A 52-year-old woman presents with prominent dilated veins on the medial aspect of her left lower limb. Duplex ultrasound confirms saphenofemoral junction incompetence with reverse flow during Valsalva maneuver. She is otherwise healthy with no contraindications to intervention. Which of the following is the most appropriate first-line definitive treatment for her condition?

Explanation

## Varicose Veins: Definitive Treatment **Clinical Context:** This patient has **primary varicose veins** with **saphenofemoral junction (SFJ) incompetence**, confirmed on duplex ultrasound. The presence of reverse flow during Valsalva indicates valvular insufficiency at the SFJ—the hallmark of great saphenous vein (GSV) pathology. **Why EVLA is First-Line:** **Key Point:** Current NICE and international guidelines (2013 onwards) recommend **endovenous thermal ablation** (EVLA or radiofrequency ablation) as first-line definitive treatment for symptomatic varicose veins with SFJ incompetence. **Advantages of EVLA:** - Minimally invasive (local anesthesia, day-case procedure) - Lower complication rates (saphenous nerve injury <1% vs. 5–15% with open stripping) - Faster recovery (return to work in 1–2 weeks) - Equivalent or superior efficacy to open surgery (recurrence ~5–10% at 5 years) - Reduced pain and bruising compared to stripping - Can be performed in outpatient setting **Clinical Pearl:** The shift from open surgery to endovenous techniques reflects the principle of **minimal invasiveness** while maintaining efficacy—the modern standard of care. **Mnemonic:** **SAFE** approach to varicose vein management: - **S**urgery (open stripping) — now second-line - **A**blation (EVLA/RFA) — **first-line** - **F**oam sclerotherapy — adjunct or alternative - **E**lastication/compression — conservative management