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Advancements in Varicose Vein Treatment:
Anatomy, Pathophysiology, Minimally Invasive
Techniques, Sclerotherapy, Patient Satisfaction,
and Future Directions
Faris Fayyaz , Viralkumar Vaghani , Chukwuyem Ekhator , Muhammad Abdullah , Rashed A. Alsubari ,
Omar A. Daher , Danyal Bakht , Hanen Batat , Hareem Arif , Sophia B. Bellegarde ,
Pakeezah Bisharat , Muhayya Faizullah
1. Surgery, Dow University of Health Sciences, Karachi, PAK 2. McWilliams School of Biomedical Informatics, The
University of Texas Health Science Center at Houston, Houston, USA 3. Neuro-Oncology, New York Institute of
Technology, College of Osteopathic Medicine, Old Westbury, USA 4. General Surgery and Medicine, Jinnah Medical and
Dental College, Karachi, PAK 5. Medicine and Surgery, October 6 University, Raleigh, USA 6. Obstetrics and
Gynaecology, Beirut Arab University, Tripoli, LBN 7. Medicine and Surgery, Mayo Hospital, Lahore, PAK 8. Medicine,
Yarmouk University, Irbid, JOR 9. Internal Medicine, Ghulam Muhammad Mahar Medical College, Sukkur, PAK 10.
Pathology and Laboratory Medicine, American University of Antigua, Coolidge, ATG 11. Internal Medicine, Khyber
Medical University, Peshawar, PAK 12. Medicine and Surgery, King Edward Medical University, Lahore, PAK
Corresponding author: Muhayya Faizullah, muhayya999@gmail.com
Abstract
Varicose veins are a common vascular condition known for causing discomfort and cosmetic concerns. This
comprehensive narrative review delves into their anatomy, pathophysiology, and modern treatment options,
with a focus on endovenous techniques and sclerotherapy. The review starts by emphasizing the intricate
anatomy of lower extremity venous circulation, underlining the significance of both superficial and deep
venous networks in venous return. It also addresses how changes in the venous wall, including valvular
insufficiency, contribute to the development of varicose veins. Endovenous techniques like endovenous
laser ablation (EVLA), radiofrequency ablation (RFA), and mechanochemical endovenous ablation (MOCA)
are explored in detail. These minimally invasive procedures have revolutionized varicose vein treatment,
offering high success rates and quicker recovery compared to traditional surgery. The review also highlights
their efficacy and safety profiles, aiding clinicians in informed decision-making. Sclerotherapy, a vital
modality for varicose veins, is thoroughly examined, covering both liquid and foam sclerotherapy. Foam
sclerotherapy, in particular, is recognized for its improved outcomes. The review provides a comprehensive
comparison of these treatment modalities, highlighting differences in technical success, recurrence rates,
and cost-effectiveness. Patient preferences and satisfaction play a significant role in choosing the right
treatment. Safety and potential complications associated with these treatments are explored, with a focus
on minor issues and rare adverse events. This review also emphasizes the positive impact of varicose vein
interventions on patients' quality of life.
Categories: Internal Medicine, Cardiac/Thoracic/Vascular Surgery, General Surgery
Keywords: cryotherapy, radioablation, endovenous management, sclerotherapy, varicose seins
Introduction And Background
Varicose veins are a prevalent manifestation of chronic venous disease, affecting a substantial portion of the
global population [1]. These visibly enlarged and tortuous veins, often appearing as protruding purple or
blue-green structures on the legs and feet, extend beyond mere cosmetic concerns. They serve as indicators
of underlying venous insufficiency, a condition characterized by impaired blood circulation back to the
heart. This insufficiency arises due to malfunctioning valves within the affected veins, leading to inefficient
blood pumping, retrograde blood flow, and heightened pressure within the veins. While some individuals
with varicose veins may remain asymptomatic, others experience localized discomfort, including aching,
throbbing, or itching around the affected veins. Over time, more severe symptoms may develop, such as
fatigue, heaviness, and leg cramps [2]. If left untreated, chronic venous insufficiency can advance to a more
severe stage of venous disease. This progression may entail the emergence of edema (swelling), persistent
skin discoloration, eczema (skin inflammation and itching), lipodermatosclerosis (skin and underlying fat
hardening), and venous ulcers (open wounds). Estimates indicate that up to 10% of adults with varicose
veins may eventually develop advanced venous disease, including venous ulcers, superficial
thrombophlebitis (inflammation leading to blood clots), or bleeding from varicosities [3]. It is important to
note that the course of chronic venous insufficiency varies among individuals and does not necessarily
follow a linear progression [2].
