If you’ve ever been told you have varicose veins and wondered what happens next, you’re probably familiar with the basics — compression stockings, perhaps a referral, maybe a vague mention of sclerotherapy or laser treatment.

What you’re less likely to have heard about is the step that determines whether any of those treatments will actually work.

That step is duplex ultrasound mapping. And in clinics that take vein health seriously, it happens before anything else.

Why Surface Treatment Without Mapping Often Fails

This is where many patients run into trouble — not because they chose the wrong treatment, but because the underlying cause was never properly identified before treatment began.

Imagine a leaking tap. You can mop the floor as many times as you like, but until someone turns off the water at the source, the problem keeps returning.

The venous system works in a similar way. When reflux is present in a deeper feeding vein and only the surface tributaries are treated, the underlying pressure remains. Blood continues to pool and back-fill through the same pathways. Within months — sometimes weeks — the visible veins return, and occasionally new ones appear alongside them.

Recurrence after vein treatment is not inevitable. But it is far more likely when the source of reflux hasn’t been mapped and addressed first.

Research supports this consistently. Studies examining recurrence rates after sclerotherapy found that patients treated without prior ultrasound mapping had significantly higher rates of returning varicosities compared to those who underwent comprehensive duplex assessment beforehand. In some reviews, the difference in five-year recurrence rates between mapped and unmapped treatment cohorts exceeded 40 per cent.

That’s not a marginal difference. It’s the difference between a treatment that holds and one that doesn’t.

Ultrasound-Guided Injection: Precision Under Pressure

For many patients, treatment involves ultrasound-guided sclerotherapy — a technique where a sclerosing agent is injected directly into the affected vein under real-time ultrasound visualisation.

This is not the same as surface sclerotherapy, where injections are placed into visually identified vessels at the skin’s surface. Ultrasound-guided injection targets deeper veins that can’t be seen with the naked eye, guided entirely by the live ultrasound image.

The challenge is that it requires doing two demanding things simultaneously.

With one hand, the clinician holds the ultrasound probe in position, maintaining the target vessel clearly in frame. With the other, they introduce a fine-gauge needle at the correct angle, advance it into the vessel, confirm intraluminal placement on screen, and then inject the sclerosant — all while monitoring the surrounding tissue for any signs of extravasation or unintended spread.

The margin for error is narrow. Misplacement of the sclerosant outside the vessel causes tissue damage. Injection into an adjacent artery carries serious risk. Both are avoidable with adequate skill and experience. Neither is avoidable without them.

This is why ultrasound-guided sclerotherapy is considered a procedural skill, not simply an extension of standard sclerotherapy. It requires dedicated training, regular practice, and a level of hand-eye coordination that only develops through volume and repetition.

Same-Day Scanning and Treatment: Why Timing Matters

Some clinics separate the duplex mapping appointment from the treatment appointment. There are circumstances where that’s appropriate — particularly in complex cases where findings need to be reviewed before a treatment plan is finalised.

But when a same-day approach is clinically appropriate, it carries a real advantage: the information from the scan is used immediately, while the clinician’s understanding of that individual’s anatomy is freshest.

Same-day scanning and treatment keeps the clinical picture intact. The clinician moves directly from diagnosis to intervention with a complete mental model of that patient’s venous system. Treatment decisions are informed by the most current and detailed understanding possible.

It also reduces the burden on patients, who would otherwise need to attend multiple appointments across separate days — an important consideration for those travelling distances or managing busy schedules.

What Accurate Mapping Means for Outcomes

The connection between thorough pre-treatment assessment and durable outcomes is well-established in the clinical literature.

When the source of reflux is correctly identified and treated before attention turns to the surface veins, recurrence rates drop substantially. Patient-reported satisfaction rises. The number of repeat treatment sessions decreases. And the likelihood of progressive venous disease — including complications such as lipodermatosclerosis, ulceration, and deep venous thrombosis — is meaningfully reduced.

The evidence is consistent enough that leading phlebological societies, including the Australasian College of Phlebology, recommend duplex ultrasound as a prerequisite for any significant vein treatment. It isn’t a premium add-on. It’s the accepted standard of care.

Clinics that skip this step aren’t offering a simpler version of the same treatment. They’re offering a different treatment altogether — one with a fundamentally higher chance of not working.

Getting It Right From the Start

Vein disease is often dismissed as a cosmetic concern. But for most people living with it, the reality is more than that — it’s aching legs at the end of the day, swelling that worsens in summer, and a slow erosion of confidence in how their legs look and feel.

Treatment can genuinely change that. But it does so reliably only when the full picture is understood first.

Same-day duplex ultrasound isn’t a marketing term. It’s a commitment to doing the diagnostic work properly — so that what follows is targeted, informed, and built to last.

Because the best outcomes aren’t the ones that look good straight after treatment. They’re the ones that hold up a year later, five years later — quietly, without demanding a return visit.

And that starts with getting the diagnosis right.

Most people notice varicose veins and think: cosmetic problem. Something to deal with eventually, when there's time, when it feels urgent enough.

But here's what changes that thinking — understanding what's actually happening inside the vein wall, and where it leads when left alone.

Varicose veins are a progressive condition. They don't stay still. For many patients, the trajectory moves from mild discomfort to genuine medical complexity — slowly, quietly, and often without the dramatic warning signs people expect.

Dr. Nolan, the founder of Odyssey Vein Clinic and a specialist with over 8,000 successful vein procedures, sees this pattern regularly. Patients arrive having monitored their veins for years, certain things were stable, only to discover the disease had been advancing the entire time.

That's the thing about venous insufficiency. It's easy to underestimate.

It Usually Starts With Aching and Heaviness

The earliest symptoms are easy to explain away.

A heaviness in the legs after a long day. An ache that arrives in the afternoon and eases when you lie down. Some mild swelling around the ankles by evening.

These aren't dramatic symptoms. They're the kind of thing people chalk up to being on their feet too long, getting older, or not drinking enough water.

