01Purpose and principlesWhat the treatment does and how it fits into care.
Intervention aims to abolish a pathological superficial reflux pathway, reduce venous hypertension and improve symptoms or complications. It does not remove the person's lifelong tendency to venous disease. Duplex must match symptoms and skin changes to a treatable truncal source, define the great or small saphenous course and junctions, and identify deep obstruction or reliance on superficial collaterals. Endothermal ablation, usually radiofrequency or endovenous laser, places a catheter within the refluxing trunk and delivers controlled thermal energy while tumescent anaesthetic surrounds the vein. The treated vein fibroses and is no longer a reflux conduit; physiological venous return continues through competent deep and remaining superficial channels.
NICE CG168 gives a clear sequence for confirmed truncal reflux: offer endothermal ablation; if it is unsuitable, offer ultrasound-guided foam sclerotherapy; if foam is unsuitable, offer surgery. That hierarchy is a decision framework rather than a promise that one procedure fits every anatomy. Tortuous access, a very superficial vein, previous intervention, thrombosis, deep venous disease, pregnancy, patient preference and local expertise all affect suitability. Avulsion or foam can treat tributaries during the same session or later. Consent must cover incomplete occlusion, residual tributaries, recurrence, thrombophlebitis, pigmentation, nerve injury, burns, wounds and VTE, with technique-specific neurological and visual effects for foam.
Key points
- Confirm symptomatic truncal reflux with duplex before intervention; identify the refluxing target, deep-vein patency and anatomy that may make superficial ablation unsafe or ineffective.
- For confirmed truncal reflux, NICE offers endothermal ablation first, ultrasound-guided foam sclerotherapy if endothermal treatment is unsuitable, and surgery if foam is unsuitable.
- Explain that treatment may require more than one session, new or recurrent veins can develop, and post-procedure DVT or PE symptoms require urgent assessment.
- Endothermal techniques close the treated trunk using heat delivered by an intraluminal catheter; tumescent anaesthesia separates and protects surrounding tissue as well as providing local anaesthesia.
- Foam displaces blood and exposes endothelium to sclerosant, but concentration and volume are vein-specific and must follow the product licence and trained ultrasound-guided technique.
- High ligation and stripping remains a useful concept when minimally invasive options are unsuitable, although wounds, haematoma, infection, nerve injury and recovery burden are greater concerns.
- Treating a refluxing trunk and treating visible tributaries are related but distinct tasks; tributary phlebectomy or sclerotherapy may be simultaneous or staged.
- Routine compression after intervention is an individual procedural decision; NICE advises that when offered it should not be used for more than seven days.
02Indications, selection and cautionsWho may benefit, who needs urgent treatment and important alternatives.
Symptoms such as aching, heaviness, swelling, itching or venous skin change should map to reflux in a named truncal vein on duplex. Visible tributaries alone do not show which axial pathway requires treatment.
A cannulatable, reasonably straight refluxing segment with a safe relationship to skin and nerves favours catheter treatment. Severe tortuosity, inaccessible segments or anatomy near vulnerable structures may alter technique.
Foam can traverse tortuous veins and recurrent networks without surgical exposure. Assess previous thromboembolism, thrombosis risk, migraine with aura, pulmonary hypertension and patent foramen ovale concerns before selecting it.
Ligation and stripping may be considered when foam is unsuitable or when anatomy and specialist judgement favour open treatment. Previous scars, obesity, anticoagulation and wound-healing risk influence consent and planning.
Local bruising, tightness, tenderness and superficial phlebitis can follow any occlusive treatment. Distinguish these from spreading infection, extensive thrombosis, sensory or motor deficit, and acute arterial compromise.
03Assessment before treatmentTests and checks that guide safe selection.
Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.
- 01
Full lower-limb venous duplex ultrasoundFirst step - Why
- Confirm the reflux source, map truncal and tributary anatomy, and establish deep-vein patency before treatment.
- Interpretation and limitations
- A named refluxing trunk that fits the clinical territory is a procedural target. Deep obstruction, post-thrombotic change or important superficial collaterals require specialist interpretation before ablation.
- 02
Procedure-planning ultrasound - Why
- Measure diameter and depth, choose access, trace tortuosity and locate junctions, perforators and nearby vulnerable structures.
- Interpretation and limitations
- A superficial segment may need extra tumescent separation or another technique; tortuosity may prevent catheter passage but remain accessible to carefully controlled foam.
- 03
VTE risk assessment - Why
- Identify previous VTE, thrombophilia, active cancer, immobility, hormonal exposure and other factors relevant to thromboprophylaxis and foam suitability.
- Interpretation and limitations
- Risk does not automatically dictate one treatment, but high thrombotic risk can contraindicate licensed sodium tetradecyl sulfate and should prompt an explicit specialist plan.
- 04
Arterial assessment when compression is contemplated - Why
- Check pulses and investigate suspected peripheral arterial disease before firm post-procedure compression or concurrent ulcer care.
- Interpretation and limitations
- Reduced perfusion changes safe compression and may redirect priorities; incompressible ankle vessels can make ABPI misleading and require alternative vascular assessment.
- 05
Targeted post-treatment duplex - Why
- Assess occlusion and exclude extension into deep veins when symptoms, technique or local protocol make imaging appropriate.
- Interpretation and limitations
- A treated closed segment is expected; thrombus propagating into a deep vein or a new symptomatic DVT requires entry to a formal VTE management pathway.
04Treatment approachPreparation, options, escalation and aftercare.
01Treatment selectionConfirmed symptomatic truncal refluxFirst stepUse after specialist clinical assessment and duplex have demonstrated a refluxing superficial trunk that explains symptoms or complications.+
- 1Offer endothermal ablation when the target can be accessed and treated safely, explaining catheter placement, tumescent anaesthesia, expected discomfort and alternatives.
