Injection treatment (sclerotherapy) is satisfactory for thread veins, spider veins, and telangiectasias. Such treatment is done by dermatologists, family medicine doctors, internists, and surgeons. Intervention by surgical means is referred to by many terms. Ambulatory phlebectomy means removing veins on an outpatient basis. Surgical stripping is surgical removal of veins including the long saphenous vein and its branches. Stab avulsion is also known as hook phlebectomy. Both are removal of branch veins or tributary veins that are varicose. Such removal is done through tiny 1/8-inch or 1/4-inch incisions. Finally, ligation refers to the tying off a vein and removing its attachment to the general circulation. Although the following options are those that are available, the favored treatment consists of removing the long saphenous vein from the circulation and removing the varicose veins physically from the limb:

• Ankle-to-groin stripping of saphenous vein with stab avulsion

• Stripping of segment(s) of saphenous vein with stab avulsion

• Ligation of saphenous vein—high, low, or both

• Ligation of saphenous vein and sclerotherapy (injection of a chemical irritant to eventually obliterate the vein's lumen)

• Ligation of saphenous vein and stab avulsion of varicosities

• Stab avulsion of varicosities without stripping (called phlebectomy)

Stripping has a bad reputation and has been replaced in many centers by other means of taking the saphenous vein out of the circulation. Among these is the VNUS Closure® technique in which a catheter is placed within the saphenous vein and is connected to a radiofrequency generator. The generator is activated, and the saphenous vein is cooked by microwaves so that it is destroyed and is no longer part of the venous circulation. This technique, when properly done, produces very little postoperative pain and accomplishes the first step in surgical intervention for varicose veins.

Another technique that has come into vogue is the endoluminal laser. In this method, a quartz fiber is placed within the vein, and laser light is used to destroy the vein and take it out of the circulation. The VNUS Closure® and the endovenous laser act in very nearly the same way. Each has its advantages in the hands of those who have experience.

Surgery of the lesser saphenous vein is very little like surgery of the greater saphenous vein. There is one similarity, however; the anatomy of the saphenopopliteal junction (behind the knee) is just as irregular as the anatomy of the saphenofemoral junction (in the upper thigh).