But clinically, this stage — classified as C2 in the CEAP (Clinical, Aetiological, Anatomical, Pathophysiological) classification system — marks the point where incompetent valves in the superficial venous system are already failing to return blood efficiently against gravity. Venous hypertension begins to build. Pressure in the lower limb veins increases chronically.

The body compensates. For a while.

Then it stops compensating as well.

The Swelling Becomes Harder to Ignore

As venous hypertension persists, fluid begins leaking from the capillaries into surrounding tissue. This is oedema — and it's more than discomfort.

At this point, patients often describe their legs as feeling 'full' or tight by the end of the day. Shoes that fit in the morning feel snug by afternoon. Socks leave marks.

This progresses to C3 in the CEAP classification: chronic oedema. The swelling may partially resolve overnight with elevation, but it returns. Over time, it becomes less responsive to rest.

It's also at this stage that the risk of skin changes begins to escalate — and that's where the clinical picture gets more serious.

Skin Changes: The Visible Evidence of Internal Damage

Chronically elevated venous pressure doesn't just cause swelling. It causes structural changes to the skin and subcutaneous tissue that are largely irreversible once established.

The first sign is often haemosiderin staining — a brownish discolouration of the skin, typically around the inner ankle and lower leg. This happens when red blood cells escape from congested capillaries and break down, depositing iron into the tissue.

Then comes lipodermatosclerosis: a hardening and thickening of the skin and underlying fat, sometimes accompanied by a reddish-brown pigmentation and a characteristic 'inverted champagne bottle' appearance of the lower leg. The skin feels indurated — firmer than normal — and the tissue beneath it loses its elasticity.

These changes are classified as C4a and C4b in the CEAP system. They represent significant chronic venous disease, not a cosmetic concern.

They also signal that the tissue is under sustained physiological stress — and that the next stage is closer than most patients realise.

Varicose Eczema: Inflammation at the Surface

Varicose eczema — also called venous eczema or stasis dermatitis — is one of the more distressing complications for patients, partly because it looks and feels like a skin problem rather than a vascular one.

The skin becomes itchy, red, scaly, and inflamed. In some cases it weeps. In others it becomes thickened and leathery over time. It tends to affect the lower legs and ankles, often bilaterally, and it doesn't respond well to standard eczema treatments because the underlying cause is haemodynamic, not dermatological.

Scratching — a natural response to the itch — breaks the already fragile skin barrier, introducing the risk of infection and, critically, creating a pathway to ulceration.

Without treating the underlying venous disease, varicose eczema is chronic. It can be managed on the surface, but it will return.

Thrombophlebitis: When the Vein Itself Becomes Inflamed

Thrombophlebitis is a complication that patients sometimes describe as a sudden change — a hardening along a visible vein, redness, warmth, and localised pain.

What's happening is inflammation of the vein wall, combined with clot formation within the lumen of the varicosity. In superficial veins, this is termed superficial thrombophlebitis (SVT), and while it's usually not life-threatening on its own, it requires proper clinical evaluation.

The reason is propagation risk.

Superficial thrombus that extends toward the saphenofemoral or saphenopopliteal junction — where the superficial system meets the deep venous system — carries a risk of deep vein thrombosis (DVT).

Venous Ulcers: The Most Serious End of the Spectrum

Venous leg ulcers represent the most advanced stage of chronic venous disease — CEAP class C6 — and they are far more common than people expect.

They account for approximately 70–80% of all chronic leg ulcers in Australia, and they carry a significant burden: pain, restricted mobility, wound care demands, repeated infection, and substantial impact on quality of life.

A venous ulcer typically develops in the 'gaiter zone' — the area between the ankle and mid-calf — often at the medial malleolus. The wound is usually shallow with irregular borders, surrounded by lipodermatosclerotic or eczematous skin. It may be exudative, and it may have been present for months or years.

What's particularly important clinically is that venous ulcers will not heal reliably without treatment of the underlying venous insufficiency. Compression therapy alone can close many ulcers — but the recurrence rate without definitive venous intervention approaches 70% at five years.

With appropriate treatment — whether that's endovenous laser ablation, radiofrequency ablation, or ultrasound-guided sclerotherapy, depending on the anatomy — healing rates improve substantially and recurrence risk reduces dramatically.

Dr. Nolan has managed a significant number of complex venous ulcer cases at Odyssey Vein Clinic. The consistent finding: the longer the underlying disease had been present without treatment, the more difficult and prolonged the healing process.

When to Monitor — and When to Act

This is where an honest, patient-first approach matters most.

Not every varicose vein requires urgent intervention. But not every varicose vein is safe to simply watch, either. The distinction depends on what's happening clinically — and that requires assessment, not assumptions.

It's reasonable to monitor if:

• You have visible varicosities but no symptoms, no skin changes, and no history of clots.
• Your symptoms are mild and stable, and you're using compression stockings consistently.
• You've had a recent duplex ultrasound that confirmed no significant reflux or deep venous involvement.

Seek a clinical review promptly if:

• You've noticed skin changes around the ankle or lower leg — discolouration, hardening, or scaling.
• You're experiencing varicose eczema that isn't responding to topical treatment.
• You've developed any open or non-healing wound on the lower leg.
• Your leg swelling has stopped resolving with elevation or compression.

Seek emergency assessment if:

• You have significant leg pain combined with swelling and warmth — this may indicate DVT.
• A varicosity has bled, either spontaneously or after minor trauma. Superficial varicosities under elevated pressure can bleed significantly, and this requires urgent management.
• You have an active, worsening ulcer with signs of infection — increased pain, spreading redness, warmth, or systemic symptoms like fever.

The Honest Truth About 'Just Watching It'

After more than 8,000 procedures, Dr. Nolan's clinical perspective is clear: the patients with the most complex presentations are rarely those who sought help too soon. They're the ones who waited longer than they needed to.