Historically, varicose veins were primarily considered a cosmetic concern, with patient preferences heavily
influencing treatment decisions. However, advancements in medical imaging, particularly the adoption of
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Open Access Review
Article DOI: 10.7759/cureus.51990
How to cite this article
Fayyaz F, Vaghani V, Ekhator C, et al. (January 10, 2024) Advancements in Varicose Vein Treatment: Anatomy, Pathophysiology, Minimally
Invasive Techniques, Sclerotherapy, Patient Satisfaction, and Future Directions. Cureus 16(1): e51990. DOI 10.7759/cureus.51990
color flow duplex ultrasonography since the 1980s, have revolutionized our comprehension of varicose
veins. This technology has enabled a more precise assessment of venous reflux and its association with
varicose veins [4]. It is essential to recognize that varicose veins are not merely a benign cosmetic issue but
are associated with more substantial health risks [5]. Recent research has shown that individuals with
varicose veins face up to a five-fold increased risk of developing deep vein thrombosis (DVT), a potentially
life-threatening condition. Moreover, varicose veins have been linked to peripheral arterial disease and
other vascular disorders. While certain risk factors for varicose vein formation, such as age, gender,
pregnancy, obesity, and prior DVT, are well-established, others remain unconfirmed. Genetic components
are also suspected in varicose vein disease, although genetic studies have produced conflicting results [6].
Treatment options for varicose veins range from conservative approaches like compression therapy, lifestyle
adjustments, leg elevation, weight management, and medical treatments to interventional methods such as
laser thermal ablation, endovenous treatments, and surgery [7]. Surgery, once the standard, has been largely
replaced by endovenous thermal ablation (EVTA), offering improved outcomes and fewer complications [8].
Current evidence and guidelines suggest that compression therapy is unnecessary before considering EVTA,
although it may be required for insurance purposes [7]. While surgical procedures like vein stripping and
ligation are effective, they come with higher complication rates and longer recovery times. Emerging
endovenous therapies, including endovenous laser ablation (EVLA), radiofrequency ablation (RFA), steam
vein sclerosis (SVS), and endovenous microwave ablation (EMWA), have demonstrated comparable efficacy
to surgery in treating varicose veins. Importantly, they offer lower complication rates and shorter recovery
times, making them increasingly popular options [8]. Ultrasound-guided foam sclerotherapy (UGFS) serves
as a second-line treatment. However, it may not match the long-term success of EVTA methods like EVLA
and RFA, particularly in cases with thick-walled veins. Nevertheless, UGFS can be effective in specific
scenarios, such as small-diameter or thin-walled veins, making it the optimal choice. Overall, these
advancements in treatment options have significantly improved the management of varicose veins [4].
The objective of this review is to thoroughly analyze diverse therapeutic strategies and their efficacy in
addressing this prevalent vascular condition. Grasping the intricacies of varicose vein anatomy and
pathophysiology becomes imperative. This review will extensively investigate various endovenous
techniques, such as EVLA, RFA, and mechanochemical ablation (MOCA), alongside sclerotherapy
methodologies, encompassing foam and liquid sclerotherapy. It will meticulously evaluate their
mechanisms, relative advantages, and associated complications. Furthermore, this analysis will explore
patient satisfaction, quality of life, and the determinants influencing treatment decisions. By engaging in a
comprehensive discussion concerning prevailing and emerging treatments, as well as emphasizing safety
precautions and outlining future avenues of research, this review aspires to enrich clinical practice,
anticipate forthcoming trends in the management of varicose veins, and ultimately elevate the quality of
patient care and outcomes.
