INTRODUCTION — Superficial venous insufficiency can manifest across the entire clinical spectrum from dilated veins (telangiectasias, reticular veins, varicose veins) to advanced chronic venous stasis skin changes and venous ulceration. Venous disease related to axial vein reflux can be isolated to the superficial venous system (great saphenous, anterior saphenous, accessory saphenous, small saphenous veins) or can include concomitant deep vein and perforator vein disease. Identification of superficial axial sources of reflux is important, and when present, treatment should include therapy directed at the source of superficial reflux as well as treatment of the visible symptomatic veins and other manifestations. Superficial venous insufficiency involving the great saphenous vein (GSV), small saphenous vein (SSV), and other nonaxial superficial veins is very amenable to treatment.
The approach to treating patients with symptomatic chronic venous disease and duplex ultrasound confirmed superficial vein reflux is reviewed. The overall approach to the patient with clinical manifestations of chronic venous disease, including those with deep vein insufficiency, is presented separately. (See "Overview of lower extremity chronic venous disease".)
INITIAL ASSESSMENT — Initial assessment should include evaluating the clinical severity of chronic venous disease, the anatomic location of reflux based on venous duplex ultrasound testing, the response to initial nonoperative measures to manage chronic venous disease and the effect of the venous disease on the patient's quality of life, and the patient's risk factors for venous thrombosis, along with an overall medical assessment, which should be performed to identify potential contraindications to venous ablation therapies. (See "Overview of the causes of venous thrombosis" and 'Contraindications to ablation therapies' below and "Diagnostic evaluation of lower extremity chronic venous insufficiency".)
Clinical severity — Superficial venous insufficiency can manifest across the entire clinical spectrum from dilated veins (telangiectasias, reticular veins, varicose veins) to advanced chronic venous stasis skin changes and venous ulceration (table 1). (See "Clinical manifestations of lower extremity chronic venous disease" and "Classification of lower extremity chronic venous disorders".)
Symptoms can include pain, leg heaviness or aching, swelling, dry skin, tightness, skin irritation, heaviness, muscle cramps, and itching. Physical findings may include any one or all of the following.
●Telangiectasias and reticular veins (CEAP [Clinical, Etiologic, Anatomic, Pathophysiologic] category 1) are dilated intradermal and subdermal veins, respectively (picture 1 and picture 2).
●Varicose veins (CEAP category 2) are dilated, elongated, tortuous, subcutaneous veins 3 mm or greater in diameter (picture 3A-B). They may involve the saphenous veins (great or small) (figure 1A-B), saphenous tributaries, or nonsaphenous superficial leg veins.
●Patients with signs and symptoms of edema (picture 4), chronic venous skin changes (picture 5), or ulceration (CEAP categories C3, C4, C5, and C6) (picture 6) are regarded as having advanced clinical manifestations of venous disease [1].
While the CEAP classification provides categorical severity, the revised Venous Clinical Severity Score (rVCSS) (calculator 1) is a more sensitive measure of response to treatment over time, and both should be used in combination to assess change in severity over time and with intervention.
Response to initial measures — Whether to offer venous ablation to symptomatic patients with duplex ultrasound confirmed superficial vein reflux depends upon the response to initial measures, ongoing symptoms, patient expectations, and likelihood that treatment would provide a durable benefit either with respect to appearance or improvement in symptoms [2].
Initial management includes:
●Leg elevation, exercise, and compression therapy improve oxygen transport to the skin and subcutaneous tissues, decrease edema, reduce inflammation, and compress dilated veins. Some patients have contraindications to compression therapy or may not tolerate compression. (See "Medical management of lower extremity chronic venous disease", section on 'General measures' and "Medical management of lower extremity chronic venous disease", section on 'Compression therapy' and "Compression therapy for the treatment of chronic venous insufficiency", section on 'Static compression therapy'.)
●Skin changes ("stasis dermatitis") respond to topical dermatologic agents. (See "Medical management of lower extremity chronic venous disease", section on 'Skin care'.)
