Approach to treating symptomatic superficial venous insufficiency

INTRODUCTION — Superficial venous insufficiency manifests across the entire clinical spectrum from dilated veins (telangiectasias, reticular veins, varicose veins) to chronic venous stasis skin changes or venous leg ulceration. Venous insufficiency, or reflux, is defined as a prolonged duration of retrograde flow on ultrasound (table 1) and leads to chronic venous hypertension. Superficial venous insufficiency can involve the superficial axial venous system (eg, great saphenous, anterior saphenous, accessory saphenous, small saphenous veins) or nonaxial superficial veins. Some patients may have concomitant deep venous insufficiency or venous perforator insufficiency.

Identification of superficial venous reflux is important, and when present, treatment should be directed at the superficial axial vein that is the source of venous hypertension, as well as treatment of the visible symptomatic veins or other manifestations. Superficial venous insufficiency 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 and extent of venous reflux based on venous duplex ultrasound testing, the effect of the venous disease on the patient's quality of life, and the response to initial nonoperative measures to manage chronic venous disease. In addition, the patient's risk factors for venous thrombosis, along with an overall medical assessment, should be performed to identify potential contraindications to venous ablation therapies. (See "Overview of the causes of venous thrombosis" and 'Contraindications' below and "Diagnostic evaluation of lower extremity chronic venous disease", section on 'Venous duplex ultrasound'.)

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 2). (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 superficial venous ablation to symptomatic patients with duplex ultrasound-confirmed superficial venous reflux depends upon the response to initial measures, ongoing symptoms, patient expectations, and the 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 to 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 "Compression therapy for the treatment of chronic venous insufficiency", section on 'Static compression therapy'.)

●Skin changes ("stasis dermatitis") respond to topical dermatologic agents. (See "Stasis dermatitis", section on 'Acute disease'.)

●Venous ulceration is treated with a combination of ulcer wound management and compression therapy (stockings, bandaging systems). (See "Evaluation and management of chronic venous insufficiency including venous leg ulcer", 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 "Overview of lower extremity chronic venous disease", section on 'Symptomatic'.)

●Identification of venous thromboembolic risk factors and appropriate reduction of risk important. Other risk factors such as immobility, obesity, malignancy, pregnancy, hypercoagulable conditions, surgery, trauma, or other chronic medical disabilities should be managed in conjunction with venous disease. For patients with prior deep venous thrombosis, management may include anticoagulation. (See "Overview of the causes of venous thrombosis".)

Addressing obesity with weight loss and potentially surgery has been shown to improve venous insufficiency [3]. (See "Obesity in adults: Overview of management".)

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 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, 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.

CANDIDATES FOR VENOUS INTERVENTION — For most patients with persistent symptoms/signs of chronic venous disease (dilated veins, skin changes, ulceration) and documented saphenous venous reflux (ie, retrograde flow >0.5 second duration for the superficial axial veins (table 1)) as a source of their symptoms, we suggest superficial venous ablation rather than continuing long-term compression therapy. The goals of venous intervention include improvement of symptoms and appearance, reduction of edema, improvement in skin changes, and healing of ulcers. Venous intervention produces beneficial effects by reducing venous volume in the limb and thereby the effects of venous hypertension on the cutaneous tissues [4].

The updated 2022 Society for Vascular Surgery/American Venous Forum/American Vein and Lymphatic Society clinical practice guidelines for management of varicose veins of the lower extremities provide a framework for clinical decision making for patients with superficial venous reflux [5,6]. There has also been attention given to overutilization of some venous interventions. The 2020 Appropriate Use Criteria for Chronic Lower Extremity Venous Disease of the American Venous Forum, the Society for Vascular Surgery, the American Vein and Lymphatic Society, and the Society of Interventional Radiology has provided additional guidance in treatment of superficial venous insufficiency based on methodology using expert determination of clinical appropriateness [7].

Visibly dilated and varicose veins — For most patients with symptomatic varicose veins and axial reflux in the great or small saphenous vein as the source of venous hypertension, we suggest venous intervention rather than long-term compression therapy without intervention. Options for superficial venous ablation include minimally invasive thermal or nonthermal ablation and surgical methods. (See 'Intervention for axial vein reflux' below.)

