thermal skin injury, and paraesthesias. These occur infrequently.[43]​​

Patients should also be counselled on lifestyle modifications, including weight loss, leg elevation, and exercise.[42]

2nd line – foam sclerotherapy

Back
ONGOING
|
symptomatic superficial vein insufficiency, no evidence of peripheral vascular disease or superficial tributary insufficiency: truncal axial insufficiency only
2nd line – 

foam sclerotherapy

Involves injection of liquid solution such as sodium tetradecyl sulfate or polidocanol that is foamed with air and then injected into varicose vein under ultrasound guidance. Complications include pigmentation, headaches, and visual changes. It has a higher recurrence rate than radiofrequency ablation, endovenous laser therapy, or surgery, but is much faster and cheaper.[26][44][45]​​

Patients should also be counselled on lifestyle modifications, including weight loss, leg elevation, and exercise.[42]

3rd line – open surgery (stripping and ligation)

Back
ONGOING
|
symptomatic superficial vein insufficiency, no evidence of peripheral vascular disease or superficial tributary insufficiency: truncal axial insufficiency only
3rd line – 

open surgery (stripping and ligation)

The main goal of stripping and ligation is to permanently remove the varicose vein. It is performed when the greater saphenous vein or small saphenous vein has reflux that gives rise to the varicose veins. Complications include bleeding, infection, saphenous nerve injury, and neovascularisation.

Patients should also be counselled on lifestyle modifications, including weight loss, leg elevation, and exercise.[42]

symptomatic superficial vein insufficiency, no evidence of peripheral vascular disease: truncal axial and tributary insufficiency

1st line – endovenous thermal ablation (radiofrequency or laser) and phlebectomy or foam sclerotherapy

Back
ONGOING
|
symptomatic superficial vein insufficiency, no evidence of peripheral vascular disease: truncal axial and tributary insufficiency
1st line – 

endovenous thermal ablation (radiofrequency or laser) and phlebectomy or foam sclerotherapy

Patients may undergo concomitant truncal vein and varicosity treatment as this may reduce the need for further procedures and improve quality of life.[34][35]

Radiofrequency ablation (RFA): generally performed on the great saphenous vein (GSV), anterior accessory saphenous vein (AASV), or small saphenous vein (SSV). Special probes are available for use in perforator veins if needed. The vein is accessed under ultrasound guidance. In the case of the GSV, the RFA probe is passed up to just below the epigastric vein, remaining 2 cm below the saphenofemoral junction (SFJ). It is slowly withdrawn in segments or continuously while energy from radiofrequency causes closure of the vein. Patients may still require phlebectomies for varicosities. Complications include endothermal heat-induced thrombosis (EHIT), phlebitis, thermal skin injury, and paraesthesias. These occur infrequently.

Endovenous laser therapy (EVLT): generally performed on GSV, AASV, or SSV but may be possible in branch varicosities as well. The vein is accessed under ultrasound guidance. In the case of GSV, a laser probe is passed up to just below the epigastric vein, remaining below the SFJ. The fibre is slowly withdrawn while the laser is on, causing thrombosis and destruction of the vein. Patients may still require phlebectomies for varicosities. Complications include EHIT, phlebitis, thermal skin injury, and paraesthesias. These occur infrequently.[43]​​

Phlebectomy may be achieved by stab avulsion of portions of varicose vein, through small stab incisions not requiring suture closure. Foam sclerotherapy involves injection of a foamed solution such as sodium tetradecyl sulfate or polidocanol into small veins, followed by compression.

Recurrence requires repeat phlebectomies or sclerotherapy.

Complications include haematoma, deep vein thombosis, infection, skin pigmentation, and poor cosmetic outcome. Foam sclerotherapy has had scattered reports of stroke after intervention.[41]

Patients should also be counselled on lifestyle modifications, including weight loss, leg elevation, and exercise.[42]

2nd line – foam sclerotherapy of truncal and tributary veins

Back
ONGOING
|
symptomatic superficial vein insufficiency, no evidence of peripheral vascular disease: truncal axial and tributary insufficiency
2nd line – 

foam sclerotherapy of truncal and tributary veins

Foam sclerotherapy involves injection of a foamed solution such as sodium tetradecyl sulfate or polidocanol into small veins, followed by compression.

Recurrence requires repeat phlebectomies or sclerotherapy.

