Venous Reflux Disease, also known as Chronic Venous Insufficiency (CVI), occurs when the one-way valves within the leg veins become damaged or weakened. This failure allows blood to flow backward (reflux), leading to blood pooling and increased pressure (venous hypertension) in the lower extremities. The resulting pressure can cause discomfort, swelling, varicose veins, and skin changes over time. Treatment focuses on eliminating the faulty mechanism causing the backflow and managing the symptoms.
Conservative Management and Lifestyle Adjustments
The initial approach to managing venous reflux involves therapies that minimize symptoms and prevent disease progression. Medical-grade graduated compression stockings are the most commonly prescribed therapy, applying the highest pressure at the ankle and gradually decreasing it up the leg. This external pressure reduces the diameter of distended veins, helping the native valves regain functionality and increasing the velocity of blood flow back toward the heart. Consistent use of these garments is often required alongside more definitive treatments.
Lifestyle modifications play an important supportive role in reducing venous pressure. Elevating the legs above the level of the heart several times a day encourages the passive drainage of pooled blood and reduces swelling. Regular low-impact exercise, such as walking or swimming, activates the calf muscle pump, which is the body’s natural mechanism for propelling venous blood upward. Maintaining a healthy body weight also decreases the overall pressure placed on the leg veins, contributing to better circulation and symptom control.
Modern Minimally Invasive Endovenous Procedures
The definitive treatment for incompetent main superficial veins, such as the Great Saphenous Vein, involves minimally invasive endovenous procedures that close the diseased vessel. These techniques have largely replaced traditional surgical stripping due to reduced recovery time and high efficacy rates. Endovenous thermal ablation (EVTA) uses heat energy delivered via a catheter inserted through a small skin puncture, typically under local anesthesia.
Radiofrequency Ablation (RFA)
Radiofrequency Ablation (RFA) employs radiofrequency energy to heat the vein wall in a controlled manner. A specialized catheter delivers this energy, causing the collagen in the vein wall to contract and the vessel to collapse and seal shut. This segmental heating method provides consistent thermal delivery along the length of the targeted vein.
Endovenous Laser Ablation (EVLA)
Endovenous Laser Ablation (EVLA) is the other widely used thermal technique, utilizing a laser fiber to deliver energy. The intense heat generated causes irreversible thermal damage to the vein lining and surrounding tissue. Both RFA and EVLA cause the vein to turn into fibrotic tissue, which the body eventually absorbs, rerouting blood flow to healthy veins.
Newer, non-thermal techniques are available as alternatives that avoid the need for extensive local anesthesia. Mechanochemical ablation (MOCA) combines the mechanical disruption of the vein lining with the simultaneous injection of a chemical sclerosant. Another option, VenaSeal, involves the use of a medical-grade adhesive to physically seal the vein shut. These methods offer an option for patients who may not tolerate heat-based procedures or for veins difficult to treat with thermal energy.
Targeted Injection Therapy and Surgical Options
While minimally invasive procedures treat the main source of reflux, targeted injection therapy, known as sclerotherapy, addresses residual varicose veins and smaller branch vessels. This therapy involves injecting a liquid or foam chemical irritant (sclerosant) directly into the vein. The sclerosant damages the internal lining of the vessel, causing it to swell, collapse, and eventually scar down, redirecting blood to healthier pathways.
Foam sclerotherapy is particularly effective because mixing the sclerosant with air creates a microfoam that displaces blood and increases the contact time with the vein wall. This technique is frequently used to treat smaller, tortuous varicose veins or as a follow-up treatment after endovenous ablation. Ultrasound guidance is often employed to ensure accurate placement of the sclerosant into the targeted veins.
Traditional surgical interventions are now reserved for complex cases where minimally invasive options are not feasible. Ambulatory phlebectomy is a procedure where larger, bulging varicose veins are removed through several tiny incisions using specialized hooks. This is done under local anesthesia and is less invasive than the older vein stripping technique.
Vein stripping involves surgically removing a long segment of the saphenous vein through incisions in the groin and lower leg. Although it was once the standard of care, it is associated with a longer recovery time and a higher rate of recurrence compared to modern ablation techniques. Today, stripping is generally limited to cases involving large vein segments or those with complex anatomy that prevents catheter insertion.