Not because they were careless. Because varicose veins progress slowly. Because the early stages feel manageable. Because people assume that if it were serious, something would feel more obviously wrong.

Chronic venous disease doesn't always announce itself. It accumulates.

The good news — and it is genuinely good news — is that modern vein treatment is minimally invasive, highly effective, and available without hospital admission. For most patients, the procedures performed at Odyssey Vein Clinic are with minimal downtime and durable long-term results.

But the window for the simplest intervention narrows as the disease progresses.

Getting a Proper Assessment

If you've been watching varicose veins for a while — or if you're noticing any of the changes described above — the most useful next step isn't more waiting. It's a proper duplex ultrasound assessment that maps the anatomy of your venous system and identifies where reflux is occurring.

That information tells you — and your treating clinician — exactly what you're working with and what options are appropriate.

Odyssey Vein Clinic offers consultations with Dr. Nolan for patients across Australia. The approach is straightforward: understand the disease fully, explain the options honestly, and let patients make informed decisions about their care.

Because the goal isn't just to treat varicose veins. It's to stop the progression before it takes something harder to get back.

If you've just had Ultrasound-Guided Sclerotherapy (UGS), your clinician probably handed you a list of post-care instructions and said something like: "Walk for 30 minutes straight after the procedure. Wear your compression stockings for two weeks. No long-haul flights or heavy gym sessions."

Simple enough, right?

Except most people hear those rules and think, "Do they really matter that much?"

They do. And the reason why comes down to something much more precise than general caution—it's haemodynamics.

What's Actually Happening Inside Your Veins Right After UGS

To understand why recovery protocol exists the way it does, it helps to understand what sclerotherapy is actually doing at a vascular level.

UGS involves injecting a sclerosing agent—typically a foamed solution of polidocanol or sodium tetradecyl sulphate—directly into a diseased vein under ultrasound guidance. The chemical irritates the endothelial lining of the vessel wall, triggering an inflammatory cascade that causes the vein to spasm, collapse, and eventually fibrosis into a non-functional cord of scar tissue.

That conversion process—from open, blood-carrying vessel to inert fibrous tissue—doesn't happen overnight. It unfolds over days to weeks. And what you do in that window has a direct bearing on two things: the risk of Deep Vein Thrombosis (DVT), and how cleanly the treated vein resolves.

That's why post-procedure behaviour isn't optional. It's physiologically active.

The 30-Minute Walk: Driving Blood Through the Right Channels

The instruction to walk immediately after the procedure surprises some patients. They assume rest would make more sense.

It doesn't—and here's why.

Your legs contain two venous systems: a superficial network close to the skin (the one UGS targets), and a deep venous network buried within the muscle compartments. These systems communicate through perforating veins that act as one-way valves.

When a superficial vein is sclerosed and taken offline, the blood that previously travelled through it needs somewhere to go. It reroutes—through perforating veins—into the deep venous system.

Venous stasis is one of three components of Virchow's Triad—the classic clinical framework for understanding DVT formation. The triad identifies stasis, hypercoagulability, and endothelial injury as the three conditions that together create clot risk. After UGS, endothelial injury is a given—that's the mechanism of the treatment. Hypercoagulability is present to some degree simply because the body is responding to the chemical insult. What you can actively control is stasis.

This is addressed directly by walking. With every step, the calf muscles act as a peripheral venous pump, contracting and squeezing the deep veins, pushing blood up toward the heart. Research published in Phlebology and consistent with findings from the American Venous Forum shows that when the calf muscle pump is activated, deep venous flow velocity is significantly increased and venous transit time is reduced. Post-sclerotherapy patients have shown that a brisk 30-minute walk can clear residual sclerosant from the treated segment, reduce local inflammatory by-products and maintain adequate flow through the deep system.

Put simply: walking is not an indicator of comfort. It is a dynamic haemodynamic intervention.

Compression Stockings: Sustained Mechanical Support Over Two Weeks

The compression requirement is where patients most commonly cut corners. Two weeks feels long. Stockings aren't comfortable in warm weather. By day four or five, the treated leg looks fine and feels manageable—so why keep going?

Because the process happening beneath the skin is still far from complete.

Medical-grade graduated compression stockings—typically prescribed at 20–30 mmHg following UGS—work by applying external circumferential pressure that reduces the cross-sectional diameter of superficial and deep veins. This has several clinically significant effects.

First, venous reflux is reduced by compression. In the post-procedure leg, the vein walls are inflamed and the sclerosant is still active. Any residual venous incompetence in adjacent vessels can lead to pooling of blood in the treated segment. This is mechanically restricted by compression, which keeps the blood flowing forward rather than allowing it to pool.

Second, interstitial oedema is reduced by compression. Sclerotherapy causes a local inflammatory reaction which results in localised capillary leakage - fluid leaking out of the vessels into the surrounding area. This swelling compresses local lymphatic channels and decreases the fluid clearance that the body needs to process the treated vein without enough compression. Sustained compression counteracts this by maintaining external pressure gradients that maintain venous return and lymphatic drainage.

Third—and this is the one most directly relevant to DVT risk—compression has been shown in multiple randomised controlled trials to reduce the incidence of superficial thrombophlebitis extending into the deep system after sclerotherapy. A 2019 systematic review in the *European Journal of Vascular and Endovascular Surgery* found that patients who wore compression consistently for two weeks post-UGS had significantly lower rates of deep venous thrombus extension compared to those who used compression for less than seven days.

Two weeks isn't an arbitrary number. It reflects the time window in which the treated vein transitions from an acutely inflamed, chemically irritated vessel to a stabilising fibrous structure. Until that stabilisation is sufficiently advanced, the risk profile remains elevated—and compression remains active medicine.

Avoiding Flights and Heavy Gym Work: The Other Side of the Equation

The long-haul flight and heavy exercise restrictions relate to a different set of risks, but the underlying physiology ties directly into everything above.