Complications include haematoma, deep vein thombosis, infection, skin pigmentation, and poor cosmetic outcome. Foam sclerotherapy has had scattered reports of stroke after intervention.[41]

Patients should also be counselled on lifestyle modifications, including weight loss, leg elevation, and exercise.[42]

3rd line – open surgery (stripping and ligation) and phlebectomy

Back
ONGOING
|
symptomatic superficial vein insufficiency, no evidence of peripheral vascular disease: truncal axial and tributary insufficiency
3rd line – 

open surgery (stripping and ligation) and phlebectomy

The main goal of stripping and ligation is to permanently remove the varicose vein. It is performed when the greater saphenous vein or small saphenous vein has reflux that gives rise to the varicose veins. Complications include bleeding, infection, saphenous nerve injury, and neovascularisation.

Phlebectomy may be achieved by stab avulsion of portions of varicose vein, through small stab incisions not requiring suture closure.

Patients should also be counselled on lifestyle modifications, including weight loss, leg elevation, and exercise.[42]

symptomatic superficial vein insufficiency, no evidence of peripheral vascular disease: perforator veins with reflux located near healed or active venous ulcers

1st line – foam sclerotherapy or endovenous thermal ablation

Back
ONGOING
|
symptomatic superficial vein insufficiency, no evidence of peripheral vascular disease: perforator veins with reflux located near healed or active venous ulcers
1st line – 

foam sclerotherapy or endovenous thermal ablation

The success of thermoablation procedures is around 60% to 80%, with better occlusion rates with repeated therapy. Ultrasound-guided foam sclerotherapy has a lower thrombosis rate, but may be easier to perform for varicosities located near the ulcer bed in addition to the feeding perforator. Successful closure of pathologic perforators using these techniques may improve ulcer healing and decrease recurrence.[36] However, up to 80% of incompetent perforators will revert to competence after successful ablation of truncal vein incompetence.[37]

Plus – compression therapy: bandage or stockings

Back
ONGOING
|
symptomatic superficial vein insufficiency, no evidence of peripheral vascular disease: perforator veins with reflux located near healed or active venous ulcers
Plus – 

compression therapy: bandage or stockings

Treatment recommended for ALL patients in selected patient group

Compression therapy should be utilised in addition to intervention to improve patient quality of life and reduce venous symptoms.[17][38]​​​

2nd line – perforator surgery

Back
ONGOING
|
symptomatic superficial vein insufficiency, no evidence of peripheral vascular disease: perforator veins with reflux located near healed or active venous ulcers
2nd line – 

perforator surgery

Subfascial endoscopic perforator surgery or open perforator surgery may be used for perforator closure.

Plus – compression therapy: bandage or stockings

Back
ONGOING
|
symptomatic superficial vein insufficiency, no evidence of peripheral vascular disease: perforator veins with reflux located near healed or active venous ulcers
Plus – 

compression therapy: bandage or stockings

Treatment recommended for ALL patients in selected patient group

Compression therapy should be utilised in addition to intervention to improve healing rates and improve patient quality of life.[38]

deep vein insufficiency without superficial truncal vein insufficiency but with superficial tributary insufficiency

1st line – phlebectomy or foam sclerotherapy

Back
ONGOING
|
deep vein insufficiency without superficial truncal vein insufficiency but with superficial tributary insufficiency
1st line – 

phlebectomy or foam sclerotherapy

Phlebectomy may be achieved by stab avulsion of portions of varicose vein, through small stab incisions not requiring suture closure. Foam sclerotherapy involves injection of a foamed solution such as sodium tetradecyl sulfate or polidocanol into small veins, followed by compression.

Recurrence requires repeat phlebectomies or foam sclerotherapy.

Complications include haematoma, deep venous thrombosis, infection, skin pigmentation, and poor cosmetic outcome. Foam sclerotherapy has had scattered reports of stroke after intervention.[41]

Patients should also be counselled on lifestyle modifications, including weight loss, leg elevation, and exercise.[42]

Plus – compression therapy: bandage or stockings

Back
ONGOING
|
deep vein insufficiency without superficial truncal vein insufficiency but with superficial tributary insufficiency
Plus – 

compression therapy: bandage or stockings

Treatment recommended for ALL patients in selected patient group

Compression therapy should be utilised in addition to intervention to improve patient quality of life and reduce venous symptoms.[17][38]​​​

deep vein insufficiency with superficial truncal vein insufficiency

1st line – endovenous thermal ablation (radiofrequency or laser)

Back
ONGOING
|
deep vein insufficiency with superficial truncal vein insufficiency
1st line – 

endovenous thermal ablation (radiofrequency or laser)

Radiofrequency ablation (RFA): generally performed on the great saphenous vein (GSV), anterior accessory saphenous vein (AASV), or small saphenous vein (SSV). Special probes are available for use in perforator veins if needed. The vein is accessed under ultrasound guidance. In the case of the GSV, the RFA probe is passed up to just below the epigastric vein, remaining 2 cm below the saphenofemoral junction (SFJ). It is slowly withdrawn in segments or continuously while energy from radiofrequency causes closure of the vein. Patients may still require phlebectomies for varicosities. Complications include endothermal heat-induced thrombosis (EHIT), phlebitis, thermal skin injury, and paraesthesias. These occur infrequently.