- 2If endothermal treatment is unsuitable, consider ultrasound-guided foam after checking product contraindications and counselling about pigmentation, phlebitis, VTE, visual and neurological effects.
- 3If foam is also unsuitable, discuss surgery, commonly junctional control with stripping and tributary phlebectomy, including anaesthesia, wound, nerve and recovery implications.
- 4Plan tributary treatment at the same session or later and document how success, residual symptoms and recurrence will be reviewed.
02Endothermal pathwayPreferred endothermal pathwayPreferredUse when a suitable refluxing great or small saphenous segment makes catheter-based thermal closure the preferred agreed procedure.+
- 1Use ultrasound to access the target, position the catheter safely relative to the deep junction and infiltrate tumescent anaesthetic around the vein.
- 2Deliver radiofrequency or laser energy along the planned segment, then mobilise the patient and apply the agreed dressing or short compression course.
- 3Give written advice on expected soreness and urgent VTE, arterial, infection or neurological warning symptoms, with a clear route for review.
03Foam pathwayUltrasound-guided chemical ablationUse when endothermal treatment is unsuitable and sclerosant foam is appropriate for the vein, patient and licensed product.+
- 1Confirm deep patency and the target under duplex, keep the foam injection site at least 8 to 10 cm from the saphenofemoral junction for truncular varicosities, select the lowest effective licensed concentration and observe the maximum total foam volume per session.
- 2Prepare foam immediately before use and inject small intravenous aliquots under trained ultrasound guidance while preventing extravasation or intra-arterial delivery.
- 3Observe for hypersensitivity, visual or neurological symptoms and provide follow-up able to detect phlebitis, pigmentation, recanalisation and thromboembolism.
04Surgical pathwayOpen treatment and tributary removalUse when foam is unsuitable or open surgery is selected after anatomy, comorbidity, anaesthesia and patient preference are considered.+
- 1Mark refluxing anatomy with duplex and decide the extent of junctional ligation, stripping and phlebectomy without removing functioning collateral pathways needed for drainage.
- 2Provide appropriate anaesthesia and thrombosis prevention, protect the saphenous or sural nerve territory, and secure haemostasis through the operative field.
- 3Review wounds, haematoma, sensory disturbance, infection and VTE symptoms, then reassess persistent or recurrent veins rather than assuming immediate failure.
05Regimens, contraindications and interactionsTreatment details and the circumstances that modify them.
Sodium tetradecyl sulfate foam (Fibrovein 1% or 3%)
Inject intravenously in 0.5–2 mL foam aliquots at suitable sites; maximum total foam volume is 16 mL per session. Because volume is limited, repeated sessions are usually needed, with 2 to 4 sessions on average.Specialist ultrasound-guided administration only; for truncular varicosities keep the foam injection site at least 8 to 10 cm from the saphenofemoral junction. Contraindications include recent SVT, DVT or PE, high thrombotic risk, occlusive arterial disease and symptomatic PFO for foam. Postpone in pregnancy; avoid extravasation and intra-arterial injection.
06Complications, monitoring and follow-upAdverse effects, response and longer-term review.
- Confirm that the intended truncal segment has been treated and that symptoms, swelling, skin change or ulcer trajectory are improving at the planned review.
- Ask specifically about calf swelling, chest pain, breathlessness, visual disturbance, migraine, focal neurological symptoms and severe limb pain during the early post-procedure period.
- Examine puncture or wound sites, tributary thrombophlebitis, pigmentation, sensory loss and distal perfusion; use duplex promptly when thrombus extension or technical failure is suspected.
- Review residual symptomatic tributaries and decide whether planned staged phlebectomy or sclerotherapy remains necessary after the truncal effect has settled.
- Reassess recurrent symptoms with a new clinical and duplex map because recanalisation, neovascularisation and reflux in another trunk need different responses.
07Special situationsVariants, exceptions and circumstances that change the usual approach.
Hierarchy follows suitability
NICE's sequence preserves an effective minimally invasive option while acknowledging anatomical and patient constraints. Moving to foam or surgery should have a recorded reason rather than reflect appearance alone.
Closure is not extraction
Endothermal and foam methods leave a treated vein in situ to fibrose, whereas stripping removes a segment. All three aim to interrupt reflux, and clinical benefit matters more than whether a cord remains palpable briefly.
Tributaries may be staged
Prominent branches can shrink once axial reflux is abolished. Treating every visible vein immediately may add morbidity; a planned reassessment distinguishes residual disease from a normal settling period.
Foam has unique screening
Bubble passage can provoke visual, migraine or rare neurological effects. A symptomatic PFO is a licensed contraindication, while migraine with aura or prior TIA demands particular caution and product-specific review.
Recurrence has several mechanisms
Recanalisation, untreated tributaries, new reflux in another trunk and neovascularisation after surgery are different findings. Repeat duplex identifies the mechanism before another procedure is chosen.
08Common pitfallsFrequent interpretation and management errors.
- 01
Selecting a procedure from visible-vein pattern without a duplex reflux map risks treating a tributary while leaving the pathological trunk or deep obstruction unrecognised.
- 02
Describing foam as a harmless injection omits hypersensitivity, tissue necrosis after extravasation or arterial injection, thromboembolism and neurological or visual adverse effects.
- 03
Offering surgery simply because veins are large bypasses the national sequence; size alone does not establish that endothermal ablation and foam are unsuitable.
- 04
Interpreting a tender treated cord as automatic DVT can cause unnecessary alarm, but failing to investigate new whole-leg swelling or cardiopulmonary symptoms is dangerous.
- 05
Promising permanent eradication undermines consent because new reflux and recurrent varicosities can develop after technically successful treatment.