Introduction

Chronic venous disease (CVD) is a long-lasting morphological or functional abnormality of the venous system leading to the occurrence of subjective and/or objective symptoms that require diagnosis and appropriate management.

Treatment methods for chronic venous disease include:

• conservative treatment, which includes compression therapy and pharmacotherapy,
• surgical treatment, which includes classic Babcock’s surgery, endovenous thermal ablation, methods of mechanical-chemical vein ablation, and chemical ablation using obliterating drugs such as sclerotherapy and glue.

Depending on the therapeutic measures taken, 20–40% of patients experience a recurrence of the disease, which is described as recurrent varicose veins. They are a significant clinical problem, defined as the appearance of new varicose veins in a previously treated area or in another location on the same limb.

Risk factors for recurrent varicose veins include: inappropriate intervention (e.g., inadequate pre-operative duplex ultrasound, not identifying the source(s) of reflux, inadequate choice of cannulation site(s)), errors during the procedure (e.g., poor ultrasound visualisation of the target segment, insufficient delivery of energy/glue/sclerosant to the target segment), neovascularisation, recanalisation, development of venous reflux as a result of the natural course of the disease, with reflux occurring in new locations, advanced age, female gender, prolonged standing, increased BMI, earlier recurrence of the disease and pelvic venous reflux.

The aim of this case report is to describe the case of a patient with recurrent varicose veins who underwent laser thermal ablation of the left great saphenous vein (GSV) stump with sclerotherapy of neoangiectasia in the groin. The remaining part of the GSV on the thigh was also treated with a laser, and sclerotherapy was performed on the thigh and calf (Figures 1–3).

Case report

In April 2025, a 54-year-old patient visited JBS Phlebology Clinic, Specialist Medical Center of Phlebology in Gdansk for diagnosis and treatment due to recurrent varicose veins in the left lower limb. The patient had undergone 3 classical procedures and had recurring varicose veins complicated by thrombosis. Due to the changed anatomy of the veins and the patient’s previous surgical interventions, ultrasound diagnostics before the procedure was crucial for evaluation and planning the surgery. The patient reported symptoms such as pain, swelling, a feeling of heaviness in the limb, and itching of the skin over the varicose veins.

To assess the degree of clinical severity and treatment effectiveness the following were used:

1. Revised venous clinical severity score:

• before treatment: pain – 2 (moderate), varicose veins – 3 (severe), oedema – 2 (moderate), pigmentation – 2 (moderate), compression – 1 (mild), total – 10 points,
• after treatment: pain – 0, varicose veins – 0, oedema – 0, pigmentation – 1 (mild), compression – 1 (mild), total – 2 points;

    2. Clinical etiological anatomical pathophysiological classification:

• C4c – changes in skin and subcutaneous tissue secondary to CVD,
• Es – secondary,
• As2 – superficial, great saphenous vein, above knee,
• Pr – reflux.

The patient underwent a Doppler ultrasound of the left lower limb veins. A wide, incompetent stump of the left GSV approximately 40 mm long was identified in the groin (about 30 mm above the inguinal ligament). Below, an incompetent wide neoangiectasia is shown, connecting with a remaining fragment of the left great saphenous vein, 7 mm in diameter, on the thigh, from which numerous varicose veins branch off into the thigh and calf.

Treatment applied

During the first visit, the patient was presented with treatment options. Due to the remaining long and wide left GSV stump, the proposed surgical treatment consisted of two stages.

The first stage involved laser thermal ablation of the left GSV stump (using a 1940 nm laser) in local tumescent anaesthesia. Another laser puncture was performed on the thigh, and a catheter was inserted into the remaining part of the GSV. During the same procedure, sclerotherapy of neoangiectasia was performed using 4 ml of 3% Polidocanol (POL) foam. 8 ml of 3% POL foam was administered to the varicose veins on the thigh. Compression therapy was applied using a 2^nd compression class stocking. As thromboprophylaxis, a low molecular weight heparin was used for four days.

The second stage involved sclerotherapy of varicose veins on the calf. This procedure was performed one month after the previous one. 8 ml of 2% POL and 2 ml of 1% POL were administered.

Before the second procedure, an ultrasound was performed, which showed closed varicose veins on the thigh. A thrombectomy (evacuation of blood clots from the closed varicose veins) was performed. This procedure was repeated a month after the last sclerotherapy, when a significant amount of blood clots was evacuated from the varicose veins on the calf.

