Laser, Sclerotherapy or Medical Glue: Which Varicose Vein Treatment to Choose

Patients often come to an appointment with their mind already made up. Some have read about medical glue and want only that, some heard from a friend that "injections" helped her without any surgery, and some are set on laser treatment because that is how their father was treated. The patient's wishes matter, but the choice of varicose vein treatment is not decided by advertising or a neighbour's experience. It is decided by what the phlebologist sees on the ultrasound screen.

At Chekhovskyi Clinic Verika we perform all three techniques: endovenous laser ablation, vein closure with medical glue and sclerotherapy. So we have no reason to "promote" any single method. Over more than 15,000 procedures, a clear decision logic has taken shape, and below we will walk through it step by step: which vein parameters matter, when laser remains the best option, in which cases glue really wins and why sclerotherapy is rarely the only stage of treatment.

It all starts with an ultrasound, not with the name of a procedure

A varicose vein you can see on the skin is usually a consequence rather than the cause. The cause typically lies deeper: the valves in the great or small saphenous vein stop working, blood flows backwards, and this backward flow (reflux) gradually stretches the tributaries. If you remove only the visible bulging veins and leave the source of reflux, the varicose veins will come back.

People usually see a doctor because of heavy legs in the evening, burning, night cramps or skin discoloration on the lower legs. We explained in detail how these signs are linked to the veins in our article on impaired circulation in the legs. But whatever the symptoms, the first step is always the same: a phlebologist consultation with a duplex ultrasound scan.

During an ultrasound of the leg vessels, the doctor checks several things that later determine the choice:

• whether there is reflux and which vein it starts from;
• the diameter of the affected vein at different levels of the thigh and lower leg;
• how tortuous the main vein is and whether a catheter can pass through it;
• how deep the vein lies under the skin and what is located next to it;
• the condition of the deep veins and perforators, and whether there are any blood clots.

Two people with equally visible veins can receive different recommendations. One has a problem in the great saphenous vein in the thigh, the other in the small saphenous vein in the lower leg, which runs next to a sensory nerve. The legs look similar, but the technical conditions for treatment are completely different.

Phlebologists describe the stage of the disease using the international CEAP classification. Class C1 means spider veins and reticular veins, C2 varicose veins, C3 swelling, C4 skin changes, C5 and C6 a healed and an open venous ulcer. The classification shows how severe the condition is, but on its own it does not tell you how to treat it. Besides, not every case of swelling has a venous cause, as we discuss in our article on leg swelling at the end of the day.

Three levels of the problem: main vein, tributaries and small vessels

It helps to picture the venous system of the leg as a tree. The trunk, meaning the great or small saphenous vein, carries most of the blood. Tributaries branch off from it, and these are what form the familiar twisted bulges. Further out are reticular veins a few millimetres in diameter and the finest capillaries that look like a web or spider veins.

Each level is treated with its own tool. Laser and glue are designed to close main veins and long straight vein segments: a thin catheter is guided into the vein under ultrasound and the vessel is closed from the inside. Sclerotherapy deals with tributaries, reticular veins and spider veins, where a catheter simply cannot go. Hence the main idea of this article: for the most part the three methods do not compete with each other, they close different parts of the same tree.

Laser ablation: when it remains the first choice

Endovenous laser ablation (EVLA) closes the vein with heat. A light guide is inserted into the vessel through a small puncture, a "cushion" of local anaesthetic solution is created around the vein (so-called tumescent anaesthesia), and as the doctor slowly withdraws the light guide, the laser seals the wall from the inside. Over time the closed vein turns into a strand of connective tissue and is gradually absorbed.

In its 2022 clinical practice guidelines, the European Society for Vascular Surgery names endovenous thermal ablation as the first choice treatment for great saphenous vein incompetence. The reasons are many years of evidence, a high rate of lasting closure and predictable results even when the vein is large.