Review
Anatomy and pathophysiology of varicose veins
Lower extremity venous blood circulation entails a complex system comprising both superficial and deep
venous networks. Within the superficial system, prominent entities include the great saphenous veins (GSV),
small saphenous veins (SSV), and their respective tributaries [9]. The GSV courses along the medial aspect of
the calf and thigh, eventually merging with the common femoral vein at the saphenofemoral junction (SFJ).
Conversely, the SSV traverses the posterior calf, entering the popliteal vein at the sapheno-popliteal
junction (SPJ), frequently accompanied by gastrocnemius veins. These systems are intricately
interconnected through various tributaries, bearing vital significance in the return of venous blood to the
heart [10].
In a normally functioning venous system, the deep venous network significantly contributes to
approximately 90% of venous return from the lower limb. The superficial system predominantly receives
drainage from the skin and subcutaneous tissues, with a significant portion of this blood seamlessly entering
the deep system through perforators situated in the foot, calf, and thigh regions. The venous wall comprises
three discernible layers, albeit less distinct compared to arteries. These layers encompass the intima, media,
and adventitia, their composition varying depending on vein size and function [10]. As age and pathological
conditions progress, all three layers succumb to abnormalities, leading to structural derangement of the
venous wall [11].
From a physiological standpoint, venous return against the omnipresent force of gravity hinges upon the
muscle pumps in the foot and calf. Contraction of the calf muscles exerts pressure on intramuscular veins,
channeling blood into the deep system, subsequently propelling it upwards through the leg. The superficial
veins, in turn, serve as collectors of blood from the skin and subcutaneous tissues, facilitating its
transference into the deep system during periods of muscle relaxation, mediated by perforating veins. The
presence of valves within these veins acts as a barrier, preventing retrograde blood flow during muscle
relaxation phases [10]. This valve-mediated closure divides the high-pressure blood column into multiple
lower-pressure segments, thereby substantially mitigating venous pooling and capillary hydrostatic
pressure, effectively averting edema formation in the lower extremities [12]. However, individuals afflicted
2024 Fayyaz et al. Cureus 16(1): e51990. DOI 10.7759/cureus.51990 2 of 9
with venous insufficiency manifest elevated ambulatory venous pressure (AVP), culminating in the
manifestation of symptoms and clinical signs associated with chronic venous insufficiency [10].
Typically, varicose veins are characterized as dilated, tortuous veins exceeding 4 mm in diameter. In
contrast, reticular veins represent smaller, nonpalpable dermal veins measuring less than 4 mm in diameter.
The histological attributes associated with varicose veins exhibit variability, encompassing irregular intimal
thickening, fibrosis, elastic fiber atrophy, collagen fiber thickening, and disarray in muscular layers [13].
These irregularities may display heterogeneity throughout the vein structures [14].
Although reflux serves as the primary hemodynamic aberration in primary venous disorders, it does not
singularly instigate the development of varicose veins. Instead, intrinsic structural and biochemical
anomalies within the vein wall are postulated to play a pivotal role in their etiology. In secondary venous
conditions, the coexistence of both reflux and obstruction is more prevalent than either anomaly in
isolation. Limbs exhibiting post-thrombotic skin alterations and ulceration frequently present with a
combination of these factors [13]. The specific anatomy of reflux and venous obstruction can significantly
influence the severity of chronic venous manifestations, often involving multiple anatomical venous
systems, characterizing multisystemic involvement [15]. The emergence of valvular insufficiency subsequent
to venous recanalization remains an area of active investigation, with potential mechanisms encompassing
thrombus adherence to valve cusps and endothelial erosion [13].
Endovenous techniques
Over the past decade, the landscape of managing symptomatic varicose veins has experienced a substantial
transformation, primarily driven by the introduction of minimally invasive endovascular techniques. Among
these approaches, EVTA techniques, exemplified by EVLA and RFA, have risen to prominence as the first-
line treatments, effectively supplanting conventional surgical interventions for alleviating the discomfort
and cosmetic concerns associated with varicose veins [16].
