Varicose Vein Treatment: What to Check Before Asking Which Procedure Is Best

"Is laser better, or radiofrequency?"

People looking into varicose vein treatment often start by comparing procedure names. One is described as less painful, another as quicker to recover from, another as the newest technology, and the choice gets harder. But before choosing a procedure, there is something to check first: which vein has blood flowing backwards, and over what extent.

Varicose veins develop when the valves in the leg veins stop working properly, so that blood flows backwards and the veins enlarge. Legs that look similar on the surface can differ in which vein is affected and how far the reflux extends. Finding the treatment that fits you means looking at the blood flow inside the veins, not only at the veins you can see.

1. Visible veins alone do not show how much needs treating

When a thick vein is visible on the calf, it is easy to assume that treating that spot is enough. But the reflux may start in a larger trunk vein connected to it (the great or small saphenous vein). The reverse is also true: a prominent vein does not necessarily mean extensive treatment is needed.

The test that tells these situations apart is duplex (Doppler) ultrasound. It assesses the shape and diameter of the veins, the direction of blood flow, and the location and extent of reflux together. The UK guideline from the National Institute for Health and Care Excellence (NICE) recommends using duplex ultrasound to confirm the diagnosis and the extent of truncal reflux, and to plan treatment, in people with suspected primary or recurrent varicose veins. The 2022 joint guideline of the Society for Vascular Surgery (SVS), American Venous Forum (AVF) and American Vein and Lymphatic Society (AVLS), and the 2022 guideline of the European Society for Vascular Surgery (ESVS), also treat ultrasound as the basic examination before treatment.

How ultrasound detects reflux is explained in our column on Doppler ultrasound.

2. Ultrasound findings need to be read together with symptoms

Finding reflux on a scan does not explain every discomfort in the leg. In a study of 1,566 adults in Edinburgh, UK, symptoms such as heaviness, aching, and itching were common in the general population. The association between trunk varicose veins and symptoms was limited to some symptoms, and in men only itching showed a significant association. The authors concluded that even when varicose veins are present, most leg symptoms regarded as "venous" have another cause.

This is why a consultation looks at when the discomfort occurs, whether it gets worse after long standing, and whether swelling or skin changes are present, alongside the scan results. Other causes, such as muscle, joint, or nerve problems, also need to be checked.

The goal of treatment should be clear as well. The focus of the consultation differs depending on whether the aim is to reduce recurring pain and swelling, to respond to skin changes or an ulcer, or to improve appearance. In a randomised trial of 450 patients with venous leg ulcers (EVRA), the median time to ulcer healing was shorter in the group that had superficial venous reflux treated early alongside compression (56 days) than in the group whose treatment was deferred (82 days). When the disease has progressed, the purpose and urgency of treatment change.

3. The same procedure is not the best one for everyone

There are several ways to treat varicose veins.

• Thermal ablation: laser, radiofrequency
• Non-thermal ablation: medical adhesive (cyanoacrylate), mechanochemical ablation (MOCA)
• Sclerotherapy: ultrasound-guided foam sclerotherapy and others
• Surgery: high ligation and stripping, and phlebectomy to remove bulging tributary veins

These methods have been compared in a number of studies. A 2021 Cochrane systematic review of 24 randomised trials (5,135 participants) reported that technical success was comparable between most methods, and that rates of quality-of-life improvement were also comparable. Foam sclerotherapy, however, may have lower technical success than laser or surgery. The review also noted that its conclusions are limited because the trials defined and timed their outcomes differently.

In the UK CLASS trial (798 participants), disease-specific quality of life at five years was better after laser ablation or surgery than after foam sclerotherapy. The difference was about 3 points on a 100-point scale, and generic quality of life did not differ among the three groups.

Guidelines set the general direction on the basis of this evidence. For confirmed truncal reflux, NICE recommends thermal ablation first, ultrasound-guided foam sclerotherapy if that is unsuitable, and surgery if foam sclerotherapy is also unsuitable. The US joint guideline addresses surgery versus endovenous treatment, and thermal versus non-thermal ablation, as separate questions. Whether to treat the trunk vein and the tributaries in one session or in stages is also covered by its recommendations.