●Venous ulceration is treated with a combination of ulcer wound management and compression therapy (stockings, bandaging systems). (See "Medical management of lower extremity chronic venous disease", section on 'Ulcer care'.)
●Systemic therapy may be beneficial for patients with symptoms that are refractory to compression therapy or who are unable to tolerate compression therapy. (See "Medical management of lower extremity chronic venous disease", section on 'Pharmacologic therapy'.)
Although compression therapy and the other measures listed are appropriate first-line treatments to manage symptoms associated with chronic venous disease, they do not provide a definitive treatment of superficial venous insufficiency. However, for many patients, stockings control mild symptoms and avoid intervention, and many insurance companies require a trial of initial conservative care. Thus, initially, symptomatic patients are generally treated with nonoperative measures for a few weeks to months (may vary depending on insurance provider), prior to offering ablation therapy.
Quality of life — Generic quality of life assessments, such as short form-36 (SF-36), and venous-specific quality of life measurements, such as the Venous Insufficiency Epidemiologic and Economic Study-Quality of Life/Symptoms (VEINES-QOL/Sym), Aberdeen Varicose Vein Questionnaire, Chronic Venous Insufficiency Questionnaire (CIVIQ), and Charing Cross Venous Ulceration Questionnaire (CXVUQ), can greatly augment other outcome measurement tools like CEAP and rVCSS. Using vein-specific quality of life assessment tools can be used to document patient-oriented factors that, combined with CEAP and rVCSS, can provide a more complete picture of change with both nonoperative measures and venous intervention.
SUPERFICIAL VENOUS INTERVENTION
Candidates — Candidates for venous ablation are patients with persistent symptoms/signs of venous disease (dilated veins, skin changes, ulceration) and documented saphenous vein reflux (ie, retrograde flow >0.5 second duration for the superficial axial veins) as a source of their symptoms.
The goals of venous ablation in patients with symptomatic superficial venous disease are improvement in symptoms as well as appearance. Venous ablation is thought to produce beneficial effects by reducing venous volume in the limb and thereby the effects of venous hypertension on the cutaneous tissues [3].
When combined saphenous and perforator reflux are identified, saphenous reflux is treated first. Perforator reflux often resolves following saphenous ablation [4]. Persistent perforators identified by duplex ultrasound following saphenous ablation can be managed concurrently with phlebectomies as needed, or at a later time with ultrasound-guided sclerotherapy or endovenous methods.
Options — Several venous ablation techniques, including minimally invasive and surgical methods, are available and are classified by their method of vein destruction: chemical, thermal, or nonthermal (ie, mechanical, chemical). Combination treatments (eg, mechanochemical) have also been described [5,6]. The choice of most appropriate intervention for superficial vein reflux depends on the size and location of the involved veins. Treatment goals include improvement of symptoms and appearance, reduction of edema, improvement in skin changes, and healing of ulcers. When offered, superficial venous reflux should be treated by ablation before, or in conjunction with, the management of visibly dilated veins [7]. (See 'Residual veins following ablation' below.)
Thermal ablation — Thermal ablation involves generation of heat at a temperature high enough to denature the proteins that constitute the vein wall. This can be accomplished with radiofrequency energy, or with laser light introduced into the lumen of an incompetent vein (great saphenous, small saphenous) using specialized catheters to effect closure (figure 1A-B). The use of steam has also been described [8]. Because of the need for heat generation to effectively ablate the vein, additional infiltration of tumescent anesthesia (local anesthetic saline mixture) is required to reduce pain along the saphenous vein and provide a cold buffer from the heat generated by the laser or radiofrequency energy. These techniques are discussed in more detail in separate topic reviews:
●(See "Techniques for radiofrequency ablation for the treatment of lower extremity chronic venous disease".)
