# Varicose Veins: Evaluation and Treatment Options

## Overview

Varicose veins are dilated, tortuous subcutaneous veins measuring 3 millimeters or more in diameter, which arise due to incompetence of venous valves. They affect approximately 20 to 35 percent of adults, with prevalence increasing with age, female sex, pregnancy, obesity, and prolonged standing. The clinical spectrum ranges from a cosmetic concern to severe symptoms and skin complications that can significantly impair quality of life. Over recent decades, treatment approaches have evolved dramatically, shifting from traditional surgical stripping to minimally invasive endovenous techniques.

## Anatomy of Superficial Venous System

### Great Saphenous Vein (GSV)

The great saphenous vein originates at the dorsal venous arch of the foot and courses anterior to the medial malleolus. It ascends along the medial aspect of the calf and thigh before terminating at the saphenofemoral junction (SFJ), where it drains into the common femoral vein. At the SFJ, tributaries include the superficial epigastric, superficial circumflex iliac, and external pudendal veins. The GSV is enclosed within the saphenous compartment, a fascial envelope visible as the "eye sign" on ultrasound imaging.

### Small Saphenous Vein (SSV)

The small saphenous vein originates posterior to the lateral malleolus and courses along the posterior midline of the calf. It typically terminates at the saphenopopliteal junction (SPJ), draining into the popliteal vein. Its anatomy is variable; the SSV may extend as the Giacomini vein into the thigh or join other veins. Because the SPJ location varies, preoperative duplex mapping is essential for accurate localization.

### Accessory Saphenous Veins

Accessory saphenous veins include the anterior accessory saphenous vein (AASV), which is a common source of thigh varicosities, and the posterior accessory saphenous vein (PASV). These veins can be the primary source of reflux even when the GSV trunk remains competent.

### Perforating Veins

Perforating veins connect the superficial venous system to the deep venous system by traversing the muscular fascia. They are named according to their anatomical location, such as Cockett perforators in the posterior tibial region, Boyd perforators below the knee, and Dodd or Hunterian perforators in the mid to distal thigh. Pathologic perforators are defined as those with a diameter greater than 3.5 millimeters and outward (superficial-directed) flow lasting more than 0.5 seconds.

<image>Anatomical diagram of the lower extremity superficial venous system showing the great saphenous vein, small saphenous vein, accessory veins, and key perforating vein locations</image>

## Evaluation

### Clinical Assessment

Patients with varicose veins commonly report symptoms such as aching, heaviness, throbbing, pruritus, leg fatigue, and cramping. These symptoms typically worsen with prolonged standing and improve with leg elevation. Physical examination should be performed with the patient standing to visualize varicosities clearly. The distribution of varicosities helps localize the affected venous territory: medial varicosities suggest involvement of the GSV, posterior varicosities implicate the SSV, and lateral thigh varicosities may arise from the AASV or pelvic veins. Skin changes such as pigmentation, eczema, lipodermatosclerosis, and ulceration should be assessed. In women presenting with vulvar or medial thigh varicosities, evaluation for pelvic venous disease is warranted.

### Duplex Ultrasound

Duplex ultrasound is essential prior to any intervention, serving as the roadmap for treatment planning. It is performed with the patient standing or in the reverse Trendelenburg position to optimize venous filling. The examination assesses the SFJ, SPJ, saphenous trunks, tributaries, perforators, and deep veins. Reflux duration, vein diameters, and the competence of venous segments are documented. It is also important to exclude deep venous obstruction or post-thrombotic changes. Mapping the GSV diameter and its depth from the skin is relevant for planning thermal ablation. The "eye sign" on ultrasound refers to the GSV enclosed within the saphenous compartment, aiding in identification.

### Additional Workup

If pelvic venous reflux is suspected, such as in pelvic congestion syndrome or May-Thurner syndrome, CT or MR venography may be indicated. These imaging modalities are also considered in cases of recurrent varicosities after prior treatment. Ankle-brachial index (ABI) measurement is recommended in patients with suspected concurrent peripheral arterial disease.

## Treatment Options

### Conservative Management

Conservative management includes the use of compression stockings with pressures of 15-20 or 20-30 mmHg, along with exercise, weight loss, and leg elevation. This approach is appropriate for patients who decline intervention, those with mild symptoms, or as an adjunct to other treatments. However, conservative measures do not correct the underlying hemodynamic abnormalities causing venous reflux.

