Treatment approaches for varicose veins are personalized based on factors like the patient’s degree of venous insufficiency, vessel anatomy, co-existing health issues, aesthetic expectations, and tolerance for time off from work. Thanks to technological advancements, especially in interventional radiology, it’s now possible to achieve excellent results with outpatient procedures that don’t require general anesthesia or large incisions.

Varicose veins are a chronic circulatory disorder resulting from the weakening of vein walls and insufficiency of valves. This causes blood to flow backward, leading to twisted, prominent veins in the legs. While cosmetic concerns are often the initial motivation, varicose veins are more than just an aesthetic problem. Symptoms like nighttime cramps, a constant feeling of heaviness and swelling, increased pain after prolonged standing, itching, and in advanced cases, skin discoloration and non-healing sores (venous ulcers), can significantly reduce a person’s quality of life.

The Importance of Doppler Ultrasonography in Varicose Vein Diagnosis

The path to varicose vein treatment begins with an accurate diagnosis. Color Doppler ultrasonography is a non-invasive imaging method routinely used in interventional radiology departments. It provides a real-time view of blood flow direction, valve function, and additional pathologies like clots or blockages. The exam takes about 15-20 minutes, requires no fasting, and uses no radiation. The Doppler data precisely maps which vein segments are insufficient, allowing for a personalized treatment plan. For example, determining the diameter of the saphenous vein is critical for setting the parameters for laser or radiofrequency energy. Doppler is also used in post-procedure check-ups to confirm that the vein has been completely sealed.

Why is Treatment Necessary? What Are the Possible Complications?

Untreated varicose veins are a progressive condition. As valve insufficiency continues, pressure increases, the vein diameter expands, and new twists form. This domino effect starts with pain and swelling and can lead to pigment accumulation under the skin, eczema-like itchy lesions, hardened tissue (lipodermatosclerosis), and eventually, difficult-to-heal sores called venous ulcers. Furthermore, stagnant blood flow slightly increases the risk of deep vein thrombosis. Therefore, even for patients who say, “I have no pain yet, I’m just bothered by the appearance,” timely treatment is important to avoid the need for more complex interventions in the future.

Minimally Invasive Varicose Vein Treatment with Interventional Radiology

Interventional radiology is a medical specialty that performs minimally invasive procedures using imaging guidance like X-rays, ultrasound, CT scans, or MRIs. It plays a central role in varicose vein treatment, as most modern techniques fall within its scope:

1. Endovenous Thermal Ablation Methods

• Laser (EVLA) Ablation: A thin, flexible laser fiber is inserted into the saphenous vein under ultrasound guidance. The vein wall is then heated in a controlled manner with a 1470 nm wavelength of energy along the fiber. The heat causes the endothelium to shrink, leading to the vein’s fibrotic closure. The procedure takes about 30-40 minutes under local anesthesia, and the incision is only the size of a needle stick.
• Radiofrequency (RFA) Ablation: The working principle is similar to laser, but the energy is delivered via a heated catheter tip. The heat, around 120°C, triggers venous collapse. Some centers prefer it as the thermal profile is more homogeneous.
• Microwave Ablation & Steam Therapy: These are newer thermal techniques that offer an effective alternative, especially for veins with a larger-than-normal diameter. Microwaves use high-frequency electromagnetic waves, while steam therapy uses controlled, pressurized steam to damage the endothelium.

2. Non-Thermal, Adhesive, or Chemical Ablation Techniques

• Foam Sclerotherapy: This involves injecting sclerosing agents like polidocanol or sodium tetradecyl sulfate, mixed with air or CO₂, into the target vein under ultrasound guidance. Compared to classic liquid sclerotherapy, the foam form provides greater contact with the vein surface. It is effective for small- to medium-sized side branches or recurrent varicose veins.
• Cyanoacrylate Glue Ablation (Vein Sealing): A biological tissue adhesive is dispensed drop by drop into the saphenous vein through a thin catheter. The adhesive polymerizes in seconds, sealing the vein. Since no thermal energy is used, there is no risk of heat damage to surrounding nerves, and the use of compression stockings is required for a shorter period compared to other methods.
• Mechano-chemical Ablation: A rotating wire (rotor) is inserted into the vein to mechanically abrade the endothelial surface while a liquid sclerosing agent is simultaneously delivered. This dual action eliminates the need for thermal energy and reduces the rate of post-procedure bruising and pain.

