Venous insufficiency that is not significant, as determined by the severity of symptoms and the venous ultrasound findings, does not necessarily require any kind of invasive treatment, but just conservative management.
Early stage spider or varicose veins may be primarily a cosmetic problem and it is absolutely reasonable to seek treatment for cosmetic reasons, particularly if the risks of the procedures offered are minimal.
Severe cases of varicose veins, especially those involving ulcers, typically require treatment.
Varicose veins are frequently treated by eliminating the "bad" veins. This forces the blood to flow through the remaining healthy veins. Various methods can be used to eliminate the problem. Advertisements for treating venous disease often tout "unique, "permanent", "painless" or "absolutely safe" methods, making it difficult to decide on the best treatment. Treatment can be lifestyle changes with medical treatment, sclerotherapy, vein laser or radiofrequency ablation and surgery (vein stripping / saphenectomy). All options have a place in contemporary practice and your vascular surgeon will guide you towards the best option.
Conservative Treatment
Symptoms may be alleviated and the disease progression will slow down with simple lifestyle changes, compression stockings and occasionally some medication.
If you have mild to moderate varicose veins, elevating your legs can help reduce leg swelling and relieve other symptoms. Try to elevate your feet above the level of your heart 3 or 4 times a day for about 15 minutes at a time. You may sleep at night with your feet on a pillow. When you sit try to place your legs on a stool. If you need to sit or stand for a long period of time, flexing (bending) your legs occasionally can help keep blood circulating.
Exercise will also help your symptoms improve. Walking or running make your calf and thigh muscles contract, thus acting like a pump that pushes blood upward.
Compression stockings are particularly important. These elastic stockings squeeze the venous blood out of the leg back to the heart. Most compression stockings are worn just below the knee and there is no additional benefit with thigh-high stockings. These stockings are tight at the ankle and become looser as they go up the leg. This causes gentle external compression (pressure) on your leg. It is recommended that the compression pressure is 20-30 mmHg and they should be worn daily. Ideally they should be worn early morning after wake up when the swelling is minimal and removed before bed time. Compression stockings may help prevent the need for more invasive treatment. They will also help with healing of skin sores and prevention of new ones.
No medication can make spider and varicose veins disappear. There are however some drugs (venotonics) and nutritional supplements that may alleviate the symptoms of venous insufficiency by improving the venous wall contractility. Their use is controversial in between vascular professionals, but still they may have some role in a selected subgroup of patients. Discuss with your doctor.
Sclerotherapy (injections)
Sclerotherapy is the most common treatment for both spider and varicose veins and many times will follow an endovenous ablation procedure or surgery. It is wrong to start with sclerotherapy of spider veins before checking for underlying venous insufficiency that should be treated first. Many spider and some varicose veins will disappear if the deeper and larger veins, that are feeders of the spider veins, are removed. The residual ones can be taken care with sclerotherapy.
Sclerotherapy involves injection with a tiny needle of a liquid chemical solution into the spider veins that causes them to harden so that they no longer fill with blood. The veins that received the injection will eventually shrivel and disappear. The scar tissue is absorbed by the body. For larger varicose veins the chemical solution can be more effective if used as foam (instead of liquid). The procedure is called foam sclerotherapy and it can be done in deeper veins requiring ultrasound guidance.
Both "straight" and foam sclerotherapy are essentially painless and the process takes 20-40 minutes depending of the size of the treated area. The leg will then be dressed in a stocking or multilayer compression dressing for 48 continuous hours and then daily for 2 weeks (no need to wear them during the night sleep). You will need to return to your vascular surgeon's office in 2 weeks for reassessment and to continue sclerotherapy as needed. In most cases, more than one treatment session will be required. You should also expect that sclerotherapy in really big bulging varicosities may result in redness and tenderness of the injected area that may need a few months to resolve. In such cases mini phlebectomies may be preferable.
Sclerotherapy as all medical interventions carries some risks, rare (less than 1%) but sometimes can be quite critical: skin discoloration and skin necrosis that will heal overtime, allergic reaction and deep venous thrombosis (extremely rare).
Endovenous Ablation (Laser or Radiofrequency)
Endovenous ablation with either laser or radiofrequency, has largely replaced the traditional surgery (vein "stripping") in the management of venous insufficiency. It is usually used for the great or small saphenous veins, or any other superficial vein that may be insufficient. Both laser and radiofrequency ablation are essentially similar procedures with similar outcomes and risks. Overall they are highly effective with minimal complications. No incisions are required and they can be done in an office environment. Endovenous laser ablation should not be confused with the skin laser done for spider veins. Endovenous ablation targets the larger veins that are feeders of the spider veins.
Using real-time ultrasound guidance, the diseased vein is identified and a catheter is inserted into the vein through a puncture. Local anesthesia is injected around the vein, first isolating it from surrounding tissues and, then, making vein area numb. Once the anesthesia has reached the vein, the laser or radiofrequency is activated and heats (ablates) the vein from inside. The leg will be then placed into compression stocking or wrapped with multilayer compression which you need to keep continuously for 48 hours and then daily for 2 weeks (no need to wear them during the night sleep). You may walk out of the office within 2-3 hours and resume your activities immediately.
The ablated vein will gradually clot, harden, shrink and disappear. The blood will continue to flow through the other healthy veins of the leg. You will need to return to your vascular surgeon's office in 2 weeks for reassessment and to continue with sclerotherapy as needed.
Endovenous ablation therapies, as all medical interventions, carry some risks, rare (approximately 1%) but sometimes can be quite critical: skin discoloration, skin burn or necrosis that will heal overtime and deep venous thrombosis.