EVLA, pioneered by Dr. Carlos Bone in 1999, has emerged as a pivotal pillar in contemporary varicose vein
management. This method entails the insertion of a laser fiber into the targeted vein, emitting laser energy
to induce thermal injury within the vessel. The ensuing consequences comprise vein constriction,
thrombosis (clot formation), and the development of venous fibrosis. Within the realm of EVLA,
investigations into variations in laser wavelengths have been undertaken to enhance effectiveness and
mitigate side effects [16]. Radial fibers and lasers characterized by higher wavelengths (such as 1470-1940
nm) have been introduced to promote more uniform damage to the vein wall [17]. Applying a 1470 nm laser
in conjunction with a radial probe, for instance, has yielded promising outcomes, marked by reduced post-
procedural discomfort and diminished recurrence rates when contrasted with the 940 nm fiber [18].
Nonetheless, the overall success rates for EVLA continue to be notably high, residing at 92% [19].
RFA represents another noteworthy minimally invasive modality for varicose vein management guided by
ultrasonography [16]. It harnesses thermal energy delivered via a radiofrequency catheter to ablate the
refluxing segment of the vein. During RFA, radiofrequent energy is used to heat the vein wall of the GSV. The
catheter is inserted into the vein and direct energy is delivered to the endothelium with the result of
collapsing and sealing the vein. One particular device, the ClosureFAST™ RFA system (Medtronic, Dublin,
Ireland), has garnered recognition in RFA procedures. The catheter attains temperatures of 120°C during a
20-second treatment cycle, efficaciously sealing the targeted vein [20]. Significantly, RFA has manifested
high patient satisfaction and quality of life scores, accompanied by swifter recovery periods relative to
traditional surgical interventions [16].
In the comparative analysis between EVLA and RFA, these two modalities exhibit congruous safety profiles
and clinical effectiveness. Both offer elevated occlusion rates and expedited resumption of routine activities
while exhibiting minimal complications such as thrombophlebitis and hematoma [21]. Long-term follow-up
assessments further unveil analogous outcomes regarding venous occlusion rates and patient recuperation.
Particularly noteworthy, a decade-long observational study employing a 1470-nm diode laser with radial
fibers has substantiated enduring and valuable results for EVLA [17].
MOCA, introduced in 2010 through the ClariVein device (Merit Medical, Utah, United States), introduces a
non-thermal and non-tumescent alternative for treating varicose veins. This innovative technique combines
mechanical trauma to the vein wall with concurrent injection of a liquid sclerosant, effectively sealing the
veins [16]. Polidocanol, also known as Aethoxysclerol®, serves as the sclerosant [20]. MOCA is particularly
appealing for addressing veins below the knee and the small saphenous vein, as it mitigates the risk of nerve
injury associated with thermal methods such as EVLA and RFA. In a recent multicenter randomized study,
MOCA was discerned to be significantly less painful than RFA, rendering it a preferred choice for patients
with concerns regarding procedural discomfort. While MOCA may exhibit slightly lower overall success rates
compared to other thermal methodologies, it nevertheless represents a valuable alternative characterized by
diminished pain and reduced potential for nerve damage [16].
Sclerotherapy
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Sclerotherapy represents a versatile medical procedure that assumes a pivotal role in managing varicose
veins, addressing a spectrum of venous concerns through the intravenous administration of a chemical
sclerosant in either liquid or foam form. This technique is adept at targeting intradermal, subcutaneous, and
transfascial veins, as well as epi-, supra-, and subfascial vessels afflicted by venous malformations. The
sclerosant's mode of action revolves around the destruction of the vein's endothelium, initiating a
transformative process known as sclerosis, ultimately converting the varicose vein into a contiguous string
of connective tissue over the long term [22-24].
The primary objective of sclerotherapy does not center on thrombosing the vein, as recanalization may
ensue after this phase. Instead, the paramount goal is to transmute the vein into a continuous strand of
connective tissue, rendering recanalization an impossibility. This outcome culminates in a functional result
commensurate with vein removal or EVTA, thus rendering sclerotherapy a valuable therapeutic option [23].