Nonthermal ablation — Nonthermal ablation techniques are also available. Because there is no heat, nonthermal ablation has the advantage of avoiding any discomfort associated with tumescent infiltration, and there is a decreased likelihood for adjacent nerve injury. (See "Comparison of methods for endovenous ablation for chronic venous disease".)
Nonthermal techniques include:
●Mechanical occlusion chemically assisted (MOCA) ablation – Uses both mechanical damage to vein endothelium with a rotating wire and simultaneous chemical injury with installation of a liquid sclerosant. (See "Nonthermal, nontumescent ablation techniques for the treatment of lower extremity superficial venous insufficiency", section on 'Mechanochemical ablation'.)
●Cyanoacrylate embolization – Using catheter access, a glue is delivered into the saphenous vein that induces a foreign body reaction leading to inflammation and fibrotic occlusion of the vessel. (See "Nonthermal, nontumescent ablation techniques for the treatment of lower extremity superficial venous insufficiency", section on 'Cyanoacrylate adhesive closure'.)
●Polidocanol endovenous microfoam (PEM) – PEM uses a proprietary gas mixture of O2:CO2 (65:35) with 1% polidocanol solution within a pressurized sterile canister to create uniform microfoam bubbles that can be delivered into the saphenous vein under ultrasound guidance. (See "Nonthermal, nontumescent ablation techniques for the treatment of lower extremity superficial venous insufficiency", section on 'Sclerotherapy'.)
Saphenous vein ligation/stripping — Saphenous vein ligation and division refers to detachment of the great saphenous vein (GSV) through a small oblique groin incision at its confluence with the saphenofemoral junction and common femoral vein. The incision is usually located along the groin crease, and all tributaries at the saphenofemoral junction are ligated to prevent persistent superficial venous flow directly into the femoral vein and potential for recurrent reflux and varicosities. Flush ligation of the GSV at the saphenofemoral junction without narrowing of the femoral vein is performed to avoid a residual GSV stump as a potential source for thromboembolism. Stripping refers to removal of an extended segment of the GSV either with external stripper, intraluminal stripper (such as Codman or Myer), or perforation-invagination (PIN) stripper (such as Oesch). (See "Open surgical techniques for lower extremity vein ablation", section on 'Techniques'.)
Most GSV reflux patterns include the thigh segment, which is most routinely included in stripping. GSV stripping below the knee is rarely performed to avoid possible saphenous nerve injury, unless it is obviously incompetent with clinically significant reflux or in the setting of recurring calf varicosities. For the most part, saphenous vein ligation, division, and stripping has been replaced by ablation techniques as described above, but it may still be an option in select cases where ablation is not an option.
Anatomic limitations for endovenous ablation — Anatomic constraints that limit the ability to perform an endovenous procedure include the following:
●Chronic or recurrent phlebitis in the target vein, since formation of synechiae in the vein can prevent passage of the endovenous sheath or catheter.
●Severe tortuosity in which passage of the device may not be possible.
●Target veins that are not at least 1 cm deep to the skin dermis after tumescent anesthesia is administered. Ablation of veins closer to the skin may lead to skin burns.
●Large veins (>1.0 cm) have a high risk of nonclosure, but successful closure has been reported. Alterations in technique can be used to manage larger veins. However, saphenous veins with very large diameters at the saphenofemoral junction may be a risk factor for endovenous heat-induced thrombus.
Contraindications to ablation therapies — Contraindications to lower extremity endovenous ablation generally include the following [9-12].
●Acute deep venous thrombosis – Endovenous ablation is contraindicated in patients with acute deep vein thrombosis due to the risk of developing a new thromboses [13].
●Superficial vein thrombophlebitis – Endovenous ablation generally should not be performed in patients who have signs of acute superficial vein thrombosis due to the increased risk of deep venous thrombosis and/or thromboembolism. However, case reports have documented potential benefit from early endovenous ablation in patients with superficial vein thrombosis of the distal great saphenous vein with a thrombus-free segment proximally. In such circumstances, passing the catheter through the clot should be avoided.
