Recent trends in management of lower limb varicose veins

Abstract

Varicose veins are a manifestation of chronic venous disease (CVD) and are characterized by tortuous, dilated superficial veins >3 mm in diameter. The condition can occur anywhere in the body where there is poor venous return, but it is most often associated with the lower limb. Along with causing significant physical and physiological morbidity, varicose veins are known to have a negative impact on patients' quality of life. Risk factors for developing varicose veins are unclear although prevalence rises with age and they often develop during pregnancy. In some people varicose veins are asymptomatic or cause only mild symptoms, but in others they cause pain, aching or itching and can have a significant effect on their quality of life. Varicose veins may become more severe over time and can lead to complications such as changes in skin pigmentation, eczema, superficial thrombophlebitis, bleeding, loss of subcutaneous tissue, lipodermatosclerosis or venous ulceration. Varicose veins and even chronic venous insufficiency can be managed conservatively with stockings and compression. More aggressive management can be pursued for cosmesis, worsening cutaneous findings or symptoms despite conservative management, or if the patients prefer surgical management. Most procedures to treat varicose veins can be elective, and emergency treatment and workup is usually reserved for bleeding varicosities or if deep venous thrombosis (DVT) is suspected. The treatment of varicose veins has, in turn, been shown to improve the quality of life of patients. Traditional techniques of saphenofemoral and saphenopopliteal junction ligation with or without vein stripping have been the mainstay of treatment for a long time. However, over the past 15 years, day-case minimally invasive endovascular interventions carried out under local anaesthetic have gradually replaced surgical methods. Nowadays, the majority of procedures are carried out using one of the endothermal ablation techniques (radiofrequency ablation [RFA] or endovenous laser ablation [EVLA]). However, these endothermal methods are often associated with discomfort as well as complications due to the use of heat energy. Recently, newer non-thermal, non-tumescent (NTNT) ablation techniques have been launched with the promise of similar effectiveness, but with less pain. In conclusion, the management of varicose veins has changed with the advent of thermal ablation, with equivalent quality of life improvement noted. Endovenous ablation also offers the possibility of day-case interventions and more rapid return to normal activities. The non-thermal methods, so far, are showing similar effectiveness and improvement in quality of life without the risks of thermal nerve damage.