Certain contraindications necessitate consideration when contemplating sclerotherapy. Absolute
contraindications encompass a known hypersensitivity to the sclerosant, acute venous thromboembolism,
localized infections in the sclerotherapy region or severe systemic infections, and the presence of a
symptomatic right-to-left shunt, particularly pertinent in the context of foam sclerotherapy. Relative
contraindications warrant an individualized risk-benefit evaluation and encompass factors such as
pregnancy, lactation (with potential discontinuation of lactation for two to three days if urgent treatment is
warranted), severe peripheral arterial occlusive disease, compromised general health, a heightened risk of
thromboembolism, extended periods of immobility or bedridden patients, and neurological disorders,
including migraines, following prior foam sclerotherapy [23].
While liquid sclerotherapy has been in use for a substantial duration, its efficacy, particularly for primary
varicose veins, has faced scrutiny due to perceived recurrence rates. However, the advent of foam
sclerotherapy has markedly improved outcomes by creating a more extensive interface between the
sclerosant and the vein, achieved by incorporating air or carbon dioxide bubbles into the foam [25]. This
enhanced methodology engenders improved adhesiveness, heightened echo-visibility attributable to the
presence of air, and an amplified sclerosing potential, consequently facilitating reductions in drug dosages
and concentrations [26].
The sclerosing agent Aethoxysclerol (with the active ingredient polidocanol) has established itself as a
leading choice in sclerotherapy and holds approval for treating both spider veins and varicose veins. Based
on currently available data, liquid sclerotherapy is recommended for spider veins and reticular veins. In
instances where there are inadequate perforating veins, main or side branch varicosities, recurrent
varicosities, pudendal vein varicosis, or venous malformations, foam sclerotherapy has demonstrated its
effectiveness [27].
The generation of sclerosant foam entails the application of various techniques, including the Tessari,
Monfreux, Frullini, and Cabrera methods [26]. These methodologies yield a mixture of air or carbon dioxide
with the liquid sclerosant, with bubble size and sclerosant properties dictating the durability and
effectiveness of the foam [28]. Diminutive bubble sizes and elevated sclerosant concentrations within the
foam engender superior results. Foam sclerotherapy offers numerous advantages, encompassing efficient
displacement of blood, uniform contact of the sclerosant with the endothelium, and provocation of
venospasm post injection. When executed meticulously, this approach attains immediate or early closure in
medium-to-large veins in over 85% of instances, frequently necessitating multiple sessions for
comprehensive success [26].
Sclerotherapy, notably foam sclerotherapy, has garnered favor as a primary modality for refluxing saphenous
veins. It is due to its relatively economical nature, feasibility as an outpatient procedure devoid of
anesthesia, minimal post-procedural discomfort, and procedural repeatability. Nonetheless, the accurate
delineation of indications, selection of the most suitable sclerosant, and utilization of the most efficacious
technique remain areas of ongoing exploration. Long-term data relating to quality of life, symptomatic
amelioration, and aesthetic outcomes continue to accrue, with ongoing clinical trials striving to furnish
more definitive insights into the effectiveness and safety of foam sclerotherapy [26].
Comparison and efficacy
The therapeutic landscape for managing varicose veins encompasses a diverse array of modalities, each
endowed with unique attributes and clinical outcomes. An imperative metric, technical success,
demonstrates a broadly consistent performance across these modalities. Nonetheless, subtle differentiations
in technical success become evident when juxtaposing EVLA with UGFS. EVLA is superior in terms of
technical success compared to UGFS. It is paramount to underscore that, although technical success holds
substantial significance, an equally critical determinant is the recurrence rate. Existing evidence suggests
that, with the exception of a potential long-term benefit for RFA over EVLA, there is generally no substantial
variance in recurrence rates among these therapeutic approaches. This suggests that while EVLA may excel
in terms of technical success, RFA may potentially demonstrate superior long-term efficacy in preventing
the recurrence of varicose veins [29].