Long-haul flights, generally taken to mean flights in excess of four to six hours, expose passengers to conditions of prolonged immobility, low cabin humidity and reduced atmospheric pressure. Each of these factors decreases venous return individually. Together, they create conditions that significantly increase the risk of DVT in any patient. In someone with recent UGS, where the conditions of Virchow's Triad are already partly met, the added haemodynamic stress of a long flight can push a subclinical process into a clinical event. Most vascular specialists recommend avoiding flights longer than four hours for at least two weeks after the procedure.

Heavy resistance exercise introduces a different problem: intrathoracic pressure changes.

When you perform heavy compound lifts—squats, deadlifts, overhead presses—the Valsalva manoeuvre increases intra-abdominal and intrathoracic pressure significantly. This pressure is transmitted retrograde through the venous system, briefly opposing the return of blood from the lower limbs. In a healthy venous system with competent valves, this is tolerated well. In a post-sclerotherapy leg with inflamed, chemically disrupted vessels, the repeated retrograde pressure waves can mechanically stress the treated segment, potentially disrupting the early fibrous organisation of the collapsing vein.

This delays the conversion of the treated vessel into inert scar tissue—which directly affects the aesthetic outcome.

The Link Between Recovery Compliance and Scar Tissue Conversion

That last point is worth dwelling on, because it connects the medical risk management to the cosmetic result patients actually care about.

After UGS, the goal is clean fibrosis. You want the treated vein to collapse completely, form a uniform cord of scar tissue, and be gradually reabsorbed by the body over months. When this process goes smoothly, the vessel disappears. When it doesn't—when there's residual flow through the treated segment, or when the inflammatory process is disrupted by haemodynamic stress—the outcome is often pigmentation, a palpable cord that takes longer to resolve, or, in some cases, recanalisation of the vessel.

Walking, compression, and activity restrictions all protect the fibrosis process. They maintain the haemodynamic conditions that allow the treated vein to convert cleanly, without the interference that comes from venous stasis, pressure surges, or inadequate support to adjacent vessels.

The Protocol Is the Treatment

Here's the part that's easy to miss.

The sclerotherapy procedure itself is only one part of what produces the outcome. The post-care protocol is the other part—and it's not supplementary. It's built into the clinical result.

Odyssey’s post-UGS rules are not conservative recommendations hedged for liability. They represent the true physiology of vein wall injury, inflammatory resolution, deep venous haemodynamics and DVT risk stratification. The calf muscle pump is activated by the 30-minute walk. The two weeks of compression preserves venous geometry, through the window of fibrosis. Avoiding flights and heavy lifting takes away the haemodynamic stressors which are most likely to interfere with clean vein conversion.

Follow the protocol, and your body can do exactly what the treatment set it up to do.

Skip it, and you're not just ignoring advice—you're working against the physiology.

The science is fairly clear on this one. Walk. Compress. Wait.

Varicose veins affect roughly one in three adults at some point in their lives. For most of those people, the question isn’t whether to seek treatment — it’s which treatment to seek. And increasingly, that conversation starts with one method sitting firmly at the top of clinical guidance: ultrasound-guided sclerotherapy, or UGS.

Understanding why requires more than a surface-level comparison. It means looking at what the evidence actually shows — success rates, recovery timelines, procedural risks — and understanding how modern phlebology arrived at its current position.

This is that comparison.

The Traditional Approach: Surgical Stripping

For much of the twentieth century, surgical stripping was the default intervention for symptomatic varicose veins. The procedure involves ligation of the saphenofemoral or saphenopopliteal junction, followed by physical removal of the great or small saphenous vein through a series of incisions.

It works. In appropriately selected patients, surgical stripping produces saphenous vein abolition in approximately 80 to 85 per cent of cases at five-year follow-up. Symptom relief rates are comparable, and for many years this was considered the benchmark.

But the costs are significant.

The procedure requires general or regional anaesthesia. Post-operative recovery typically spans two to four weeks, with patients advised to avoid strenuous activity for the full duration. Wound complications — including haematoma, infection, and nerve injury — occur in a meaningful proportion of cases. Saphenous nerve injury, which produces numbness or paraesthesia along the medial calf, is reported in up to 40 per cent of patients undergoing below-knee stripping. Wound infection rates sit at around three to five per cent, and haematoma formation is documented in up to seven per cent of cases.

There is also the matter of recurrence. Long-term studies — including the landmark REACTIV trial — have demonstrated that surgical recurrence rates at ten years can reach 25 to 30 per cent, driven largely by neovascularisation at the ligation site.

The Modern Standard: Ultrasound-Guided Sclerotherapy

Ultrasound-guided sclerotherapy uses real-time duplex imaging to deliver a sclerosant agent — typically polidocanol or sodium tetradecyl sulphate in foam form — directly into the target vein. The chemical disrupts the vessel’s endothelial lining, triggering fibrosis and permanent closure. No incisions. No anaesthesia. No hospitalisation.

Over the last two decades, clinical evidence to support UGS has matured. Truncal varicosities have been reported to have technical success rates of 85 to 95 percent in pooled data from controlled trials, defined as confirmed venous closure on duplex at twelve weeks. Cumulative success rates improve further when combined with targeted sessions for residual vessels.

Recovery is where the contrast becomes most pronounced. Patients undergoing UGS typically return to normal daily activity within 24 to 48 hours. Compression hosiery is worn for five to seven days post-procedure. There is no wound to manage, no sutures to remove, and no requirement for general anaesthesia — which itself carries non-trivial perioperative risk, particularly in older or medically complex patients.

What the Clinical Guidelines Say

The shift in clinical preference is not simply a matter of patient convenience. It reflects a body of evidence that has accumulated to the point where major bodies have revised their formal positions.

The UK’s National Institute for Health and Care Excellence — NICE — updated its guidance on varicose veins in 2013 and has maintained this position in subsequent reviews. NICE recommends endothermal ablation — laser or radiofrequency — as first-line treatment where suitable, with ultrasound-guided foam sclerotherapy as the recommended second-line option. Surgical intervention is positioned as a last resort, recommended only when minimally invasive techniques are contraindicated or have failed.