●Pregnancy – Pregnant patients should defer vein treatments until at least six weeks after delivery due to prothrombotic risk and postpartum hormonal changes.
●Caution in patients with deep venous insufficiency – Patients with combined deep and superficial venous insufficiency are often not good candidates for venous ablation therapies (endovenous, surgical) due to coexisting medical issues. In this population, varicose vein recurrence and ulcer recurrence rates following intervention are much higher. Because of this and also the potential for the development of nonhealing ulcers, dilated veins in patients with isolated deep venous reflux are generally managed medically. However, in several studies, deep vein reflux was noted to resolve following saphenous removal, and aggressive management should be considered in patients with refractory symptoms or skin changes, persistent ulcer, or recurrent ulcer [14,15].
●Moderate-to-severe peripheral artery disease – Peripheral artery disease (PAD) is a relative contraindication to venous ablation (endovenous, surgical) because of the increased risk for nonhealing wounds. Patients with lower extremity ulceration should be assessed to ensure the adequacy of the arterial circulation since patients with chronic venous disease complicated with ulceration can have coexistent PAD. An appropriate history and ankle brachial index ≤0.9 identifies patients with PAD. If the arterial circulation is inadequate for wound healing (ankle-brachial index [ABI] <0.5, absolute ankle pressure <60 mmHg), the arterial disease should be addressed prior to treating the venous disease. Patients with mixed arterial/venous ulcers are difficult to manage, and the patient should be referred to a vascular specialist. While less common, if there is decreased perfusion due to nonatheromatous vascular diseases (eg, popliteal entrapment, adventitial cystic disease), these arterial disorders should be addressed first prior to any venous interventions.
●Klippel-Trenaunay syndrome or other congenital venous abnormalities – Patients with congenital venous abnormalities (eg, Klippel-Trenaunay syndrome, Parkes Weber syndrome) should generally not undergo ablation of major superficial veins except for special circumstances and depending on the status of the deep system. Selected patients may, however, benefit from localized management of symptomatic segments (sclerotherapy, stab phlebectomy). (See "Open surgical techniques for lower extremity vein ablation", section on 'Ambulatory phlebectomy'.)
●Other conditions that limit quality of life improvements – Disease that limits the potential improvement in quality of life expected following venous intervention such as advanced generalized systemic disease or other conditions that interfere with mobility (eg, joint disease) contraindicate venous ablation.
EFFICACY AND SELECTION OF ABLATION METHOD
Minimally invasive ablation versus surgery — For patients with axial vein reflux who elect to proceed with venous ablation, based on randomized trials and meta-analyses that demonstrate an overall benefit, minimally invasive endovenous ablation (specifically thermal methods) is recommended rather than surgical stripping. Although long-term outcomes (recanalization, recurrence) are similar, immediate postoperative outcomes (pain scores, blood loss, return to activity) are improved for endovenous ablation. The efficacy of endovenous methods, in general, compared with surgery is discussed in the sections below. A comparison of the various nonsurgical methods of venous ablation are discussed in more detail separately (table 2). (See "Comparison of methods for endovenous ablation for chronic venous disease".)
Varicose veins — Meta-analyses comparing surgery with minimally invasive ablation therapies have concluded that minimally invasive therapies appear to be at least as effective as surgical excision, with long-term success rates of 78 to 84 percent [16-20]. However, postoperative pain is generally less and return to work quicker with minimally invasive therapies, compared with surgery [21]. Minimally invasive procedures are also generally associated with fewer complications. In one trial, each of the groups showed significant improvements in quality of life scores, and 84.3 percent of treated patients had improved CEAP (Clinical, Etiologic, Anatomic, Pathophysiologic) clinical category following treatment, although vein closure rates varied at one year (highest at 88.5 percent for endovenous laser ablation, followed by 88.2 percent for conventional surgery, and 72.2 percent for foam sclerotherapy) [22].
