Approach

The main interventional treatment options for varicose veins include endovenous ablation, foam sclerotherapy, phlebectomy, and open surgery.​[16][17]​​[18]​​

Compression stockings may be offered if interventional treatment is unsuitable (e.g., in pregnancy) or if the patient is unwilling to have intervention. These need to be replaced and remeasured every 3 months.

All treatment outcomes can be improved with adjunctive lifestyle modifications such as weight loss, leg elevation, and exercise (especially aqua-aerobics).

All venous ulcers need urgent specialist review, arterial and venous assessment, venous incompetence treatment, and compression therapy. This increases the rate of healing and reduces the rate of recurrence.

Tributary insufficiency

If the patient only has varicosities (insufficiency of tributaries) without major venous trunk reflux, phlebectomy of affected veins via stab avulsion, or foam sclerotherapy of the affected veins, is all that is necessary.[16]​ Phlebectomy can be achieved via small incisions with removal of the veins, and this can easily be performed under local anesthetic in an ambulatory procedure. Patients need to be counseled that, although current varicosities will be treated and removed, they will very likely develop new varicosities in other veins in the future, as varicose veins are a progressive disease. 

Foam sclerotherapy is the ultrasound-guided injection of a foamed solution, such as polidocano or sodium tetradecyl sulfate, which causes endothelial cell death and vein inflammation, leading to vein occlusion.

Treatment for recurrence is repeated phlebectomy or foam sclerotherapy.

Superficial truncal system insufficiency

If the superficial axial system (the great saphenous vein, the small saphenous vein, or the anterior accessory saphenous vein) is involved, the patient will require treatment of the axial system. Typically, endovenous thermal ablation (radiofrequency or laser ablation) is offered as a first-line option, followed by ultrasound-guided foam sclerotherapy if endovenous ablation is unsuitable, or open surgery (stripping and ligation) if neither are suitable.[17][16][18]​​​​[19][20]​​​​​​[21]​​ [ Cochrane Clinical Answers logo ] [Evidence B]

Ablative procedures and foam sclerotherapy are routinely performed under local anesthetic, or as a day case under general anesthetic. Surgery can also be performed as a day case under general or regional anesthetic.

Radiofrequency and endovenous laser ablation have been shown to be as effective as open surgery, but with decreased postoperative pain and recovery time.[16]​​[22][23][24][25][26][27][28][29] Radiofrequency ablation has been shown to have reduced pain profiles compared with laser treatment; however, multiple new laser wavelengths have improved the pain profile.[30][31]

Five-year results of a randomized clinical trial of conventional surgery, endovenous laser ablation, and ultrasound-guided foam sclerotherapy found that endovenous laser ablation and conventional surgery were more effective than foam sclerotherapy.[29] However, while foam sclerotherapy has been shown to have lower technical success rates and disease-specific quality of life scores, it has similar generic quality of life outcomes and significantly lower procedural cost and impact.[32][33] Long-term follow-up of endovenous thermal ablation has shown no significant difference in recurrence or symptom relief between surgery and endovenous ablation.[32]

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

Recurrence after radiofrequency or endovenous laser ablation can be treated with repeat endovenous approach, foam sclerotherapy, or stripping and ligation.

Recurrence after stripping and ligation may be the result of a duplicate system (which should be excluded on the initial venous duplex map), and which can be treated via repeat stripping and ligation (though this is a significantly complex procedure) or one of the endovenous approaches.

Perforating veins

Clinical practice guidelines from the Society for Vascular Surgery, the American Venous Forum, and the American Vein and Lymphatic Society published in 2022 recommend against perforator treatment in CEAP class 2 patients, unless patients remain symptomatic despite all other causes being treated.[16] Updated US guidance for CEAP class 3-6 patients is expected in 2023. The 2022 European Society for Vascular Surgery guidance also recommends against the routine usage of perforating vein treatment, unless only the perforating veins remain as an issue.[18] Subfascial endoscopic perforator surgery (SEPS), open perforator surgery, sclerotherapy, and thermal ablation have all been used for perforator closure. 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, providing more treatment area coverage. 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]

Deep vein insufficiency

If the patient has deep system insufficiency giving rise to varicosities without evidence of superficial truncal vein insufficiency, treatment of the varicosities with phlebectomy or foam sclerotherapy may be performed; however, compression therapy will be necessary for long-term control, and is key in all cases where compression is possible. Patients with deep system insufficiency should be counseled that they may not have complete symptomatic relief through treatment of the varicosities, but can expect at least partial relief of their symptoms by reduction in the reflux burden.​

Patients with deep vein insufficiency and superficial truncal vein insufficiency may be treated with endovenous thermal ablation, foam sclerotherapy, or open surgery. Compression therapy should be utilized in addition to intervention to improve patient quality of life and prevent progression in patients with deep vein insufficiency.[38][39]

In patients with co-existent superficial and segmental deep venous reflux, superficial venous surgery alone corrects the deep venous insufficiency in almost 50% of limbs, and is associated with ulcer healing in 77% of limbs at 12 months. This finding suggests an extended role for superficial venous surgery in the management of patients with complicated venous disease.[40] In specialist centers, open deep venous reconstruction may be considered in severe cases. 

Deep vein obstruction

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 centers.

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