This is corroborated by the European Society for Vascular Surgery. Thermal ablation and sclerotherapy are the preferred treatment options in clinical practice guidelines because they are as effective or more effective than surgery but with far less risk to the patient and a faster recovery.

The Australian College of Phlebology also advocates the use of non surgical modalities as first line therapy, with surgical stripping reserved for those cases where the anatomy or vessel characteristics make catheter-based or injection techniques impossible.

Recurrence: The Long-Term Picture

Historically, one of the criticisms levelled at sclerotherapy has been its long-term durability. Early liquid sclerotherapy without imaging guidance was associated with variable results and a relatively high rate of recanalization. That changed with ultrasound guided foam sclerotherapy.

Comparative data at five years suggest that UGS with appropriate technique and adequate follow-up achieves broadly similar recurrence rates to surgery. The REACTIV and RABIT trials, which directly compared surgery with sclerotherapy, found no statistically significant difference in quality-of-life outcomes at five years, although surgery resulted in marginally better freedom from varicosities in selected cases of complex truncal disease.

The key variable is the operator. UGS outcomes are strongly influenced by procedural precision — accurate placement under duplex guidance, appropriate foam concentration, and correct patient positioning. In the hands of an experienced phlebologist, the recurrence rates for UGS are clinically comparable to surgery, without the associated procedural burden.

Risk Profiles: Maintaining an Honest Account

Neither approach is without risk. Objective transparency requires stating both clearly.

Surgical stripping carries the following documented risks:

• Wound infection: three to five per cent
• Haematoma formation: up to seven per cent
• Deep vein thrombosis: less than one per cent, but present
• Anaesthesia-related complications, particularly in older patients

UGS carries its own risk profile:

• Superficial thrombophlebitis: two to six per cent, typically self-limiting
• Skin pigmentation at injection sites: reported in ten to thirty per cent, usually temporary
• Inadvertent intra-arterial injection: rare but serious; underscores the necessity of duplex guidance
• Transient neurological events: reported in less than one per cent of foam procedures
• Allergic reaction to sclerosant: very rare with polidocanol; higher risk with older agents

Why the Change of Heart—And What it Means in Practice

The argument for minimally invasive approaches is not based on one study or one guideline. It’s the cumulative weight of evidence going one way: equivalent long-term outcomes, much lower procedural risk and a recovery burden that patients can reasonably manage without disrupting work or family life.

Surgery still plays a role. Surgical treatment is still indicated in some anatomical situations, with vessel diameters unsuitable for foam techniques or in case of recurrence after previous endovenous procedures. Phlebology is not a one-size-fits-all discipline.

But the default has changed. Most patients presenting with symptomatic truncal varicosities today 2014 particularly great saphenous vein incompetence 2014 are candidates for non-surgical management. The question worth asking is not: can this be treated surgically? It is: why would we operate when the evidence supports a safer alternative with comparable results?

That shift in framing is what defines modern phlebology.

The Takeaway

Most clinical metrics don’t strongly favour surgical stripping over UGS. The evidence supports non-surgical intervention as the primary line of treatment for the majority of varicose vein patients. Not because it’s newer, but because it consistently demonstrates acceptable efficacy with a substantially more favourable risk and recovery profile.

Clinical reality of contemporary UGS is success rates of 85 to 95 per cent at twelve weeks, return to normal activity within 48 hours, no general anaesthesia and a documented safety record over large patient populations.

Surgery has its role. But it is no longer the starting point.

And understanding that distinction — clearly, technically, honestly — is what allows patients and clinicians to make decisions grounded in evidence rather than habit.

There’s a moment that’s familiar to a lot of South Australians with varicose veins.

You’ve finally decided to do something about it. You book an appointment. The specialist confirms what you already suspected — treatment is warranted. And then, somewhere between the diagnosis and the conversation about costs, the clarity disappears.

Medicare covers some of it. Private health might cover part of it. And then there’s a gap — sometimes a significant one — that nobody seems to explain until the invoice arrives.

This article breaks it down honestly. The item numbers. The safety net thresholds. The difference between what Medicare considers medically necessary and what it considers cosmetic. And why the public hospital route, once a reliable alternative, is becoming less practical for a growing number of patients.

If you’ve been putting this off because the financial side felt too opaque to navigate, this is the read you’ve been waiting for.

Medicare Coverage: What the Item Numbers Actually Mean

Medicare doesn’t cover varicose vein treatment as a blanket category. Coverage depends on the procedure, the clinical indication, and whether your specialist has used the correct Medicare Benefits Schedule (MBS) item number.

The key item numbers most patients encounter are:

These figures reflect the Medicare Schedule Fee — not the actual fee your specialist charges. Most private vascular surgeons and interventional radiologists bill above the Schedule Fee, sometimes substantially. The gap between what they charge and what Medicare reimburses is your out-of-pocket expense.

item number will be used.

The Medicare Safety Net: How It Works and When It Kicks In

Once your out-of-pocket Medicare costs in a calendar year exceed a threshold, the Medicare Safety Net increases your future rebates for the remainder of that year.

For 2024–2025, the relevant threshold is:

• Extended Medicare Safety Net (EMSN): $2,141.80 for general patients, $686.00 for concession cardholders and families on FTB Part A — once reached, Medicare pays an additional 80% of your out-of-pocket costs, up to a cap per item

The safety net accumulates across your household. Keep your receipts and make sure your Medicare records are up to date, particularly if you have dependants.

Why Public Hospital Waitlists Are No Longer a Reliable Alternative

It used to be a reasonable option for patients without private cover: wait a bit longer, access treatment through a public hospital, and avoid the out-of-pocket costs.

That window is narrowing.

Across South Australia, waitlists for elective varicose vein procedures at public hospitals have grown significantly. The SA Health System Performance data shows elective surgery category 3 procedures — which is where most non-complicated varicose vein cases are classified — routinely exceed recommended wait times.