In practice, we offer laser treatment in these situations:

• the main vein is straight enough and the catheter passes without obstruction;
• the vein has a large diameter or there is a long segment of reflux in the thigh;
• the patient tolerates local anaesthesia well and can wear compression stockings for a few weeks;
• the person has reacted to medical adhesives before or a glue allergy is suspected, so glue cannot be used.

Modern 1470 nm lasers with radial light guides distribute energy evenly around the circumference of the vein wall. Compared with earlier generations of equipment, this has noticeably reduced pain and bruising after the procedure, so in the first days most patients manage with ordinary painkillers or do not need them at all.

The downsides are also worth knowing in advance. Tumescent anaesthesia means several injections along the vein, so bruising and a feeling of tightness are possible after the procedure and can last a few days. In the lower leg, sensory nerves run next to the small saphenous vein and the lower segment of the great saphenous vein. Here the doctor works especially carefully and sometimes deliberately chooses a method without heat.

Medical glue: when it really wins

Vein closure with medical glue works without heat. A catheter is guided into the main vein under ultrasound and medical cyanoacrylate glue is delivered in small portions while the doctor presses the vein with the probe for a few seconds. The walls stick together and blood continues through healthy veins. There is no heating, so tumescent anaesthesia is not needed either: only the puncture site is numbed. At our clinic the procedure itself takes roughly 10 to 30 minutes. Verika was the first clinic in Western Ukraine to use the VenaBLOCK system, so the clinic has extensive experience with it.

Glue offers the most benefits when:

• a vein needs to be closed in the lower leg near nerves, where heat is undesirable;
• the patient finds a series of anaesthetic injections hard to tolerate;
• the person cannot wear compression stockings because of heat, the nature of their work or skin problems (in most cases compression is not needed after glue);
• it is important to get back to work, training or a business trip the very next day.

At the same time, glue is not suitable for everyone. It is not used in people allergic to cyanoacrylates, in acute thrombosis, during pregnancy or breastfeeding. Some patients develop redness and tenderness over the closed vein for a few days: this is how the tissues react to the glue, and the reaction resolves on its own or after a short course of anti-inflammatory medication. The procedure is usually more expensive than laser treatment because a separate single-use kit is used for each patient. That is why we offer glue when it gives the person a real advantage, not by default.

Sclerotherapy: from spider veins to tributaries under ultrasound guidance

Sclerotherapy closes a vein without a catheter. Using a fine needle, the doctor injects a sclerosant into the vessel, which damages its inner lining. The walls stick together and over time the vein is absorbed. Depending on the size of the vessel, a liquid or foam form of the drug is used.

Classic sclerotherapy with a liquid drug is intended for spider veins and reticular veins. Class C1 is often seen as a purely cosmetic problem, although a web of veins on the legs sometimes comes with heaviness and burning. We discussed why spider veins appear and how they can be treated in our article on spider veins on the legs.

Larger vessels are treated with foam echosclerotherapy. The drug is mixed with air into a fine foam that pushes blood out of the vein and stays in contact with its wall for longer. Everything is done under ultrasound guidance, so the doctor can see exactly where the foam spreads. This method is used to treat:

• varicose tributaries in the thigh and lower leg;
• incompetent perforator veins;
• recurrent veins after previous surgery;
• bulging veins that remain after laser or glue treatment.

Foam sclerotherapy can also close a main vein, but when the great saphenous vein is large, it reopens more often after foam than after thermal ablation or glue. So for the main vein we mainly consider foam when catheter methods are unsuitable for some reason: for example, in an elderly person with several other conditions or when the vein is very tortuous.

Sclerotherapy is rarely done in one go. Several sessions a few weeks apart are usually needed. After the procedure, temporary pigmentation or a firm cord may remain along the vein and gradually fade. Contraindications include acute thrombosis, pregnancy, allergy to the sclerosant and, for the foam form, a known patent foramen ovale if there have been neurological symptoms in the past.