Surgical vein ablation is the standard to which minimally invasive therapies have been compared [8-11]. Surgical intervention was shown to improve symptoms and appearance compared with conservative management, and the majority of patients are generally satisfied [12-16]. The cost effectiveness of treatment for patients with severe varicose veins and reflux compared with conservative management was evaluated for surgical therapy in a randomized trial of 250 patients [17]. Venous ablation (surgical) improved outcomes (quality of life, symptomatic relief, and anatomic extent) and was cost effective at two years, with a projected cost benefit out to 10 years. Minimally invasive endovenous techniques offer significant advantages, such as a lack of a groin incision, less postoperative pain, less blood loss, and quicker return to activity [18-31]. However, less invasive methods may be associated with a higher incidence of varicose vein recurrence [32,33]. Nevertheless, for the majority of patients, chronic venous disease can be effectively managed using minimally invasive endovenous techniques [34,35].

Skin changes and venous leg ulcer — 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 [36]. The evaluation and management of patients with chronic venous insufficiency and venous leg ulcer is reviewed separately. (See "Evaluation and management of chronic venous insufficiency including venous leg ulcer".)

Superficial venous ablation may produce a beneficial effect by reducing venous reflux from the deep to the superficial veins, thereby modifying the effect of venous hypertension on the cutaneous tissues [37]. Superficial vein excision has also been shown to reduce reflux in the deep veins [38-40]. Early, rather than later, ablation of superficial reflux appears to improve outcomes [41].

Surgical and endovenous ablation (thermal, nonthermal) have both been compared with conservative management, but there are few comparisons among the various techniques [42-44]. Although surgical vein excision does not speed the rate of ulcer healing, ulcer recurrence is significantly reduced compared with compression therapy alone [45-49]. With nonsurgical ablation, elimination of saphenous reflux has also lowered recurrence rates compared with compression therapy alone, and in some studies, also improved healing rates [41,50,51]. Patients with primary venous etiologies generally benefit to a greater extent compared with secondary etiologies (ie, postthrombotic).

Two trials have evaluated venous ulcer healing in response to saphenous vein stripping and endovenous ablation:

●The Effect of Surgery and Compression on Healing and Recurrence (ESCHAR) trial randomly assigned 500 patients with open or recently healed ulcers, and evidence for reflux, to compression therapy alone (multilayer) or compression therapy plus surgery (saphenous ligation or removal and nonsaphenous vein excision) [47]. 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 [47,49]. This study unfortunately had a high number of patients lost to follow-up.

●A 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 [41]. 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.

Contraindications — Contraindications to lower extremity venous ablation generally include the following [52-55]:

●Acute deep venous thrombosis – Endovenous ablation is contraindicated in patients with acute deep vein thrombosis due to the risk of developing new thrombus [56].

●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 thrombus 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 due to coexisting medical issues, especially if there is remnant postthrombotic occlusion in the deep system from prior deep vein thrombosis. In this population, although there may be symptomatic improvement, with ongoing deep venous reflux still present, varicose vein recurrence and ulcer recurrence rates following intervention are 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. Operative management should be considered in patients with refractory symptoms or skin changes, persistent ulcer, or recurrent ulcer only if superficial venous reflux or obstructive pattern appropriate for intervention [39,57]. (See "Evaluation and management of chronic venous insufficiency including venous leg ulcer", section on 'Venous intervention' and "Evaluation and management of chronic venous insufficiency including venous leg ulcer", section on 'Ulcer recurrence'.)

●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 (ABI) ≤0.9 identifies patients with PAD. If the arterial circulation is inadequate for wound healing (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 'Ambulatory phlebectomy' below.)

●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.

INTERVENTION FOR AXIAL VEIN REFLUX — 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, mechanochemical [58,59]). The choice of most appropriate intervention for superficial axial vein reflux depends on the size and location of the involved veins (algorithm 1 and algorithm 2). When offered, superficial axial vein reflux should be ablated before, or in conjunction with, the management of visibly dilated veins [60]. (See 'Treatment timing' below.)