Category 3 carries a recommended wait of 365 days. In practice, many patients wait longer. And for ‘non-complicated’ varicose veins — even those causing real discomfort — the pathway to public hospital treatment has become increasingly uncertain.

That’s the clinical reality driving more South Australians toward private clinics, even when they weren’t planning to. Not because they prefer it. Because waiting isn’t really waiting — it’s hoping. And for a condition that can progress to venous ulceration or deep vein complications without intervention, hope isn’t a treatment plan.

For those without hospital cover, this creates a genuine dilemma. The decision isn’t just financial — it’s also clinical.

Extras Cover and Compression Stockings

Compression stockings are a routine part of post-treatment care for varicose vein patients. They’re not optional — they’re a clinical recommendation.

A standard pair of graduated compression stockings (Class 2, 23–32 mmHg) from a medical supply provider typically costs $55–$80. Custom-fitted stockings for patients with more complex presentations can run $120–$180 per pair.

Most private health extras policies that include ‘aids and appliances’ or ‘medical aids’ will provide a rebate of around $40–$60 per pair, up to an annual limit. A number of policies cap the total reimbursement for this category at $200–$300 annually. If you’re purchasing stockings on both legs or replacing them after three to six months — as is often advised — your out-of-pocket cost across the year can still be $80–$200 after the rebate.

It’s worth checking your extras policy before your procedure. If you’re close to your annual limit, timing your stocking purchase to maximise the rebate is a small but practical consideration.

Fee Variation Is Real and Significant

Specialist fees in South Australia vary widely. Two surgeons performing the same procedure at the same facility can charge vastly different amounts. The MBS does not cap what a specialist charges — only what Medicare reimburses. Asking for a written fee estimate before consenting to treatment is your right, and a good clinic will provide one without hesitation.

The Safety Net Resets Each Calendar Year

All Medicare Safety Net thresholds reset on 1 January. If your procedure is in November, the safety net benefits you accumulate won’t carry into your next round of treatment in February. Timing matters, especially if you’re planning staged procedures across multiple sessions.

The Bottom Line

Navigating varicose vein treatment costs in South Australia isn’t complicated once you understand the framework — but the framework does require some effort to understand.

Medicare covers clinically indicated procedures up to the Schedule Fee, with safety net protections that reduce your exposure over time. Private health insurance reduces gaps further, but only if your policy is the right type, your specialist participates in a gap scheme, and your waiting periods are behind you.

Public hospital waitlists, for many patients, are no longer a realistic option for timely treatment. Private clinics are filling that gap — and for patients who go in with clear expectations, the experience is often straightforward.

Ask the right questions early. Get the fee estimate in writing. Confirm your item numbers before you’re on the table. And don’t assume that private health insurance means no out-of-pocket costs — because it rarely does.

What it does mean, when you’ve done the groundwork, is that the financial side stops being a source of anxiety. And that’s a good place to be when you’re making a decision about your health.

Surface veins are often numerous, widespread and will sometimes require several treatments. Sclerotherapy is considered the choice method for the treatment of reticular (larger blue) and spider (fine pink) veins. This involves injection of a sclerosant detergent solution through a tiny needle into the diseased vein. This causes the vein wall to collapse. The veins gradually disappear as the body converts the vein to scar tissue. For some patients with spider veins the underlying reticular veins may need to be treated first.

Compression

Compression may be required for larger blue veins but is not usually required for smaller veins.

Possible side effects

There are a number of side effects seen with sclerotherapy – many of these are seen as a normal consequence of successful treatment

Stinging sensation – Some stinging may be experienced at the time of treatment. This settles within a few minutes and is generally fairy mild.

Bruising – This generally will disappear over 1-2 weeks

Darkness – Treated reticular and spider veins will initially appear darker. This is a normal stage in the healing process and a sign of successful treatment. It is not permanent and will fade. Some brownish pigmentation overlying the veins is quite normal and will gradually fade. This may take several months in larger blue reticular veins

Blood trapping – With larger reticular veins there can sometimes be trapped blood which makes the vein somewhat tender and lumpy with some overlying brown pigmentation. This is, again, a sign that treatment has been successful and will gradually resolve sometimes over the course of a couple of months.

Aching – This is more likely with the treatment of larger reticular veins. It is relieved by walking. You can take Panadol or Nurofen if this is persistent, although this is rarely necessary.

Complications of treatment

Sclerotherapy is a very safe procedure and the majority of complications experienced are relatively minor

Matting is the development of a very fine network of spider veins around the area of treatment. It is more common in people with extensive surface veins. Matting will usually resolve spontaneously although further injections can often improve the appearance.

Swelling of the leg or ankle sometimes occurs due to inflammation of the skin. Wearing the compression stocking, walking and elevating the leg will all help. If the swelling is severe or persistent please contact the clinic

Allergic reactions to the injected sclerosant are extremely rare with the treatment of spider veins. Any shortness of breath, itching, or rash at the time of treatment needs to be reported to the Doctor who will initiate appropriate treatment.

Ulcers of the skin are rare and usually appear as small, painful sores within a couple of weeks of treatment.. They do heal but quite slowly. These usually occur because of sclerosant passing from the treated vein to a small artery and are more common in smokers and people with certain medical conditions.

Phlebitis is the appearance of tender, red, swollen areas and is due to inflammation of the treated veins. It will usually occur in larger reticular veins. Phlebitis does eventually resolve by itself but anti inflammatory medication (such as Nurofen or Voltaren) or gel will help this to resolve more quickly.

How successful is Sclerotherapy ?

It is never possible to guarantee complete clearance of leg veins and depends on many factors such as number and duration of veins, age, other medical problems etc..You can generally expect approx 80 – 90 % improvement in most cases, although, a small number of people don’t seem to respond well. Totally new veins will also appear over time therefore treatment may need to be repeated some years down the track.

