Should Varicose Veins Be Treated All at Once?

In many patients with symptomatic varicose veins, treating the main leaking vein and the visible bulging veins in the same session gives a more complete treatment and may reduce the chance of needing a second procedure.

Modern varicose vein treatment is usually performed under local anaesthetic. The underlying leaking vein is commonly treated with radiofrequency ablation, often called RFA. However, many patients also have visible bulging varicose veins on the calf or thigh. These are tributary veins, or branches, that have enlarged because blood is flowing the wrong way in the superficial venous system.

A key question is whether these visible veins should be treated at the same time as RFA, or whether the main vein should be closed first and the remaining varicose veins dealt with later.

Treating the cause and treating the visible veins

Radiofrequency ablation treats the underlying source of reflux. A fine catheter is passed into the leaking long saphenous vein or short saphenous vein under ultrasound guidance. Heat is then used to close the vein from the inside.

RFA is an excellent treatment for the main leaking vein. But RFA alone does not always remove the visible bulging veins. Some of these veins may shrink after the main vein has been closed, but not all of them do. This means some patients who have RFA alone may need to return for further treatment.

What are phlebectomies or avulsions?

Phlebectomies, also called avulsions, are a way of removing larger superficial varicose veins through tiny incisions. They are usually performed under local anaesthetic at the same time as RFA. The incisions are very small and usually do not need stitches.

This technique is particularly useful for larger, bulging, palpable varicose veins that are unlikely to disappear completely after treating the main vein alone.

What is foam sclerotherapy?

Foam sclerotherapy involves injecting a foam medication into abnormal veins to make them close. It can be useful for smaller, tortuous, recurrent, or residual veins, and for veins that are less suitable for removal through tiny incisions.

Foam is sometimes used as the main treatment, but it can also be used alongside RFA and phlebectomies as part of a complete treatment plan.

Should the visible veins be treated at the same time?

In my practice, where it is clinically appropriate, I usually treat the main leaking vein and the significant visible varicose veins in the same procedure. This may involve RFA of the long or short saphenous vein, combined with phlebectomies for larger bulging veins and selective foam sclerotherapy for smaller tributaries.

The reason is straightforward. Varicose vein treatment is not just about closing one vein on an ultrasound scan. It is about treating the pattern of reflux and the veins that are causing symptoms, heaviness, aching, swelling, skin irritation, and visible bulging.

What does the evidence say?

Clinical guidelines and published studies support considering treatment of significant tributary veins at the same time as treatment of the main leaking vein. Some tributary veins will shrink after RFA alone, but a proportion of patients need further treatment if visible veins are left untreated.

Treating the visible varicose veins at the same time can reduce the likelihood of needing a second procedure and may give a better early improvement in symptoms and appearance. The exact approach should still be tailored to the patient, their duplex ultrasound findings, the size and pattern of the veins, and their own priorities.

Is staged treatment ever the right approach?

Yes. Staged treatment can be entirely reasonable in selected patients. For example, it may be better to treat the main vein first if the visible veins are relatively minor, if the anatomy is complex, if there are skin concerns, if the patient is on blood-thinning medication, or if a shorter initial procedure is preferable.

Some patients also prefer a more conservative approach, accepting that they might need further treatment later.

This is why an individual consultation and a proper duplex ultrasound scan are important. The decision should be based on the pattern of reflux, the visible veins, the risks and benefits of treatment, and what the patient wants to achieve.

Consultant-led, complete vein treatment

I believe varicose vein treatment should be planned as a complete treatment pathway, not simply as a single-vein procedure. The aim is to identify the source of reflux, treat the main leaking vein, and deal with the significant visible varicose veins where appropriate.

For many patients, this means treating the main vein and the visible varicose veins at the same time. This can mean a simpler journey, fewer treatment episodes, and a more complete early result.

Frequently asked questions

Can varicose veins be treated all at once?

In many patients, yes. The main leaking vein and the visible bulging varicose veins can often be treated in the same session under local anaesthetic.

Is RFA alone enough?

Sometimes it is. Some visible veins shrink after the main leaking vein has been treated. However, larger bulging veins often need additional treatment with phlebectomies or foam sclerotherapy.

Is it better to have phlebectomies or foam?

It depends on the veins. Larger superficial bulging veins are often best treated with phlebectomies. Smaller, tortuous, recurrent, or residual veins may be better treated with foam sclerotherapy.

Will I need a general anaesthetic?

Usually not. RFA, phlebectomies, and foam sclerotherapy can often be performed under local anaesthetic as a walk-in, walk-out treatment.

Is this suitable for everyone?

No. The best treatment depends on your symptoms, examination findings, duplex ultrasound scan, skin condition, medical history, and personal preference.

This information is general and is not a substitute for individual medical advice. A consultation and duplex ultrasound scan are needed before deciding which treatment is most appropriate for you.