The results of sclerotherapy are not visible straight away. Spider veins fade gradually over several weeks, and the final result is assessed after about two or three months. That is why a repeat session is not scheduled earlier: the doctor needs to see which vessels have already closed and which need more treatment.

Why one patient often gets two methods

The most common situation at an appointment looks like this: reflux in the great saphenous vein in the thigh and several prominent tributaries in the lower leg. If only the tributaries are treated, pressure from the main vein will stretch them again. If only the main vein is closed, some of the bulging veins will collapse over time, but others will remain visible.

So the logical plan usually has two stages:

1. the source of reflux in the main vein is closed with laser or glue;
2. the remaining visible tributaries are removed with foam sclerotherapy.

Sometimes both stages are done on the same day, and sometimes sclerotherapy is postponed for a few weeks to see which veins collapse on their own. Overall, the patient has fewer procedures and a better cosmetic result.

Another typical story: a woman with a noticeable web of spider veins wants cosmetic treatment only. We still do an ultrasound before sclerotherapy, because in some of these patients the spider veins are fed by an incompetent main vein or perforator. If that source is not dealt with, a new web appears within a few months and the person becomes disappointed with the method, even though the method was not the problem.

Even after good treatment, varicose disease can affect other veins over time, because the predisposition does not go away. That is why we recommend a follow-up ultrasound after about a year: it helps spot a new area of reflux early, when it is easy to close without a full procedure.

What affects the decision besides the vein itself

The ultrasound picture sets the boundaries, and within them the doctor takes the person's life into account. A job on your feet, a planned holiday or a competition all affect whether a method that requires three or four weeks of compression is convenient. People who run or go to the gym regularly should know in advance when they can return to training. Our article on sport with varicose veins is dedicated to this topic.

General health matters too. Before choosing a method, the doctor will always ask:

• whether you take anticoagulants or other drugs that affect blood clotting;
• whether you have had deep vein thrombosis in the past;
• whether you have had allergic reactions to medicines, anaesthetics or medical materials;
• whether you have joint problems that make it hard to walk actively after the procedure.

Planned vein procedures are not performed during pregnancy: treatment is postponed until after childbirth and the end of breastfeeding, and until then compression remains the mainstay. Read more about this period in our article on varicose veins during pregnancy.

We discuss the budget separately. Glue is usually more expensive than laser, while a course of several sclerotherapy sessions can add up to a cost comparable to one catheter procedure. The doctor explains what the price is made up of and suggests the option that solves the medical problem, not simply the most expensive or the cheapest one.

Compression and recovery after each method

After laser ablation, the patient walks home the same day, and compression stockings are usually recommended for one to several weeks. After sclerotherapy, compression helps the vein seal better and reduces the risk of pigmentation. After glue, stockings are not needed in most cases, although the doctor may prescribe them if tributaries were treated with foam sclerotherapy on the same day.

The compression class and size matter: stockings that are too weak have no effect, and ones that are too tight impair circulation. That is why compression stockings are fitted individually based on leg measurements. General rules for the first weeks after a procedure, from walks to hot baths, are collected in our article on rehabilitation after varicose vein surgery.

How to prepare for your consultation

To get the most out of your appointment, it is worth preparing in advance:

• bring the results of previous vein ultrasounds, if you have them;
• make a list of the medicines you take regularly;
• bring discharge summaries from any previous vein procedures;
• think about when you will have a few days to recover and whether there are reasons why wearing compression would be difficult;
• wear comfortable clothing so the doctor can examine your leg from groin to foot.

At the consultation, the phlebologist will show you on the screen exactly where the reflux is, explain which areas need treatment and suggest one or more options with their advantages and limitations. If you are interested in a particular method, say so directly. The doctor will honestly explain whether it suits your case and why.

Laser, glue and sclerotherapy share the same goal: to close the diseased vein and redirect blood into healthy vessels. What differs is the tool, so the right question is not "which method is best" but "which method is best for this vein in this person". The answer comes from an ultrasound examination and the doctor's experience, so it is worth having the examination before choosing a procedure, not after.