Cost

The cost of treatment is $550 for a 30 - 45 min session. This includes both legs and quite extensive work can often be done in this time period.

If you have larger blue veins you can usually claim a Medicare rebate of approx $95 – your Doctor will advise you if you are eligible.

Most people will require more than one treatment – this will be discussed at your initial consult. These are usually organized approx 1 month apart.

UGS is a safe and effective method for the eradication of varicose veins. Unlike surgery there is no need for hospitalization or a general anaesthetic, there is also no downtime or need to take time off work.

A consultation will be booked with Dr. Nolan in which you will need to bring your completed medical questionnaire. This will usually have been emailed or posted to you prior to your appointment. If not, we ask that you arrive 15 minutes prior to your appointment to complete it. The Doctor will examine your veins, perform a duplex ultrasound scan to map any abnormal veins and explain the procedure of UGS including costing. You may elect to proceed with treatment on the day, book a subsequent appointment, or elect not to proceed with further treatment.

The actual UGS treatment takes approximately 30 minutes.UGS is performed using ultrasound technology to locate the hidden abnormal veins and allow the Doctor to safely and accurately inject the veins with a sclerosant foam.

This sclerosant foam damages the inside lining of the vein – the bodies natural healing mechanism then gradually converts the vein to scar tissue. A number of injections may be required and these can be associated with a slight burning sensation that usually lasts for a few minutes. The needles used are very fine so there is very little discomfort from the injections themselves. The sclerosant becomes diluted within a short distance from the injection site and, therefore, is unlikely to damage any normal veins.

Following the injection procedure, you will be fitted with a compression stocking (or two if both legs are able to be treated) and be asked to walk normally for 30 minutes. The reason behind this is to get blood pumping through the major veins in the leg, it also helps to alleviate any discomfort following the procedure. After your walk you are free to leave.

You are able to drive yourself to and from your appointment and you can go straight back to your normal duties and work if you wish.

You are required to wear the compression stocking for 2 weeks after UGS. A follow up appointment will be made on the day for approximately 2 – 4 weeks. The stocking can be removed after 2 weeks of wear. At the follow up appointment the treated veins are scanned to ensure that they are starting to heal and have responded to treatment. It is quite normal for treated veins to be quite lumpy and tender with overlying brown pigmentation when the stocking is removed. This is a normal aspect of the healing process and indicates a successful outcome. The appearance of the treated vein rapidly improves over a few weeks with continued improvement expected over several months

Possible side effects of non- surgical vein treatment.

There are a number of possible side effects seen with Ultrasound Guided

Sclerotherapy that are considered a normal consequence of successful treatment.

Stinging sensation – Some stinging may be experienced at the time of treatment – this usually settles within minutes. Many patients find treatment almost painless

Bruising will disappear over a couple of weeks.

Blood trapping can lead to tender lumps along the course of the treated veins. It is harmless but may make the vessels more noticeable in the first few weeks. Trapped blood can be drained at review appointments if troublesome. Persistent lumps all eventually disappear as the body converts the veins to scar tissue.

Aching in the legs for the first few days can occur after treatment. This more commonly occurs when larger veins are treated and usually is relieved by walking. You may take panadol or anti-inflammatories such as Nurofen or or Voltaren. Most people do not require any pain relief.

Pigmentation is the appearance of brown marks on the skin located over or near the treated veins. This is a consequence of both UGS and spider vein treatment. Pigmented areas are composed of haemosidirin (a form of iron) that can become trapped in the skin. Some pigmentation is to be expected and is a normal consequence of treatment. Pigmentation gradually fades and disappears completely, although faint pigmentation lasting more than 12 months has been reported in 5% of cases.

Possible complications of non-surgical vein treatment

There are a number of possible complications that can occur with UGS even when the greatest of care is taken. Fortunately the majority of these are relatively minor and amenable to treatment

Phlebitis is the appearance of tender, red, swollen areas and is due to inflammation (not infection) of the treated veins. It may be associated with tender lumps along the line of the veins. Phlebitis can be treated with anti-inflammatory medication (Voltaren rapid, Nurofen, Brufen, Act-3, etc.) and improves with walking and continued wearing of the compression stocking. Please contact the clinic if you suffer excessive tenderness.

Matting is the development of an extremely fine network of spider veins likely to occur on the thighs. Matting usually improves spontaneously and it also responds to injection sclerotherapy. Some may persist despite further treatment

Swelling of the leg or ankle occurs occasionally and will usually settle with time. It tends to arise from inflammation of the treated veins, particularly if phlebitis is also present. Wearing the compression stocking, walking, and elevating the leg will all help to alleviate the swelling.

Numbness of the skin is rare and temporary, usually in the calf area. It is due to irritation of nerves that lie in close proximity to a treated vein.

Migraine sufferers may find that injection of sclerosant can precipitate a migraine although this is uncommon. Taking a mild analgesic or anti-migraine preparation can provide relief.

Ulcers of the skin are rare and usually appear as small painful sores within two weeks of injection treatment. They tend to be slow to heal. They occur from sclerosant passing from veins into small associated arteries.

Allergic reactions to injection of the sclerosant solution are rare but may be serious or life threatening. Should you feel any abnormal sensations during treatment such as itchiness, nausea, or shortness of breath, don’t hesitate to tell Dr. Nolan who will provide appropriate treatment.

Deep vein thrombosis is a clot in the deep venous system – not in the treated varicose veins. This potentially serious problem is extremely rare if the compression stocking is worn as directed and daily walks undertaken.

The approximate risk is less than 1:2000 for UGS patients (The risk of DVT with vein surgery is significantly higher). If you are considered to be at increased risk of DVT (because of prior history of DVT, strong family history of vein thrombosis, certain medical conditions or are taking particular medications) you can still undergo UGS but may need to be treated with blood thinning medication. Dr. Nolan will discuss this with you in more detail. Deep vein thrombosis may lead to clots in the lung (pulmonary embolism) which can be a life threatening condition requiring hospitalization. Symptoms of deep vein thrombosis and pulmonary embolism include a markedly painful swollen calf unrelieved by walking, unusual shortness of breath or chest pain. If you experience any of these symptoms please contact the clinic straight away.

