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Procedure Playbook — Venous Interventions

Varicose Vein Ablation

Endovascular treatment of symptomatic varicose veins and chronic venous insufficiency via endovenous laser ablation (EVLA), radiofrequency ablation (RFA/VNUS ClosureFAST), or ultrasound-guided foam sclerotherapy (UGFS). Replaces surgical vein stripping as the first-line intervention.

Varicose Veins
Sedation
Local anesthesia + tumescent (office-based)
Bleeding Risk
Low (SIR Cat 1)
Key Risk
DVT · Nerve thermal injury · Skin burns
Antibiotics
Not routine
Follow-up
Duplex US at 1 week, 3 months; compression stockings mandatory
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Indications & Contraindications

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Indications

  • Symptomatic varicose veins: pain, heaviness, swelling, fatigue, itching
  • CEAP class C2 or higher with confirmed reflux on duplex US
  • Chronic venous insufficiency (CVI) with skin changes — CEAP C4–C6 (lipodermatosclerosis, healed/active ulceration)
  • Cosmesis for isolated varicose veins after reflux source treated
  • Variceal complications: superficial thrombophlebitis, ulceration, hemorrhage
  • Pelvic congestion syndrome contributing to leg symptoms — treat pelvic source first, then leg veins

Conservative Therapy & Modality Selection

  • C2–C3 disease: most payers and SVS/AVF guidelines require ≥3 months of adequate compression (20–30 mmHg graduated stockings) before approving thermal ablation; C4–C6 may proceed earlier
  • Thermal ablation (EVLA/RFA): truncal GSV/SSV insufficiency, vein 3–12 mm diameter, ≥1 cm from dermis — first-line for saphenous reflux
  • Foam sclerotherapy (UGFS): isolated tributaries without truncal reflux; residual varicosities after ablation; vein <3 mm or too superficial; recurrent varicosities; tortuous anatomy preventing catheter access
  • Surgical stripping: no longer first-line; reserved for failed endovascular access or anatomy precluding thermal/chemical approach

CEAP Classification

  • C0: No visible venous disease
  • C1: Telangiectasias/reticular veins
  • C2: Varicose veins
  • C3: Edema from venous origin
  • C4a: Pigmentation, eczema
  • C4b: Lipodermatosclerosis, atrophie blanche
  • C5: Healed venous ulcer
  • C6: Active venous ulcer → priority for ablation

Contraindications

  • GSV/SSV not amenable: vein too small (<2 mm) or too large (>12 mm), very tortuous, close to skin surface (<1 cm from dermis — burn risk)
  • Active DVT or acute superficial thrombophlebitis — wait for resolution
  • Pregnancy (relative — defer until post-partum)
  • Inability to comply with post-procedure compression
  • Severe arterial insufficiency (ABI <0.5) — compression stocking contraindicated
  • Allergy to sclerosant (chemical technique)
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Pre-Procedure

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Bilateral lower extremity duplex US (standing position): map GSV and SSV for reflux (>0.5 sec in deep veins, >1 sec in superficial veins after Valsalva or cuff release). Document SFJ and SPJ competence. Mark incompetent tributaries.
Identify target vein: GSV is primary target for SFJ reflux; SSV for SPJ reflux; anterior accessory GSV; posterior arch vein.
Patient history: prior DVT, thrombophilia, prior sclerotherapy, anticoagulation status.
Informed consent: DVT (~1%), nerve thermal injury (saphenous nerve paresthesia — 5–7%), skin burn or hyperpigmentation, matting (sclerotherapy), incomplete ablation, recurrence (10–30% at 5 years).
Mark all veins to treat while standing (they collapse supine).
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Relevant Anatomy

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Saphenous Anatomy

  • GSV: runs along medial thigh and leg; joins common femoral vein at SFJ in femoral triangle; 3–6 mm normally; becomes tortuous with reflux; accompanied by saphenous nerve (calf), femoral nerve branches (thigh)
  • SSV: runs along posterior calf; joins popliteal vein at SPJ; accompanied by sural nerve
  • Perforating veins: connect superficial to deep; incompetent perforators in lower calf at Cockett point (medial ankle) common with chronic venous stasis

