Varicosities of the lower extremity, new approaches: cosmetic or therapeutic needs?

Varicose veins of the lower extremity (VVLE) are a frequently encountered vascular disorder in the general population. The general view that VVLE are a non-serious disease with primarily aesthetic impact is a common misconception, as the disease can have a significant negative impact on generic and disease-specific quality of life. Further, VVLE may be associated with potentially threatening clinical conditions, such as chronic venous ulceration, venous thromboembolism and haemorrhage from ruptured varicose veins. In the case of symptomatic varicose veins, in the presence of advanced lower limb skin changes or when venous complications occur, a referral for dedicated evaluation by the vascular medicine specialist is recommended. The initial diagnostic test of choice to detect the extent of the varicose disease and to plan treatment is duplex ultrasound. Traditionally, compression therapy, surgical high ligation and stripping of the truncal veins have been considered standard of care for VVLE. Driven by the aim to reduce surgical trauma and improve the long-term effectiveness, minimally invasive treatment options have been developed in the last two decades, namely endovascular vein ablation techniques (EVA). Endovenous laser ablation and radiofrequency ablation have been established as first-line treatments for varicose veins associated with axial reflux on the basis of the most recent international guidelines. For practical purposes and depending on the concrete clinical situation, the various EVA and surgical techniques are often combined, leading to multimodal varicose vein therapy management. Knowledge of the different techniques is of utmost importance for the vascular medicine specialist. The purpose of this article is to provide an overview of the new EVA techniques and to elucidate the different therapeutic strategies for VVLE.