Several methods work, and the differences between them are often small. That is why your individual circumstances matter in the actual choice. The location and course of the refluxing vein, its diameter, its distance from the skin and nerves, your general health and previous treatment, your plans for returning to daily life, cost, and your own preference are all considered together.

So the question "which procedure is best?" should lead to another: "why is this procedure suitable for my scan results?" Understanding the expected benefit and the limits in your own case matters as much as hearing the advantages of a procedure. The features of each method are summarised in our column on treatment options.

4. Questions to ask in the consultation

These questions are useful in the consultation room.

1. Which vein in my leg has reflux?
2. How is that reflux related to my current symptoms?
3. How much needs to be treated?
4. Why is the recommended method suitable for me, and what are the alternatives?
5. What change can I expect after treatment, and which symptoms may remain?
6. What are the possible side effects, and how do recovery and follow-up scans work?

Once these have been explained, it becomes easier to judge your choice than when comparing procedure names or advertising phrases alone. Why treatment can differ for the same diagnosis is covered in our column on how treatment is decided.

What matters in varicose vein treatment is the process of deciding which areas need treatment on the basis of the scan and the symptoms, and choosing a method that fits the individual. A good treatment choice starts with understanding the state of your own veins, before picking a procedure name.

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References

• National Institute for Health and Care Excellence (NICE). Varicose veins: diagnosis and management. Clinical guideline CG168, 24 July 2013. — Duplex ultrasound to confirm the diagnosis and extent of truncal reflux and plan treatment; treatment sequence (endothermal ablation → ultrasound-guided foam sclerotherapy → surgery). https://www.nice.org.uk/guidance/cg168
• Gloviczki P, Lawrence PF, Wasan SM, et al. The 2022 Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society clinical practice guidelines for the management of varicose veins of the lower extremities. Part I. Duplex Scanning and Treatment of Superficial Truncal Reflux. J Vasc Surg Venous Lymphat Disord. 2023;11(2):231-261. (PMID: 36326210) — Duplex evaluation, surgery vs endovenous ablation, thermal vs non-thermal ablation, concomitant vs staged treatment of tributaries.
• Gloviczki P, Lawrence PF, Wasan SM, et al. The 2023 Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society clinical practice guidelines for the management of varicose veins of the lower extremities. Part II. J Vasc Surg Venous Lymphat Disord. 2024;12(1):101670. (PMID: 37652254) — Compression, evaluation and treatment of varicose tributaries, management of complications.
• De Maeseneer MG, Kakkos SK, Aherne T, et al. European Society for Vascular Surgery (ESVS) 2022 Clinical Practice Guidelines on the Management of Chronic Venous Disease of the Lower Limbs. Eur J Vasc Endovasc Surg. 2022;63(2):184-267. (PMID: 35027279) — Duplex ultrasound in pre-treatment evaluation.
• Bradbury A, Evans C, Allan P, Lee A, Ruckley CV, Fowkes FG. What are the symptoms of varicose veins? Edinburgh vein study cross sectional population survey. BMJ. 1999;318(7180):353-356. (PMID: 9933194) — Cross-sectional survey of 1,566 people from the general population; relationship between symptoms and trunk varices.
• Gohel MS, Heatley F, Liu X, et al. A Randomized Trial of Early Endovenous Ablation in Venous Ulceration. N Engl J Med. 2018;378(22):2105-2114. (PMID: 29688123) — EVRA randomised trial, 450 patients; median time to ulcer healing 56 vs 82 days.
• Whing J, Nandhra S, Nesbitt C, Stansby G. Interventions for great saphenous vein incompetence. Cochrane Database Syst Rev. 2021;8(8):CD005624. (PMID: 34378180) — 24 randomised trials, 5,135 participants.
• Brittenden J, Cooper D, Dimitrova M, et al. Five-Year Outcomes of a Randomized Trial of Treatments for Varicose Veins. N Engl J Med. 2019;381(10):912-922. (PMID: 31483962) — CLASS trial five-year results; 798 randomised, 595 completed questionnaires.

This article provides general health information. Whether and how to treat depends on the examination and ultrasound findings and needs to be confirmed in consultation.