A later trial involving 798 participants with primary varicose veins compared the outcomes of surgical ablation, laser ablation, and foam sclerotherapy [23]. Clinical success was similar between the groups, but successful saphenous ablation was less common for foam sclerotherapy compared with surgery. No significant differences were found for quality of life. The frequency of serious adverse events (approximately 3 percent) was similar among the groups. A trial comparing saphenous vein high ligation plus phlebectomy with endovenous laser ablation reported follow-up to five years, at which time there were no significant differences in rates of recurrent varicose veins or reoperation [24].
Persistent ulceration — The majority of patients with chronic venous ulcers exhibit some degree of venous reflux; up to 20 percent of patients with venous ulceration have isolated saphenous incompetence [25]. Whether early ablation of superficial reflux alters outcomes is debated. Elimination of saphenous reflux lowered recurrence rates and improved healing rates compared with compression therapy alone in some studies [26-33]. Patients with primary venous etiologies generally benefit to a greater extent compared with secondary etiologies (ie, postthrombotic). (See "Overview of lower extremity chronic venous disease", section on 'With deep venous reflux'.)
Two trials have evaluated venous ulcer healing in response to superficial venous ablation therapies:
●In the Effect of Surgery and Compression on Healing and Recurrence (ESCHAR) study, ulcer healing rates and time to healing were not significantly different for surgical superficial venous ablation compared with compression alone; however, ulcer recurrence with up to four years' follow-up was significantly lower [28,30]. This study unfortunately had a high number of patients lost to follow-up.
●A later multicenter trial from the United Kingdom randomly assigned 450 patients with venous leg ulcers and proven superficial vein reflux to compression therapy plus early endovenous ablation within two weeks, or compression therapy alone with ablation at six months if the ulcer remained unhealed [32]. Early ablation resulted in a shorter median time to healing (56 versus 82 days), and more patients healed their ulcers at 24 weeks (86 versus 76 percent) and at one year (94 versus 86 percent), but there were no differences in quality of life measures. Among those with healed ulcers at one year, the rate of ulcer recurrence was lower for early compared with deferred intervention (11.4 versus 16.5 percent). Foam sclerotherapy predominated as the method of venous ablation. Whether thermal ablation methods (ie, laser, radiofrequency) would result in different rates of ulcer healing or recurrence, particularly given better rates of vein occlusion compared with sclerotherapy, requires additional study.
Specific ablation sites — Both thermal and nonthermal endovenous ablation techniques can be used in any saphenous vein, but there may be preferred techniques based on anatomic location, size of vein, length of refluxing segment, tortuosity of vein, and proximity to deep venous system (table 2). (See "Comparison of methods for endovenous ablation for chronic venous disease", section on 'Best options by anatomic location'.)
●Great saphenous vein – All techniques can be used to adequately treat the great saphenous vein (GSV). Radiofrequency or laser ablation have the most established supporting evidence and are considered the standard to which other endovenous techniques are compared. Mechanochemical ablation (MOCA) and cyanoacrylate glue have excellent closure rates and a low incidence of complications but are newer with less established supporting evidence and are more expensive to perform.
Polidocanol endovenous microfoam (PEM) may be the best choice for a very tortuous GSV but must be used carefully to avoid inadvertent extravasation into the deep vein system, which can lead to complications. In addition, several treatment sessions may be needed to effect complete closure of the target vein(s).
●Small saphenous vein – Nonthermal ablation techniques are attractive for the small saphenous vein by avoiding heat-induced nerve injury, but thermal ablation can be safely used, provided care is taken to avoid injury to the sural nerve by using tumescent infiltration and lower energy delivery. PEM (ie, Varithena) has not been approved in the United States for use in the small saphenous vein.