Endovenous options — Endovenous options for treating axial venous reflux are broadly grouped into thermal ablation and nonthermal ablation techniques. A comparison of the various nonsurgical methods of venous ablation (thermal, nonthermal) are discussed in more detail separately (table 3). (See "Comparison of methods for endovenous ablation for chronic venous disease".)

●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 [61]. 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".)

•(See "Techniques for endovenous laser 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".)

The US Food and Drug Administration approved 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'.)

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, catheter or foam.

●Severe tortuosity in which passage of an endovenous device may not be possible.

●Target veins that are not at least 1 cm deep to the skin dermis after tumescent anesthesia is administered. Thermal ablation of veins closer to the skin may lead to skin burns.

●Large veins (>1.0 cm) have a 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.

Surgical options — With the introduction of the minimally invasive methods of vein ablation discussed above, surgical options, such as saphenous ligation with or without stripping and other techniques (eg, conservative venous ligation [CHIVA]), are less commonly used. Among the open surgical techniques, great saphenous vein (GSV) ligation and stripping is the preferred technique for patients with reflux and varicose veins in the GSV distribution. The role of phlebectomy to manage residual varicose veins in conjunction with or following great saphenous stripping is discussed below. (See 'Treatment of residual veins and varicosities' below.)

●Saphenous ligation with stripping – For the most part, saphenous vein ligation, division, and stripping has been replaced by minimally invasive ablation techniques, but it may still be an option in select cases where minimally invasive ablation is not an option. 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 stripper (such as Oesch). With ligation and stripping, the risk of recanalization is low because the treated veins are removed; however, enlargement of other veins in the extremity can occur over time [17,62-65]. In randomized trials, venous ligation plus stripping has lower recurrence rates compared with venous ligation alone [66,67]. Most GSV reflux patterns include the thigh segment, which is 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 recurrent calf varicosities. With stripping limited stripping to the level of the knee, persistent reflux can lead to enlarging veins emanating from the saphenous remnant [33,34,68].

●Saphenous ligation without stripping – Saphenous vein ligation and division (without stripping) refers to detachment of the GSV at its confluence with the saphenofemoral junction and common femoral vein. 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. Ligation of the saphenous vein at the saphenofemoral junction alone, without vein removal, is not usually performed alone due to the high rate of recurrent varicose veins and persistent symptoms [66,69,70]. High ligation alone can also be complicated by the development of superficial thrombophlebitis in the saphenous vein distal to the site of ligation. However, high ligation of the saphenous vein is occasionally appropriate for selected patients who develop proximal superficial phlebitis that encroaches on the saphenofemoral junction and have a contraindication to anticoagulation [71]. For small saphenous vein reflux, ligation and division at the saphenopopliteal junction can be done with or without vein removal. Limited partial vein excision is preferred over complete stripping to avoid sural nerve injury. (See "Superficial vein thrombosis and phlebitis of the lower extremity veins".)

●CHIVA — CHIVA (conservative venous ligation; Conservatrice et Hémodynamique de l'Insuffisance Veineuse en Ambulatoire) is a method that aims to disrupt the column of hydrostatic pressure by disconnecting points of venous reflux while preserving venous drainage [72-77]. The saphenofemoral or saphenopopliteal junction is ligated and divided but not removed (ie, stripped). Additional sites for ligation are identified with duplex ultrasound and clinical examination. A systematic review identified four randomized trials comparing CHIVA with vein stripping (n = 721). In two trials that evaluated varicose vein recurrence (follow-up of 3 to 10 years), the pooled estimate for the risk of recurrence was significantly lower for the CHIVA method compared with vein stripping (relative risk 0.63, 95% CI 0.51-0.78) [76].

For each of these surgical options, the GSV in the groin is accessed. To expose the GSV, a small transverse incision (1 to 2 cm depending on body habitus) is made along the groin crease over the saphenofemoral junction, which is usually located 2 to 3 cm peripheral and lateral to the pubic tubercle. Ultrasound may be used preoperatively to mark the precise location. The junction of the GSV with the common femoral vein (ie, saphenofemoral junction) is identified and isolated. Anteromedial and posterolateral tributaries are ligated and divided to prevent persistent superficial venous flow directly into the femoral vein and potential for recurrent reflux and varicosities. However, tributaries draining the abdominal wall are preserved. In one trial, preservation of the abdominal wall tributaries was associated with lower rates of clinical and ultrasound-detected varicose vein recurrence [69]. The GSV is ligated near its junction with the common femoral vein and if the vein will be stripped, it is divided [69].