### Endovenous Thermal Ablation

#### Endovenous Laser Ablation (EVLA)

Endovenous laser ablation employs laser energy, typically in the 810 to 1470 nanometer wavelength range, delivered via an intraluminal fiber to cause endothelial damage, vein wall contraction, and subsequent fibrosis. Higher wavelengths, such as 1470 nm, used with radial fibers, target the vein wall more precisely, reducing perforation risk, pain, and bruising. The procedure is performed under ultrasound guidance with tumescent local anesthesia. The linear endovenous energy density (LEED) for the GSV is approximately 60-80 joules per centimeter. Anatomic success, defined as vein closure, is achieved in 93 to 97 percent of cases at five years. EVLA offers advantages including outpatient treatment, local anesthesia, and rapid recovery.

#### Radiofrequency Ablation (RFA)

Radiofrequency ablation uses radiofrequency energy to heat the vein wall to approximately 120°C in a segmental fashion, typically with the ClosureFast catheter. Tumescent anesthesia is required. The catheter has a 7-centimeter heating element, delivering energy in 20-second cycles. Closure rates are comparable to EVLA, ranging from 92 to 97 percent at five years. RFA may cause less postoperative pain and bruising than older laser wavelengths. Both EVLA and RFA have demonstrated superiority over surgical stripping in terms of recovery time and equivalent efficacy.

### Non-Thermal Non-Tumescent (NTNT) Techniques

#### Cyanoacrylate Closure (VenaSeal)

Cyanoacrylate closure involves delivering N-butyl cyanoacrylate adhesive intraluminally without the need for tumescent anesthesia, requiring only a single needle stick. The glue polymerizes to seal the vein, and the resulting inflammatory response leads to fibrosis. The VeClose trial demonstrated a 97 percent closure rate at three years, showing non-inferiority to RFA. Advantages include avoidance of tumescent anesthesia, elimination of thermal nerve injury risk, and no requirement for compression stockings post-procedure. However, approximately 10 percent of patients may experience a foreign body reaction such as phlebitis or granuloma. The technique is also limited by cost and the need for further long-term data. It should be avoided in patients with cyanoacrylate allergy.

#### Mechanochemical Ablation (MOCA/ClariVein)

Mechanochemical ablation combines mechanical endothelial damage via a rotating wire tip with simultaneous infusion of a liquid sclerosant, such as polidocanol or sodium tetradecyl sulfate (STS). This technique does not require tumescent anesthesia. Closure rates range from 87 to 95 percent at two to three years, which may be somewhat lower than thermal ablation. MOCA is associated with less pain than thermal methods and carries no risk of thermal nerve injury, an important consideration when treating the SSV near the sural nerve.

<image>Step-by-step illustration of endovenous laser ablation showing catheter insertion, tumescent anesthesia injection, and laser fiber activation with vein wall thermal injury</image>

### Sclerotherapy

#### Liquid Sclerotherapy

Liquid sclerotherapy involves direct injection of sclerosant agents such as sodium tetradecyl sulfate (STS) or polidocanol into veins, causing endothelial damage and fibrosis. It is most effective for treating telangiectasias, reticular veins, and small varicose tributaries. However, it is not recommended as sole treatment for saphenous trunk reflux.

#### Foam Sclerotherapy (Ultrasound-Guided)

Foam sclerotherapy is performed by mixing sclerosant with air or carbon dioxide, typically in a 1:4 ratio using the Tessari method, to create a foam with greater surface contact and potency than liquid sclerosant. This technique can treat saphenous trunks and larger varicosities. Closure rates are lower than thermal ablation, ranging from 70 to 85 percent at three to five years. Risks include visual disturbances resembling migraine, especially in patients with a patent foramen ovale, skin staining, matting, deep vein thrombosis (rare), and stroke (very rare). Foam sclerotherapy is useful for recurrent varicosities, in resource-limited settings, and as an adjunct to other treatments.

### Surgical Treatment

#### High Ligation and Stripping

High ligation and stripping was historically the gold standard treatment, involving ligation of the SFJ with flush division of tributaries and stripping of the GSV to the knee. Higher recurrence rates have been attributed to neovascularization at the SFJ. This approach is associated with more pain, bruising, and longer recovery compared to endovenous techniques. It remains relevant when endovenous ablation is not feasible or for very large, tortuous veins. Preferred stripping techniques include PIN stripping or invagination stripping over traditional methods.

#### Ambulatory Phlebectomy (Stab Avulsions)

Ambulatory phlebectomy involves removal of varicose tributaries through small (2-3 mm) incisions using phlebectomy hooks. It is performed under local anesthesia and often concurrently with saphenous ablation. This technique yields excellent cosmetic results. An alternative is ultrasound-guided foam sclerotherapy of tributaries; the CLASS trial demonstrated equivalent outcomes between these approaches.