Results

The patient was monitored one week, one month and three months after the procedure. After a week, a physical examination revealed bruising on the left thigh. This is a post-procedure standard for this type of procedure. Ultrasound examination did not reveal any signs of deep vein thrombosis in the left lower limb. Endothermal heat-induced thrombosis class I (EHIT I) was revealed, so prophylaxis was not extended. The ultrasound examination revealed a stump of the left GSV, neoangiectasia, the remaining fragment of the GSV and varicose veins on the thigh were closed (Figures 4, 5).

A one-month follow-up revealed a closed left GSV stump. A closed, narrower neoangiectasia was present. A fibrosing fragment of the left GSV was present on the thigh. The thigh drainage basin was closed. The calf drainage basin was reduced in diameter. During the visit, sclerotherapy was performed. After the procedure, compression therapy was applied.

After three months, physical examination revealed discoloration and thickening along the closed varicose veins. A thrombectomy was performed to relieve symptoms and shorten healing time. The patient was satisfied with the resolution of the symptoms he had reported before treatment and with the cosmetic effect of the procedures performed (Figure 6).

Discussion

Doppler ultrasound of the lower limbs is essential for optimising treatment planning and monitoring treatment effectiveness. The European Society for Vascular Surgery (ESVS) 2022 guidelines emphasise that Doppler ultrasound is the preferred diagnostic method for the evaluation of clinically evident recurrent varicose veins [1]. It is also widely used in post-procedural monitoring to detect possible recurrence of reflux.

Re-surgical intervention involving the saphenofemoral junction is difficult due to altered anatomical conditions. Numerous scars and adhesions make it complicated and make precise operation in this area difficult. Conventional treatment for recurrent varicose veins from the GSV typically involves surgical re-ligation of the saphenofemoral junction, often in combination with multiple phlebectomies. Unfortunately, this treatment is associated with a higher recurrence rate than primary treatment for varicose veins. This patient is an example of multiple surgical interventions with rapid recurrence and complicated by thrombosis. In the presented case, in accordance with the current ESVS 2022 recommendations, groin re-exploration is not recommended. The patient was offered laser thermal therapy as a first-line treatment for recurrent varicose veins. This method was classified as a Class IIA recommendation with a level of evidence (B) [1]. A study by Keo et al. [2] demonstrates the safety, feasibility, and early efficacy of a water-specific 1940-nm laser wavelength for ablation of saphenous incompetence. A review published by Bontinis et al. [3] evidenced superior efficacy of endovenous thermal ablation compared to surgery in the treatment of recurrent varicose vein disease, supporting its use as the preferred treatment when available. The work of Müller et al. [4] also suggests that recurrent sapheno-femoral junction can be effectively treated even in situations with tortuous or short stumps requiring direct puncture and ablation.

An important prognostic factor in the treatment of chronic venous insufficiency is the fully individualised therapeutic process. In the case of this patient, the complexity of the changes precludes the use of a single treatment method, indicating the need to implement a hybrid approach, which represents a promising alternative to traditional methods. The conclusions from Wang et al. [5] emphasise the importance of long-term follow-up and individualised treatment planning in optimising outcomes for patients with varicose veins. This study demonstrates that sclerosing foam combined with laser therapy is a safe and effective treatment for varicose veins of the lower extremities, with a high surgical success rate and sustained, significant improvement in symptoms over time.

The Ardita et al. study [6] demonstrates that ultrasound-guided foam sclerotherapy is a safe and effective alternative to open surgery for the treatment of C2r (in the CEAP classification), offering significant benefits in terms of shorter procedure time and faster recovery. This approach represents a viable option for C2r patients seeking effective treatment and a shortened recovery period.

Conclusions

Effective treatment of recurrent varicose veins requires accurate ultrasonic diagnostics. It is the foundation of preoperative planning. The use of hybrid techniques, combining endovascular laser therapy with sclerotherapy, shows high effectiveness in this group of patients. An essential element of the treatment process remains the individual selection of procedures and systematic monitoring of the patient in the postoperative period.

Disclosures

1. Institutional review board statement: Not applicable.
2. Assistance with the article: None.
3. Financial support and sponsorship: None.
4. Conflicts of interest: None.

References