To strip the GSV, the vein stripper is passed retrograde through the open end of the divided vein distally toward the foot. Due to the incompetence of the vein valves, the stripper should pass easily. A small skin incision is made over the tip of the stripper, which is palpated through the skin, usually near the knee joint. After incising the skin, a forceps is used to grasp the stripper and pull it through the incision. In the groin, the stripper is securely tied to the vein. The author prefers not to use the mushroom tips supplied with the typical stripper because excessive tissue trauma and bleeding can result. The vein inverts on itself, and the vein is removed by pulling the stripper toward the foot. Tributary veins that are tethering the vein are disrupted. Once hemostasis is achieved by direct pressure along the vein bed, the groin incision is closed in layers with interrupted, absorbable suture.

Similar techniques can be used to treat the small saphenous vein. Care must be taken to avoid injury to the adjacent structures during dissection in the popliteal fossa or the sural nerve when stripping.

Endovenous versus surgical ablation — For appropriate candidates who elect to proceed with axial vein ablation, based on randomized trials and meta-analyses that demonstrate an overall benefit, we agree with evidence-based guidelines that recommend minimally invasive endovenous axial vein ablation (specifically thermal methods) rather than surgical stripping [5,7]. Although long-term outcomes (recanalization, recurrence) are similar, immediate postoperative outcomes are improved for endovenous ablation.

Technique selection by axial vein — There are several acceptable options for endovenous ablation at most anatomic sites (table 3), but a particular technique may be preferred based on anatomic location, diameter of vein, length of refluxing segment, vein tortuosity, and proximity to deep venous system. (See 'Endovenous options' above and 'Surgical options' above.)

When combined saphenous and perforator reflux are identified, saphenous reflux is treated first; perforator reflux often resolves following saphenous ablation [45]. Persistent perforators identified by duplex ultrasound following saphenous ablation can be managed concurrently with phlebectomies as needed, or later with ultrasound-guided sclerotherapy or endovenous methods.

Great saphenous vein — All the techniques discussed above can all be used to adequately treat the GSV; for most patients, we suggest minimally invasive endovenous ablation when equipment and expertise are available, rather than surgical ligation/stripping. We further suggest thermal ablation techniques (ie, radiofrequency ablation, endovenous laser ablation) rather than nonthermal ablation techniques (eg, sclerotherapy, mechanochemical ablation [MOCA], glue) for managing great saphenous reflux above the knee. Thermal ablation techniques have lower rates of recurrence and higher patient-reported quality of life in the long-term. Radiofrequency ablation has the most established record and is considered the standard to which other endovenous techniques are compared.

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 [78-82]. Compared with endovenous techniques, varicose vein recurrence in the groin region is significantly improved for open surgery (7 versus 31 percent at five years, in one study [83]); however, this does not necessarily translate to any difference in venous symptoms, Comprehensive Classification System for Chronic Venous Disorders staging (ie, CEAP (table 2)), or other quality-of-life measures. Compared with surgery, postoperative pain is generally less and return to work is quicker with minimally invasive therapies [84].

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) [85]. A later trial involving 798 participants with primary varicose veins compared the outcomes of surgical ablation, laser ablation, and foam sclerotherapy [86]. Clinical success was similar between the groups, but successful saphenous ablation was less common for foam sclerotherapy compared with surgery. There were no significant differences 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 [31].

Sclerotherapy may be useful for tortuous veins that will not allow a thermal device to pass but must be used carefully to avoid inadvertent transfer 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). The selection among the various types of sclerotherapies is reviewed separately. (See "Nonthermal, nontumescent ablation techniques for the treatment of lower extremity superficial venous insufficiency", section on 'Sclerotherapy'.)

MOCA and cyanoacrylate glue have excellent closure rates and a low incidence of complications but are more expensive to perform and the long-term outcomes are not as well established.