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The assessment of treatment efficacy transcends mere technical success and encompasses considerations of
clinical outcomes and cost-effectiveness. Upon scrutiny of both short-term and long-term clinical
outcomes, EVLA emerges as a promising candidate for treating varicose veins. It is proposed as the preferred
therapeutic option for eligible patients, as it yields favorable results at the six-month juncture and exhibits
promise in cost-effectiveness analyses extending over a projected five-year period. This recommendation
aligns harmoniously with the concept that an initial investment in EVLA may yield superior long-term
outcomes and engender cost efficiencies [30]. Another pivotal facet to contemplate pertains to the
recuperative experience of patients. A comparative study found that the highest rate of technical failures is
observed with foam sclerotherapy, while both RFA and foam yielded quicker recovery and less postoperative
pain when compared to EVLA and stripping [31].
Cost-effectiveness represents another critical aspect in ascertaining the most appropriate treatment
modality. While UGFS initially presents as the most economically efficient option, it often necessitates a
higher frequency of subsequent interventions. Day-case surgery, EVLA, and RFA, when performed in
outpatient or office-based settings, hold the potential for cost-effectiveness compared to traditional care.
These findings provide valuable insights for healthcare providers and policymakers when deciding on the
most efficient strategies for managing varicose veins [32]. Furthermore, patient preferences wield
substantial influence in the selection of treatment modalities. While a consensus prevails in favor of
endothermal ablation for truncal reflux and UGFS for localized and recurrent varicose veins, variances in
preferences emerge predicated on factors such as vein dimensions, body mass, leg proportions, and a history
of venous thromboembolism (VTE). Patient preferences frequently contemplate the equilibrium between
invasiveness, durability, and long-term outcomes. Consequently, the involvement of patients in the
decision-making process and the provision of comprehensive information regarding treatment alternatives
assume paramount importance [33].
The recurrence of varicose veins after treatment is common, so additional interventional treatment is often
necessary. Patients commonly receive multiple interventional modalities within the same treatment session,
such as combining EVTA with phlebectomy, or over several sessions, like using laser ablation followed by
sclerotherapy for tributary or perforator veins. Relatively high rates of additional interventional treatments
have been observed, particularly for EVTA methods like laser ablation or RFA, especially in the short term
(52.4% and 40.0%, respectively). Over the course of one year, cumulative rates of additional treatments are
notably higher for EVTA techniques compared to reported recurrence rates associated with RFA, laser
ablation, and sclerotherapy [34].
Safety and complications
Endovenous techniques and sclerotherapy represent widely employed interventions for managing varicose
veins. However, it is imperative to acknowledge that these therapeutic modalities are not devoid of potential
complications and adverse effects. EVLA, a valuable option for treating varicose veins, may entail minor
complications. Notably, 42.1% of patients undergoing this procedure have reported experiencing erythema
or ecchymosis along the path of the long saphenous vein, while 31.6% have complained of induration. Some
individuals have also reported paresthesia, limb swelling, and superficial burns. However, significant
complications such as DVT and pulmonary embolism (PE) have been infrequent in these cases [35]. In
contrast, another study has indicated that EVLA presents a significantly lower incidence of paresthesia
compared to RFA and high ligation/stripping, hinting at a potentially more comfortable postoperative
experience for patients undergoing EVLA. Nonetheless, thermal skin burns have been observed with
comparable frequency in both RFA and EVLA procedures [36].
Although generally efficacious, foam sclerotherapy is associated with a spectrum of potential complications.
Notably, anaphylactic/anaphylactoid reactions, albeit exceedingly rare, are recognized as substantial
complications necessitating immediate intervention [37]. In addition, though infrequent, extensive tissue
necrosis can arise due to inadvertent intra-arterial injection [38]. Skin necrosis represents another
uncommon complication, which can emanate from the injection of high-concentration sclerosant or, in rare
instances, from the inadvertent intravascular injection of low-concentration sclerosant [39]. Furthermore,
foam sclerotherapy has been associated with the potential for transient migraine-like symptoms, with a
higher reported frequency compared to liquid sclerotherapy. These symptoms resemble a migraine with aura
rather than transient ischemic cerebrovascular events.