Intra-arterial injection is an extremely rare(1:10,000) complication that can result in significant muscle and skin damage. This now rarely occurs due to the use of ultrasound to place the needle accurately when injecting.

Precautions

Pregnancy and breast-feeding – UGS is best avoided when pregnant or breastfeeding even though there is no documented evidence to suggest that it is unsafe. Veins that appear in pregnancy can be treated before the next pregnancy to avoid a further deterioration in symptoms.

Oral contraception and hormone replacement therapy

There may be a small increased risk of DVT when on these medications. This depends on dose, duration of treatment and other medical conditions. Dr. Nolan will discuss this with you if there is a problem.

How successful is UGS ?

The majority of patients undergoing UGS will only require one treatment on each leg to eliminate their varicose veins. About 10% of patients will need some additional treatment (usually to a segment, not the entire vein). This is more likely when very large veins are treated. However, even with the most skilled therapist, there are a small number of people whose veins don’t respond well to treatment.

It is important to remember that there is no permanent cure (including surgery) for varicose veins as this is a lifelong condition. Totally new veins can appear with time, therefore the treatment is directed at the current problem.

Post treatment instructions

In order to ensure the success of your treatment it is essential you follow these instructions

• You are required to walk at a gentle pace immediately after the procedure for 30 mins. and at least 30 mins. each day for the next 2 weeks. Walking uses the calf muscles and eases pressure on the treated veins, it minimizes the risk of deep vein thrombosis and will also alleviate discomfort in the leg
• Avoid rigorous activities (e.g. running, squash, high impact aerobics or heavy lifting) for the first 2 weeks following treatment. Mild to moderate exercise such as golf or an easy stationary bike ride is permitted. You can carry on with your normal work and home duties.
• You may experience some pain and heaviness in the legs in the first few days after treatment. If this troubles you take Voltaren, Nurofen or other antiinflammatories. If you are intolerant to these medications take Paracetamol.
• The compression stocking needs to stay on for 2 weeks post procedure. It is important to try and keep it pulled up to the groin crease as it has a tendency to slip down. The stocking needs to stay on 24 hours a day – by this we mean DAY and NIGHT. The exception to this is that the stocking may be removed at night during the second week but must be put back on when standing up. Should you develop pain in the foot at night, again, try removing the stocking at night only
• Shower with the stocking on and wash the leg and stocking with shampoo. The stocking will dry in warmer weather although a hairdryer may be used in cooler weather.
• Follow up appointments will be made on the day of your treatment. These are usually 2 – 4 weeks from treatment day.

Costing of UGS

Concession card holder
(i.e. Pension card, Health care card etc.)

Cost of treating varicose veins
$950

Medicare rebate What you will get back
$95.00 - $215 depending on safety net

Cost of treating varicose veins
$900

Medicare rebate On second leg
$95 - $215 depending on the safety net

This is an ‘all in cost’ and covers all consults, scans and follow up appointments apart from the compression stocking which costs $60

If you have Private Health cover with ‘Extras’ you may get most of the stocking costs back.

Non-concession card holder

Cost of treating varicose veins 1st leg
$950

Medicare rebate
$95

Cost of treating varicose veins 2nd leg
$950

Medicare rebate
From $95 - $200 depending on Medicare safety net

The only additional cost is the compression stocking $60– you may get some of this back on Private Health cover ‘extras’

If you have any further treatment, such as sclerotherapy to spider veins, the cost will generally be $450 which will generally attract a Medicare rebate of $95 for larger veins

The Medicare Safety Net

The Medicare safety net means that more money can be claimed back from Medicare. Once an individual or family has spent over a certain amount on out of pocket medical expenses for the calendar year the Medicare rebate can increase to up to $250 (approx.) for each procedure. Singles, couples, families and concession card holders all have different thresholds for claiming the higher rebate. You will need to contact Medicare if you want more information about your safety net.

Types of veins

Abnormal dilated leg veins will affect about 50% of the population during their lifetime. ‘Spider veins’ are fine thread like veins that can be pink or blue in colour. ‘Reticular veins’ are larger blue veins that often feed spider veins. ‘Varicose veins are the largest abnormal veins and tend to bulge above the skin surface. Symptoms associated with varicose veins, apart from their unsightly cosmetic appearance, can include heaviness, burning, throbbing, swollen ankles, and leg cramps. When varicose veins are severe or long standing they can cause skin rashes, blue veins on the feet, ulcers and scarring. All of these problems will improve with treating the veins.

Why do abnormal veins develop?

A definitive cause is not known, however, a strong family history of varicose veins is often a significant factor. Women will often note that their veins worsen with pregnancy or, sometimes, the oral contraceptive pill. Obesity, occupations involving long periods of standing and trauma to the legs can also exacerbate vein problems.

Blood in leg veins normally travels upwards towards the heart. Due to gravity blood tries to flow back towards the feet .In normal veins small valves exist that prevent the backflow of blood towards the feet, it is the breakdown of these valves that causes varicose veins by increasing pressure in the vein and causing the wall to expand. Varicose veins serve no useful function in the body and the circulatory system works more efficiently if these veins are removed.

It is important to understand that varicose and spider vein development is a progressive condition and that totally new veins can develop over time. Some maintenance treatment is likely for the majority of patients.

Non Surgical treatment of leg veins

Injection micro-sclerotherapy or ‘standard sclerotherapy’ – reserved for the treatment of smaller spider veins and also blue ‘reticular’ veins.

Ultrasound Guided Sclerotherapy (UGS) – reserved for the treatment of bulging varicose veins and larger hidden veins. Almost all varicose veins can be treated with this technique

Endovenous Laser Therapy (EVLT) for large straight varicose veins.