Tumescent Anesthesia Zone

  • Perivenous fascial compartment surrounding target vein; tumescent spread protects nerve/skin and provides analgesia
  • Goal: vein walls just touching, no vein lumen visible on US (collapsed by tumescent)
  • 20–50 mL per 10 cm of vein; inject under US guidance in perivenous space
  • Critical: adequate tumescent = adequate nerve/skin protection. Never rush this step.
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Technique

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Supplies (EVLA/RFA — Thermal Ablation)

Ultrasound machine 21G micropuncture needle + 5 Fr dilator 5 Fr introducer sheath 600–810 nm laser fiber (EVLA) OR ClosureFAST catheter (RFA, 7 Fr) Tumescent: 0.1% lidocaine in 500 mL NS (50 mL 1% lido + 1 mL 1:1000 epi in 500 mL NS) Klein cannula / Touhy needle + syringe driver Class II compression stockings (30–40 mmHg)
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Vein mapping and marking

Patient standing. Mark GSV and tributaries with surgical marker. Confirm duplex reflux >1 sec at SFJ.
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Positioning and prep

Patient supine, Trendelenburg (30° head down) to dilate target vein. Prep and drape leg.
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Vein access

US-guided micropuncture of GSV at mid-calf or knee level (most distal accessible point of refluxing segment). Seldinger technique → 5 Fr sheath.
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Advance thermal catheter to SFJ

Under US guidance, advance laser fiber/RFA catheter to SFJ. Position tip 2 cm below SFJ (to avoid saphenofemoral junction thrombus extending into femoral vein).
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Tumescent anesthesia

Inject tumescent solution in perivenous fascial compartment under US guidance. 20–50 mL per 10 cm of vein. Goal: vein walls just touching, no lumen visible. Provides analgesia and protects skin/nerve from thermal injury. This is the most important step.
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Thermal ablation

Activate laser (1470 nm, 10–12 W, 45 J/cm pullback) OR RFA ClosureFAST (120°C × 20 sec per 7 cm segment). Pull catheter caudally at controlled rate. Avoid areas <1 cm from skin without adequate tumescent.
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Completion US

Confirm vein closure: lack of compressibility, echogenic thermal change, no residual flow on Doppler.
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Apply compression

Immediately apply 30–40 mmHg compression bandage, then stocking. Patient walks 30 min before leaving.

Foam Sclerotherapy (UGFS — Chemical Ablation)

  • Mix sclerosant foam: Tessalix (polidocanol) 1–3% or STS 1–3% foam (mix with air/CO2 in 1:4 ratio). USG foam preferred for large tributaries.
  • Inject foam under US guidance into varicosity: watch for foam filling and vessel spasm. 1–3 mL per injection site.
  • Compression immediately post-injection.
  • Best use: residual tributaries after thermal ablation, recurrent varicosities, isolated varicosities without reflux source (branch treatment).
  • 1% polidocanol for telangiectasias/fine veins; 3% for larger tributaries (>3 mm). Never use foam in patients with known cardiac shunt (PFO) — systemic embolization risk.
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Troubleshooting

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Cannot Access Vein

Vein Collapsing During Micropuncture Attempt

Cause: Patient inadequately volume-loaded, vein collapsing in Trendelenburg, vein too small. Next step: Sit patient up briefly to dilate vein. Use tourniquet proximally. Warm room to cause venodilation. Consider ambulatory approach (patient standing for access, then immediately supine).

Catheter Cannot Advance to SFJ

Tortuous Vein or Valve Obstruction

Cause: Tortuous vein, valve leaflet obstruction, angulation at SFJ. Next step: Try gentle advancement with rotation. Consider multiple access points (mid-thigh puncture). For severe tortuosity: accept treating partial vein length rather than risk perforation.