What are the advantages of interventional radiology for the patient?

1. Small Entry Points: A 1-2 mm puncture is sufficient; no stitches are needed, and no scars are left.
2. Local or Regional Anesthesia: The risks of general anesthesia are avoided, making it safe for elderly patients or those with heart-lung conditions.
3. Short Procedure Time: It’s completed in an average of 15-45 minutes, and the patient often walks home the same day.
4. Quick Return to Daily Life: Desk workers can return to their normal pace within 24 hours, while active field workers can do so in 2-5 days.
5. Less Pain and Bruising: Non-thermal methods are particularly advantageous in this regard.
6. High Success Rate: With proper patient selection, the vein closure success rate is in the range of 95-99%.

The most suitable method for each patient is determined by evaluating the Doppler map and clinical expectations together; in some cases, a hybrid approach, like combining laser and foam applications in the same session, may be used.

Surgical Varicose Vein Treatment: When is it necessary?

Ligation-stripping, phlebectomy, or combinations thereof still remain valid options when interventional choices fail or are insufficient, or in cases of very large-diameter, excessively twisted veins, or widespread superficial varicose clusters under the skin. Surgery, performed under general or spinal anesthesia, requires 1-2 cm incisions and stitches. The recovery period may be longer, and the rate of bruising and pain may be higher; however, in certain selected cases (e.g., patients with skin necrosis due to giant varicosities), it remains the definitive solution.

What should be considered before and after the procedure?

Before the procedure:

• Patients on blood thinners should stop the medication for the duration recommended by their physician.
• Wear comfortable clothing on the day of the procedure and bring your compression stockings to the procedure room.

Afterward:

• Light to moderate walking in the first 24 hours supports vein closure.
• Compression stockings are generally recommended for 1-2 weeks after thermal ablation and for 3-5 days after foam or glue.
• Hot baths, Turkish baths-saunas, strenuous sports, and prolonged sun exposure should be limited in the first week.
• A follow-up Doppler is performed 4-6 weeks after the procedure; if necessary, additional foam injections are used to close residual side branches.

Lifestyle Recommendations to Reduce Varicose Vein Formation

Regardless of treatment, simple habits that help maintain vein health can be summarized as follows:

• Regular Exercise: Sports that activate calf muscles, such as walking, swimming, and cycling, increase venous return.
• Avoid Prolonged Sitting/Standing: It’s important to move your legs at least every 30 minutes and perform mini-stretching exercises in an office environment.
• Weight Control and Balanced Diet: In overweight individuals, pressure on the legs increases; a diet rich in fiber and antioxidants contributes to the elasticity of vein walls.
• Limit High-heeled Shoes: Flat or medium-heeled shoes allow the calf pump to work more effectively.
• Reduce Smoking and Alcohol: Nicotine narrows blood vessels, while alcohol can cause vasodilation and an imbalance in fluid distribution.

Varicose veins are a common circulatory problem affecting one in four adults. Thanks to the minimally invasive techniques brought by interventional radiology, the current range of treatments is more extensive and comfortable than ever before. Diseased veins mapped with millimeter-level precision using Doppler ultrasound can be sealed through a needle stick using methods like laser, radiofrequency, microwave, steam, glue, or foam. These procedures offer a safe alternative for patients with a fear of surgery, with the advantages of local anesthesia and same-day discharge. Of course, classic surgical ligation-stripping remains the gold standard in some complicated cases, but in modern practice, most patients can return to their normal pace of life quickly with minimally invasive approaches.