●Anterior saphenous veins – The anterior accessory vein is often short and of large diameter. If there is an adequate length for treatment, radiofrequency or laser ablation may be the best choice, with the use of higher energy settings increasing the likelihood of vein closure. However, some studies have noted that the anterior accessory vein is more likely to recanalize after thermal ablation [34]. Nonthermal options may also be considered, although supporting evidence is still evolving. For patients with a very short length anterior accessory vein, or after endovenous failure, open ligation and stripping may be the more appropriate choice if there is not enough safe distance to the saphenofemoral junction.
Residual veins following ablation — The timing of treatment of significant symptomatic varicose veins includes microphlebectomy or sclerotherapy at the same time as venous ablation, or as deferred treatment [16-24,35].
The main advantage of performing venous ablation procedures with concomitant treatment is a reduction in the overall treatment time. The advantage of waiting four to six weeks following venous ablation is that some of the smaller veins may regress and any residual veins tend to be smaller and may be more amenable to injection sclerotherapy instead of phlebectomy; in many cases, no further treatment is needed. This effect is due to reduced venous pressure in the tributaries of the ablated saphenous vein. Studies evaluating the various approaches are presented separately.
Management of larger varicosities can also be delayed; however, because these larger varicose veins may not fully regress, particularly those locations on the thigh, concurrent phlebectomy with the ablation procedure may be preferred. (See "Open surgical techniques for lower extremity vein ablation".)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Chronic venous disorders".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topics (see "Patient education: Varicose veins and other vein disease in the legs (The Basics)" and "Patient education: Vein ablation (The Basics)")
●Beyond the Basics topic (see "Patient education: Lower extremity chronic venous disease (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
●Initial treatment for most patients with chronic venous disease is conservative and includes leg elevation, exercise, and compression therapy. (See 'Response to initial measures' above.)
●For patients with persistent symptoms and signs of venous disease (visibly dilated veins, skin changes, or ulceration) and documented superficial venous reflux as a source of their symptoms, we suggest superficial venous ablation, rather than ongoing conservative care (Grade 2B). Options for superficial venous ablation include minimally invasive thermal or nonthermal ablation, and surgical methods. The goals of treatment are improved symptoms and appearance. (See 'Options' above and 'Efficacy and selection of ablation method' above.)
●Contraindications to venous ablation therapies include deep vein thrombosis, thrombophlebitis, pregnancy, peripheral artery disease, Klippel-Trenaunay syndrome or other congenital venous abnormalities, and other conditions that limit expected quality of life improvements. (See 'Contraindications to ablation therapies' above.)
●For patients who are candidates for superficial venous ablation who elect to proceed, we recommend minimally invasive endovenous ablation, rather than surgical ligation/stripping (Grade 1B). Although long-term outcomes (recanalization, recurrence) are similar, immediate postoperative outcomes (pain scores, blood loss, return to activity) are improved for endovenous ablation. For the great saphenous vein, we prefer thermal ablation techniques (ie, radiofrequency ablation, endovenous laser ablation), rather than sclerotherapy. Thermal ablation techniques are highly successful in achieving vein closure and have lower rates of recurrence and higher patient-reported quality of life long-term. However, sclerotherapy may be useful for tortuous veins. Alternative ablation techniques include mechanochemical ablation (MOCA) and glue; however, the long-term outcomes of these are not established. (See 'Minimally invasive ablation versus surgery' above.)
●For symptomatic patients with telangiectasias, reticular veins, and varicose veins and documented saphenous reflux as a source of their symptoms, we suggest saphenous venous ablation before treatment of the visibly dilated veins, rather than afterward or not at all (Grade 2C). Management of saphenous reflux decreases vein recurrence rates. (See 'Residual veins following ablation' above.)
●Following management of superficial venous reflux, we suggest sclerotherapy as an initial treatment for residual lower extremity telangiectasias, reticular veins, and small varicose veins, rather than laser therapy (Grade 2B). Sclerotherapy improves clearance of treated veins. Laser therapy is the only option for treatment of telangiectasias too small to access, patients allergic to sclerosing agents or afraid of needles, or those who have failed sclerotherapy. (See 'Residual veins following ablation' above.)
