Glue, heat or foam? How I choose between modern varicose vein treatments

By the time patients reach my clinic, many have already done their reading. They arrive with the menu memorised — laser, radiofrequency, glue, foam — and one very reasonable question: which one should I have?

My answer is usually the same: it depends on what your veins look like on the scan, and a little on what matters most to you. Modern varicose vein treatment is not one procedure but a family of them, and choosing well between them is most of the job.

The duplex scan decides most of it

Every decision starts with a duplex ultrasound — a scan that shows both the structure of the veins and the direction of blood flowing through them. Varicose veins are usually the visible end of a hidden problem: leaking valves in one of the main superficial trunks of the leg, most often the great or small saphenous vein.

The scan tells me which trunk is refluxing, how wide the vein is, how straight or winding its course, and how close it runs to the skin and to nerves. Those few observations narrow the choice considerably before we have discussed anything else.

Thermal ablation: heat, with a protective jacket

Endovenous thermal ablation — using radiofrequency or laser energy — has the longest track record among the modern options. A thin catheter is passed up the faulty vein through a needle puncture, and controlled heat seals the vein shut from the inside.

Because heat could injure surrounding tissue, the vein is first wrapped in tumescent anaesthesia: a dilute local anaesthetic solution injected along its whole length, which numbs the area, shields nearby structures and compresses the vein onto the catheter. UK national guidance from NICE recommends endothermal ablation as the first-line option for most truncal reflux, and it remains my usual starting point for a reasonably straight great or small saphenous vein. Most patients wear a compression stocking for a period afterwards and walk out of the clinic the same day.

Cyanoacrylate glue: sealing the vein without heat

VenaSeal closes the vein with a medical-grade cyanoacrylate adhesive delivered through a similar fine catheter. Because nothing is heated, there is no need for tumescent anaesthesia — the only injection is the one that numbs the initial puncture site.

That difference matters to two groups in particular: patients who would rather avoid a series of anaesthetic injections, and veins that run close to nerves below the knee, where heat calls for extra caution. Many glue patients also do not need compression stockings afterwards — a genuine consideration in Singapore’s climate, and for anyone whose skin, mobility or occupation makes stockings difficult.

Glue has its own trade-offs. A small proportion of patients develop a temporary inflammatory reaction along the treated vein, and in very wide veins I may prefer a different method. It is an excellent tool, not a universal one.

Foam sclerotherapy: the flexible one

Foam sclerotherapy uses a sclerosant — a medication that irritates the vein lining — whipped into a fine foam and injected under ultrasound guidance. The treated vein closes down and is gradually absorbed by the body.

Its strength is flexibility. Foam can follow veins too winding for any catheter, which makes it particularly useful for tortuous varicosities and for recurrent veins after previous treatment, where the anatomy is rarely tidy. The trade-off is durability: veins treated with foam are more likely to reopen over time than veins treated with heat or glue, so foam sometimes needs repeat sessions. I often use it as a partner rather than a soloist — heat or glue for the straight trunk, foam for the winding branches, in the same sitting.

How the decision actually gets made

In practice, a handful of factors settle it:

• What the duplex shows — a straight, accessible trunk suits a catheter method; a tortuous or previously treated vein points towards foam
• Vein diameter — very large trunks generally push me towards thermal ablation rather than glue
• Where the vein runs — segments close to skin or nerves below the knee favour glue or foam over heat
• Your preferences — how you feel about injections, and whether wearing compression stockings afterwards is realistic for you
• Practical life factors — occupation, travel plans and how quickly you need to be back at full activity

No single method suits everyone, and anyone who tells you one option is right for every leg is simplifying. I frequently combine two techniques in one treatment plan, and occasionally the scan shows anatomy that is better served by conventional surgery. The honest position is that these are all good tools; the skill lies in matching the tool to the vein in front of you.

When to have your veins assessed

Whichever method eventually fits, the choice is widest when veins are treated before the skin starts to suffer. Aching and heaviness that build through the day, ankle swelling, itching or darkening skin over the lower calf — these are signs the veins deserve a scan rather than another year of watching. Vein disease progresses slowly, but it does progress, and an early duplex ultrasound keeps every one of these options on the table.