Nonthermal ablation techniques may be preferred to treat the saphenous vein in the calf without risk of injury to the saphenous or sural nerves, particularly among those with remnant saphenous venous reflux after initial above-knee great saphenous endovenous ablation.

Small saphenous vein — For treatment of the small saphenous vein, we suggest minimally invasive endovenous ablation when equipment and expertise is available, rather than surgical ligation/stripping.

Nonthermal ablation techniques are particularly useful for the small saphenous vein to avoid heat-induced sural nerve injury, but thermal ablation can be safely used, provided care is taken to avoid nerve injury by using sufficient tumescent infiltration and lower energy delivery. In the United States, PEM (ie, Varithena) has not been approved for use in the small saphenous vein.

Anterior saphenous veins — The anterior accessory vein is often short and has a large diameter. If there is an adequate length for treatment that is not tortuous, thermal 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 [87]. Nonthermal options may also be considered, although supporting evidence is still evolving. For patients with a very short length anterior accessory vein, or recanalization after endovenous ablation, open ligation and stripping may be the best option.

TREATMENT OF RESIDUAL VEINS AND VARICOSITIES — The techniques used to treat residual dilated veins and varicosities following axial venous ablation depend on the size of the vein being treated. Ambulatory phlebectomy is useful for removing larger varicose veins and some reticular veins. Treatment can be performed in conjunction with or following axial venous reflux [31,78-82,84-86,88]. (See 'Sclerotherapy' below and 'Ambulatory phlebectomy' below and 'Treatment timing' below.)

We suggest sclerotherapy as an initial treatment for residual lower extremity telangiectasias, reticular veins, and small varicose veins rather than laser therapy. Sclerotherapy improves clearance of these veins. Laser therapy is the only option for treatment of telangiectasias too small to access, for patients allergic to sclerosing agents or afraid of needles, or for those in whom sclerotherapy has not provided the desired results.

Ambulatory phlebectomy — Excision and avulsion of superficial varicosities (ie, phlebectomy) through multiple tiny incisions is referred to as "ambulatory phlebectomy" or "microphlebectomy." Phlebectomy is generally used for the management of visible veins concurrent with or following minimally invasive venous ablation, recurrent veins following minimally invasive venous ablation, and complications of varicose veins (eg, varicose vein hemorrhage, recurrent phlebitis). Ambulatory phlebectomy can be combined with saphenous vein ablation for complete treatment at a single session or delayed. When combined with minimally invasive venous ablation, surgical treatment in selected patients can reduce the number of treatments needed. (See 'Treatment timing' below.)

The effectiveness of ambulatory phlebectomy was demonstrated in the SAPTAP trial, which compared single ambulatory phlebectomy (SAP) with thermal saphenous ablation plus concomitant phlebectomy (TAP) and reported similar vein scores after one year [89]. Only 25 percent of those in the SAP group underwent subsequent TAP. Direct costs for SAP were less compared with TAP. This trial questioned the need for axial vein ablation, suggesting that saphenous reflux may be reversible after treatment of the incompetent tributary due to reduced blood volume after isolated phlebectomy, although volume measurements were not recorded.

To perform ambulatory phlebectomy, an 18-gauge needle or 11-blade scalpel is used to make a puncture immediately adjacent the marked vein. Sequential venous segments are engaged with a variety of small, specially designed crochet-like hooks and are grasped, ligated, and avulsed [90]. Bleeding is controlled with direct pressure and limb elevation.

Sclerotherapy — Following management of symptomatic axial venous reflux, residual veins tend to be small and may be amenable to liquid sclerotherapy. Foam sclerotherapy, and particularly polidocanol endovenous microfoam (ie, Varithena), is a good choice for larger varicosities or residual symptomatic veins after initial thermal ablation. Techniques for sclerotherapy are reviewed separately. (See "Injection sclerotherapy techniques for the treatment of telangiectasias, reticular veins, and small varicose veins" and "Nonthermal, nontumescent ablation techniques for the treatment of lower extremity superficial venous insufficiency", section on 'Sclerotherapy'.)