Endovenous laser therapy (EVLT): generally performed on GSV, AASV, or SSV but may be possible in branch varicosities as well. The vein is accessed under ultrasound guidance. In the case of GSV, a laser probe is passed up to just below the epigastric vein, remaining below the SFJ. The fibre is slowly withdrawn while the laser is on, causing thrombosis and destruction of the vein. Patients may still require phlebectomies for varicosities. Complications include EHIT, phlebitis, thermal skin injury, and paraesthesias. These occur infrequently.[43]​​

Patients should also be counselled on lifestyle modifications, including weight loss, leg elevation, and exercise.[42]

Plus – compression therapy: bandage or stockings

Back
ONGOING
|
deep vein insufficiency with superficial truncal vein insufficiency
Plus – 

compression therapy: bandage or stockings

Treatment recommended for ALL patients in selected patient group

Compression therapy should be utilised in addition to intervention to improve patient quality of life and reduce venous symptoms.[17][38]​​​

2nd line – foam sclerotherapy

Back
ONGOING
|
deep vein insufficiency with superficial truncal vein insufficiency
2nd line – 

foam sclerotherapy

Involves injection of liquid solution such as sodium tetradecyl sulfate or polidocanol that is foamed with air and then injected into varicose vein under ultrasound guidance. Complications include pigmentation, headaches, and visual changes. It has a higher recurrence rate than radiofrequency ablation, endovenous laser therapy, or surgery, but is much faster and cheaper.[26][44][45]​​

Patients should also be counselled on lifestyle modifications, including weight loss, leg elevation, and exercise.[42]

Plus – compression therapy: bandage or stockings

Back
ONGOING
|
deep vein insufficiency with superficial truncal vein insufficiency
Plus – 

compression therapy: bandage or stockings

Treatment recommended for ALL patients in selected patient group

Compression therapy should be utilised in addition to intervention to improve patient quality of life and reduce venous symptoms.[17][38]​​​

3rd line – open surgery (stripping and ligation)

Back
ONGOING
|
deep vein insufficiency with superficial truncal vein insufficiency
3rd line – 

open surgery (stripping and ligation)

The main goal of stripping and ligation is to permanently remove the varicose vein. It is performed when the greater saphenous vein or small saphenous vein has reflux that gives rise to the varicose veins. Complications include bleeding, infection, saphenous nerve injury, and neovascularisation.

Patients should also be counselled on lifestyle modifications, including weight loss, leg elevation, and exercise.[42]

Plus – compression therapy: bandage or stockings

Back
ONGOING
|
deep vein insufficiency with superficial truncal vein insufficiency
Plus – 

compression therapy: bandage or stockings

Treatment recommended for ALL patients in selected patient group

Compression therapy should be utilised in addition to intervention to improve patient quality of life and reduce venous symptoms.[17][38]​​​

deep vein insufficiency without superficial vein insufficiency

1st line – compression therapy: bandage or stockings

Back
ONGOING
|
deep vein insufficiency without superficial vein insufficiency
1st line – 

compression therapy: bandage or stockings

Compression therapy should be utilised to improve patient quality of life and reduce venous symptoms.[17][38]​​​

2nd line – open surgical deep vein reconstruction (rarely needed)

Back
ONGOING
|
deep vein insufficiency without superficial vein insufficiency
2nd line – 

open surgical deep vein reconstruction (rarely needed)

Open deep venous reconstruction may be considered in severe cases. This is highly specialised.

deep vein obstruction

1st line – stenting or reconstruction

Back
ONGOING
|
deep vein obstruction
1st line – 

stenting or reconstruction

In cases of significant rates of recurrence or unusual features, assessment of iliac vein stenosis or occlusion may also improve symptomatology and clinical severity from the potential use of iliac vein stenting, or open deep venous reconstruction; however, these require long-term use of anticoagulation and compression hosiery. Any intervention on the superficial system in these patients should be assessed very carefully in specialist centres.

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Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

Use of this content is subject to our disclaimer