More severe complications following sclerotherapy have been documented in rare instances, including
stroke and transient ischemic attack (TIA). These events typically manifest after a time interval and are
linked to paradoxical thromboembolism. While very rare, instances of DVT and PE have also been reported
following sclerotherapy, with the occurrence of DVT being less than 1%. Most DVT cases are asymptomatic
and typically detected during follow-up examinations employing duplex ultrasound. Additionally,
superficial vein thrombosis, occurring in up to 45.8% of cases, represents another reported complication,
although it is predominantly of minor consequence [23].
It is essential to recognize that damage to motor nerves represents an exceedingly low-incidence
complication subsequent to sclerotherapy, with an incidence lower than that associated with alternative
varicose vein treatment methods [40]. Furthermore, transient general or local reactions may ensue,
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encompassing symptoms such as chest tightness, vasovagal syncope, nausea, metallic taste, intravascular
clot, hematoma, ecchymosis at the injection site, pain at the injection site, local swelling, induration, wheals,
blistering, and erythema [23].
Patient satisfaction and quality of life
Varicose veins are a common health issue, primarily affecting adults and often causing a range of
uncomfortable symptoms, including pain, swelling, itching, cramps, and a feeling of heaviness. These
symptoms not only hinder daily activities but also negatively impact the overall quality of life for those
affected. Various factors like age, gender, pregnancy, and lifestyle choices have been recognized as factors
that can influence the development and severity of this condition [41]. As a result, the importance of
assessing and improving the quality of life (QoL) in individuals with varicose veins has become increasingly
emphasized, especially in the context of surgical treatments [42].
Numerous investigations have scrutinized the impact of minimally invasive interventions on the QoL of
patients both before and after the procedures, consistently reporting notable enhancements. Patients
frequently exhibit a reduction in varicose vein-related symptoms following these interventions, leading to
an augmentation of their overall QoL [41]. These findings are congruent with extant literature underscoring
the compromised QoL experienced by individuals afflicted with primary and recurrent varicose veins [42].
Moreover, it has been observed that most varicose vein patients encounter difficulties in the execution of
their daily activities, often accompanied by deleterious psychological ramifications [43].
Within a specific study under consideration, patients exhibited a significant diminution of symptoms and an
augmentation of QoL one month following the minimally invasive procedure. Furthermore, more than half
of these patients were able to resume their customary daily routines within the same timeframe, mirroring
outcomes from prior research endeavors. Notably, the extant body of literature suggests that minimally
invasive interventions not only alleviate symptoms but also contribute to sustained improvements in the
QoL of these patients over the long term [41]. Nurses are pivotal in identifying patients at risk by diagnosing
symptoms that impact QoL and facilitating early intervention. Their active involvement in the care and
management of varicose vein patients is crucial in ameliorating overall well-being [44].
In an investigation focusing on UGFS, the principal finding underscores that UGFS engenders a significant
amelioration of lower limb symptoms, cosmetic appearance, lifestyle, and interpersonal relationships in the
majority of patients. Many patients harbored expectations that their treatment would alleviate lower limb
symptoms, and UGFS not only met but frequently exceeded these expectations. Concerning cosmetic
enhancements, a noteworthy cohort of patients anticipated an improved leg appearance, and UGFS
effectively realized these cosmetic objectives. These favorable physical and cosmetic outcomes translated
into an array of lifestyle benefits, including the capacity to don diverse clothing, enhanced work
performance, and the ability to partake in more gratifying social and leisure activities for those who desired
such pursuits. Collectively, UGFS emerged as an efficacious modality for enhancing the QoL of individuals
grappling with varicose veins, rendering it a valuable therapeutic option [45].
Future directions and research
Ensuring long-term effectiveness is a primary objective in all varicose vein treatments. The likelihood of
recurrence remains high, as many individuals have a predisposition to develop additional varicose veins
even following comprehensive treatment [46]. Recent progress in varicose vein treatment has enhanced
safety, effectiveness, comfort, efficiency, and the ability to achieve long-term success [47]. Dermatologists
have been instrumental in advancing and introducing new, noninvasive technologies that are employed in
the treatment of both cosmetic telangiectasias and more medically significant, larger varicose veins [48].
In recent years, there has been a significant paradigm shift in treating varicose veins, characterized by the
emergence of novel technologies that offer enhanced patient experiences and improved clinical outcomes.