Persistent Flow on Completion US

Incomplete Ablation of Target Vein

Cause: Insufficient energy delivery, missed segment, vein not collapsed by tumescent. Next step: Additional tumescent injection to collapse vein. Re-treat with additional thermal passes at same or higher energy setting. For EVLA: increase pullback rate or power.

Paresthesia or Pain During Procedure

Nerve Thermal Injury Risk

Cause: Insufficient tumescent anesthesia; saphenous nerve runs adjacent to GSV in calf. Next step: Stop. Inject more tumescent adjacent to area. Most calf paresthesias are temporary (3–6 months). Avoid ablation within 1 cm of skin surface without adequate tumescent.

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Complications

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Immediate

  • Access site bruising/hematoma (common, expected)
  • Access site thrombophlebitis
  • Partial thermal skin burn (insufficient tumescent)
  • Paresthesia (saphenous/sural nerve — 5–7%)

Delayed

  • DVT (1–2%, mostly superficial; deep DVT <0.5%)
  • EHIT (endovenous heat-induced thrombosis — grades 1–4; duplex at 1 week mandatory)
  • Skin pigmentation from hematoma
  • Matting (new fine vessels at sclerotherapy sites)
  • Recurrence (up to 30% at 5 years from new reflux or SFJ neovascularization)
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Post-Procedure

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Monitoring & Activity

  • Walk immediately post-procedure (30 min walk before leaving office/clinic)
  • Avoid prolonged standing or sitting for 1 week
  • Duplex US at 1 week: screen for EHIT (look for thrombus extension at SFJ into femoral vein)
  • Compression stockings 30–40 mmHg: mandatory minimum 1–2 weeks (most protocols 2 weeks continuous)
  • Duplex US at 3 months: confirm successful closure, no recurrence
  • Additional sclerotherapy for residual tributaries at 4–6 weeks (after initial edema resolves)

EHIT Management

  • EHIT Grade 1 (thrombus to SFJ only): observation + repeat duplex at 1 week
  • EHIT Grade 2 (thrombus nonocclusive in femoral vein): therapeutic anticoagulation × 4–6 weeks
  • EHIT Grade 3–4 (occlusive or into common femoral): treat as acute DVT
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Critical Pearls

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Treat reflux source first, tributaries second. Never treat varicose vein tributaries before ablating the incompetent truncal vein (GSV, SSV). Tributaries will immediately recur if the source of reflux is not eliminated.
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2 cm from SFJ. Position laser/RFA tip exactly 2 cm below the SFJ — not at the SFJ itself. If too close: EHIT risk into femoral vein. If too far: leaves untreated refluxing segment that will drive recurrence.
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Tumescent is the procedure. Adequate tumescent anesthesia is the most important step — it provides analgesia, collapses the vein for better ablation, and protects the skin and nerve from thermal injury. Never rush the tumescent injection.
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Duplex at 1 week is mandatory. EHIT is the major short-term complication. Grade 2–4 EHIT requires anticoagulation. Catch it early on routine 1-week surveillance.
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Patient must walk after procedure. Immediate post-procedure ambulation reduces DVT risk. Send patients home walking — do NOT allow them to lie still for hours after procedure.
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Foam sclerotherapy concentration matters. 1% polidocanol for telangiectasias/fine veins. 3% for larger tributaries (>3 mm). Never use foam in patients with known cardiac shunt (patent foramen ovale) — systemic embolization risk.
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References

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Key Guidelines

  • Society for Vascular Surgery/American Venous Forum Clinical Practice Guidelines: Management of Varicose Veins (2011, updated 2022)
  • NICE Guidelines NG168 (2020)

Primary References

  • Gloviczki P, et al. SVS/AVF clinical practice guidelines on the management of varicose veins. J Vasc Surg. 2011.
  • Luebke T, Brunkwall J. Systematic review and meta-analysis of endovenous radiofrequency obliteration versus conventional stripping surgery. J Cardiovasc Surg. 2008.
  • Rasmussen L, et al. Randomized clinical trial comparing endovenous laser ablation, radiofrequency ablation, foam sclerotherapy and surgical stripping for great saphenous varicose veins. Br J Surg. 2011.