Treatment timing — For patients with symptomatic venous reflux and associated varicosities, treatment can be performed in conjunction with axial vein ablation or later. We generally suggest treating the varicosities during the same setting as ablation [31,78-82,84-86,88]. Management of varicosities can be delayed if varicose vein burden is low and connected to the area of venous drainage undergoing ablation to see if there is adequate spontaneous regression; however, larger varicosities often do not fully regress, particularly those located in the thigh. Treatment of visible varicosities before treatment of axial venous reflux is associated with high rates of varicose vein recurrence.

The main advantage of performing venous ablation procedures with concomitant treatment is a reduction in the overall treatment time. On the other hand, 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, and in many cases, no further treatment is needed. This effect is due to reduced venous pressure in the tributaries of the ablated saphenous vein.

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 5^th to 6^th 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 10^th to 12^th 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

●Superficial venous insufficiency – Superficial venous insufficiency can manifest across the entire clinical spectrum from dilated veins (telangiectasias, reticular veins, varicose veins) to advanced chronic venous disease (skin changes, venous leg ulcer). Identification of superficial venous insufficiency is based on ultrasound findings of significant reflux in the affected veins. Identifying axial sources is important because of its implications for treatment. (See 'Introduction' above.)

●Candidates for venous intervention – The goal of venous intervention is improvement in symptoms and appearance. For most patients who have symptomatic (C1-C6) superficial venous insufficiency with reflux in the great or small saphenous vein, we suggest superficial venous ablation rather than continuing long-term compression therapy (Grade 2C). Compression therapy along with other measures can be used as definitive management in patients whose ambulatory status or underlying medical conditions warrant a conservative approach, or in those who prefer or are required to undergo a trial of conservative treatment prior to considering venous intervention. (See 'Candidates for venous intervention' above.)

●Axial vein reflux – Options for treating superficial axial vein reflux include minimally invasive thermal or nonthermal ablation and surgical methods. We suggest minimally invasive endovenous ablation when equipment and expertise is available, rather than surgical ligation/stripping (Grade 2C). For patients with visibly dilated or varicose veins, long-term outcomes (vein recanalization, vein recurrence) are similar, but immediate postoperative outcomes (pain scores, blood loss, return to activity) are improved for endovenous ablation. For patients with skin changes or venous leg ulcers, minimally invasive therapies are often selected to avoid problems of surgical wound healing. (See 'Intervention for axial vein reflux' above and 'Endovenous versus surgical ablation' above.)

The approach to superficial venous ablation varies by anatomic site. (See 'Technique selection by axial vein' above.)

•Great saphenous vein – For the great saphenous vein (GSV), we suggest thermal ablation techniques (ie, radiofrequency ablation, endovenous laser ablation), rather than nonthermal ablation techniques (eg, sclerotherapy, mechanochemical ablation [MOCA], glue) (Grade 2C). Thermal ablation techniques have lower rates of recurrence and higher patient-reported quality of life in the long term. Sclerotherapy may be useful for a tortuous GSV or to manage recurrent varicose vein related to a remnant GSV below the knee. The long-term outcomes of MOCA and glue are not established. (See 'Great saphenous vein' above.)

•Small saphenous vein – Nonthermal ablation techniques avoid the potential for heat-induced nerve injury; however, thermal ablation can also be safely used with using tumescent infiltration and lower energy settings. (See 'Small saphenous vein' above.)

•Accessory saphenous vein – Either thermal ablation or nonthermal ablation can be used depending on the length and diameter of the vein. The anterior accessory vein may be more likely to recanalize after thermal ablation. Open ligation and stripping may be the more appropriate choice if the distance to the saphenofemoral junction is very short. (See 'Anterior saphenous veins' above.)

●Timing of treating visible varicosities – For patients with symptomatic saphenous reflux and associated varicosities, we treat the varicosities during the same setting as ablation. Following management of symptomatic axial venous reflux, we use sclerotherapy as an initial treatment for residual lower extremity telangiectasias, reticular veins, and small varicose veins, and laser therapy for treatment failures. (See 'Treatment timing' above.)

●Residual small veins following axial vein ablation – 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 'Treatment timing' above.)