Traditional approaches such as vein stripping have given way to a new era of minimally invasive techniques,
ushering in remarkable advancements in patient care. One noteworthy innovation is the widespread
adoption of EVTA. Typically, this procedure is carried out using either EVLA or RFA. However, alternative
methods for EVTA also exist, including steam vein sclerosis (SVS) and EMWA. Non-thermal catheter-based
techniques have also gained prominence, notably MOCA and cyanoacrylate glue (CAG). These modalities are
often conducted on an outpatient basis under local anesthesia, allowing patients to promptly return home
with minimal risk of complications, including DVT. These techniques are particularly advantageous when
veins are closely juxtaposed with nerves, mitigating concerns about thermal-related damage [4]. High-
intensity focused ultrasound (HIFU) stands out as an innovative technology for managing incompetent N2
truncal veins and incompetent perforating veins (IPVs). HIFU leverages precise, non-invasive ultrasound
energy to ablate targeted tissue, exemplified by the SONOVEIN® machine (Theraclion, Malakoff, France).
This breakthrough underscores the potential of non-thermal approaches in varicose vein treatment, offering
patients a precise and comfortable alternative [49]. Furthermore, some practitioners have explored
pioneering hemodynamic approaches such as conservative and hemodynamic treatment of ambulatory
venous insufficiency (CHIVA) and ambulatory selective varices ablation under local anesthesia (ASVAL).
While these methods may not be universally adopted across all regions, they exhibit promise in delivering
2024 Fayyaz et al. Cureus 16(1): e51990. DOI 10.7759/cureus.51990 6 of 9
effective solutions for varicose veins by addressing venous insufficiency and blood reflux [50,51]. As ongoing
research continues to assess their long-term outcomes, these innovative modalities are poised to reshape
the landscape of varicose vein management, offering patients a brighter future with enhanced treatment
options and improved QoL [47].
Conclusions
Varicose veins, a prevalent manifestation of chronic venous disease, affect a significant portion of the global
population. These enlarged and twisted veins, beyond their cosmetic implications, serve as indicators of
underlying venous insufficiency, a condition characterized by compromised blood flow due to faulty vein
valves. While some individuals remain asymptomatic, others experience discomfort such as pain, itching,
and throbbing. If left untreated, chronic venous insufficiency can progress to more severe stages, leading to
complications like edema, skin changes, ulcers, and bleeding. Recent advancements in treatment have
enhanced safety, effectiveness, and long-term success.
Dermatologists have played a pivotal role in developing noninvasive technologies for managing both
cosmetic and medically significant varicose veins. Treatment options encompass conservative measures and
minimally invasive interventions. EVTA techniques like EVLA and RFA have largely replaced surgery due to
superior outcomes and fewer complications. UGFS is a valuable second-line treatment, particularly for
smaller veins. Ongoing research explores genetics, venous tissue engineering, and stem cell therapy for
potential future treatments.
Additional Information
Author Contributions
All authors have reviewed the final version to be published and agreed to be accountable for all aspects of the
work.
Acquisition, analysis, or interpretation of data: Muhayya Faizullah, Muhammad Abdullah, Hareem Arif,
Sophia B. Bellegarde, Omar A. Daher , Pakeezah Bisharat, Rashed A. Alsubari, Danyal Bakht, Hanen Batat
Drafting of the manuscript: Muhayya Faizullah, Viralkumar Vaghani, Muhammad Abdullah, Sophia B.
Bellegarde, Omar A. Daher , Pakeezah Bisharat, Danyal Bakht, Hanen Batat
Concept and design: Faris Fayyaz, Viralkumar Vaghani, Chukwuyem Ekhator
Critical review of the manuscript for important intellectual content: Faris Fayyaz, Hareem Arif,
Chukwuyem Ekhator , Rashed A. Alsubari
Disclosures
Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the
following: Payment/services info: All authors have declared that no financial support was received from
any organization for the submitted work. Financial relationships: All authors have declared that they have
no financial relationships at present or within the previous three years with any organizations that might
have an interest in the submitted work. Other relationships: All authors have declared that there are no
other relationships or activities that could appear to have influenced the submitted work.
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