| Modality | Mechanism | Tumescent Anesthesia | Closure Rate (3-5 yr) | Key Advantage | Key Limitation |
|----------|-----------|---------------------|----------------------|---------------|----------------|
| EVLA (1470 nm) | Laser thermal injury | Yes | 93–97% | Excellent long-term data; outpatient | Tumescent required; risk of nerve injury below knee |
| RFA (ClosureFast) | Radiofrequency segmental heating | Yes | 92–97% | Less pain than older EVLA; segmental control | Tumescent required; catheter cost |
| Cyanoacrylate (VenaSeal) | Adhesive polymerization | No | ~97% (3 yr) | No tumescent; no compression needed | Foreign body reaction (~10%); cost; limited long-term data |
| MOCA (ClariVein) | Mechanical + sclerosant | No | 87–95% (2-3 yr) | No thermal nerve injury; no tumescent | Lower closure rates; sclerosant-related risks |
| Foam sclerotherapy | Chemical endothelial damage | No | 70–85% | Low cost; useful for recurrence | Lower durability; visual disturbance risk (PFO) |
| High ligation & stripping | Surgical excision | General/regional | 70–85% | Definitive removal | More pain; longer recovery; neovascularization |

### Emerging Techniques

Emerging treatments include steam vein sclerosis (SVS), which uses superheated steam pulses, and endovenous microwave ablation. These remain investigational with limited long-term data available.

<image>Comparison of endovenous treatment modalities: radiofrequency ablation catheter, laser fiber with radial tip, cyanoacrylate delivery system, and mechanochemical ablation device</image>

## Treatment Algorithm

For symptomatic saphenous reflux, endovenous ablation—either thermal or non-thermal non-tumescent—is considered first-line therapy. Tributary varicosities are managed with phlebectomy or foam sclerotherapy, which may be performed concurrently or in a staged fashion. Telangiectasias and reticular veins are treated with liquid or foam sclerotherapy or surface laser therapy. In cases of recurrent varicose veins, duplex mapping is essential to identify the source, and treatment options include foam sclerotherapy or repeat ablation. Percutaneous ablation of incompetent perforators is indicated if clinically significant, especially in patients with advanced skin changes (C5-C6 disease).

## Special Considerations

### Pregnancy-Related Varicosities

Varicose veins develop in up to 40 percent of pregnancies, with most regressing postpartum. Conservative management with compression stockings is recommended during pregnancy. Intervention should be deferred until reassessment three to six months postpartum. Vulvar varicosities usually resolve spontaneously; persistent cases warrant evaluation for pelvic venous insufficiency.

### Recurrent Varicose Veins After Treatment

Recurrence may result from neovascularization, residual or recurrent reflux, new incompetent segments, or progression of disease. Duplex ultrasound imaging is mandatory before retreatment. Foam sclerotherapy is particularly useful for post-surgical recurrence. It is important to assess for missed sources of reflux such as pelvic veins, perforators, or accessory saphenous veins.

## Clinical Pearls

Before treating superficial venous disease, it is critical to scan the deep veins because patients with post-thrombotic syndrome who rely on superficial collaterals may experience worsening symptoms after ablation. The GSV should not be ablated if it may be needed as a bypass conduit in patients with significant peripheral arterial or coronary artery disease; documenting conduit status is essential. Saphenous nerve injury, manifesting as numbness or paresthesia, is more common when treating veins below the knee; therefore, non-thermal non-tumescent techniques should be considered for below-knee GSV and SSV treatment. The sural nerve is at risk during SSV thermal ablation, so ablation should be stopped 2 to 3 centimeters from the SPJ with adequate tumescent anesthesia to minimize injury. Endovenous heat-induced thrombosis (EHIT) refers to thrombus extension from the ablated vein into the deep venous system, classified from I to IV; most cases resolve with observation or short-course anticoagulation. The EVRA trial demonstrated that early endovenous ablation of superficial reflux accelerates venous ulcer healing, emphasizing that treatment should not be delayed in patients with advanced skin changes (C5/C6).

## References
- Gloviczki P, et al. The care of patients with varicose veins and associated chronic venous diseases: clinical practice guidelines of the SVS and AVF. *J Vasc Surg*. 2011;53(5 Suppl):2S-48S.
- Rasmussen LH, et al. Randomized clinical trial comparing endovenous laser ablation, radiofrequency ablation, foam sclerotherapy and surgical stripping for great saphenous varicose veins. *Br J Surg*. 2011;98(8):1079-1087.
- Morrison N, et al. VeClose trial 36-month follow-up: cyanoacrylate closure vs. radiofrequency ablation. *J Vasc Surg Venous Lymphat Disord*. 2019;7(5):637-643.
- Brittenden J, et al. (CLASS trial) A randomized trial comparing treatments for varicose veins. *N Engl J Med*. 2014;371(13):1218-1227.
- Wittens C, et al. Editor's Choice — Management of chronic venous disease: clinical practice guidelines of the ESVS. *Eur J Vasc Endovasc Surg*. 2015;49(6):678-737.