Nonsurgical treatment is effective. Elastic graduated compression stockings (20–30 mm Hg pressure) reduce the venous pressure in the leg and may prevent the progression of disease. Good control of symptoms can be achieved when stockings are worn daily during waking hours and legs are elevated, especially at night. Compression stockings are well-suited for elderly patients or patients who do not want surgery.
B. Varicose Vein Sclerotherapy
Direct injection of a sclerosing agent induces permanent fibrosis and obliteration of the target veins. Chemical irritants (eg, glycerin) or hypertonic saline are often used for small, less-than-4-mm reticular veins or telangiectasias. Foam sclerotherapy is used to treat the great saphenous vein, varicose veins larger than 4 mm, and perforating veins. Sclerotherapy of varicose veins without treatment of underlying saphenous vein reflux is associated with varicosity recurrence rates over 50% as uncorrected reflux progressively dilates adjacent veins. Complications such as phlebitis, tissue necrosis, or infection may occur with any sclerosing agent.
C. Surgical Reflux Treatment
Treatment options for reflux arising from the great saphenous vein include surgical vein stripping (removal) or endovenous treatments using thermal devices (from a laser or radiofrequency catheter), cyanoacrylate glue injection, or foam sclerosant injection. Endovenous treatments can often be performed with local anesthesia alone and the early success is equal to vein stripping. Long-term success is highest with vein stripping and thermal treatments while the long-term durability of cyanoacrylate glue and foam is unknown. Less common sources of reflux include the small saphenous vein (for varicosities in the posterior calf) and incompetent perforator veins arising directly from the deep venous system. Correction of reflux is performed at the same time as excision of the symptomatic varicose veins. When superficial venous reflux is present, concomitant reflux in the deep venous system is often secondary to volume overload, which will resolve with correction of the superficial reflux.