Is EVLT my only option with GSV reflux when first round of sclerotherapy seemed to be effective?

 The indications for an EVLT procedure include symptoms such as swelling, aching, pain, and uncomfortable bulging veins in your leg. If you were found to have venous reflux in your saphenous vein, but have no problems with your leg as mentioned above, there is no real reason to have the procedure. If the sclerotherapy worked on the cosmetically concerning veins that you had, I think that at this point you should just keep an I on your legs and if problems do you develop, I would seek additional treatment.

Medically treating GSV for venous reflux means that blood will be rerouting to the healthy veins to prevent blood to pool in the legs that otherwise will keep forming varicose veins leading to many other signs and symptoms like leg swelling, leg pain, leg cramps, leg heaviness, burning sensation or itching of the skin, and changes like venous ulcers or sores. Options to treat reflux of the GSV include EVLT, RFA, and Venaseal. Also, there is ultrasound guided sclerotherapy and ambulatory phlebectomy for tributary veins that remain open sometimes really close to the skin after closure treatment of the GSV. 
It is great that sclerotherapy worked well for the esthetic portion, but the medical portion should be assessed and treated. Areas that look affected and show spider veins or dilated bulging veins can be treated again with sclerotherapy or laser sclerotherapy. Expect at least 50-75% improvement of overall appearance with each treatment. Most patients may need between 2 to 6 cosmetic treatments. 
Thank you for your question. 
All the best, 

If you feel that you are satisfied with the results of sclerotherapy, and you have no symptoms, then it is fine to continue with sclerotherapy. At some point though, the underlying reflux may cause newly  treated veins to reopen or not close at all with sclerotherapy. At this point you are just wasting money by continuing with the sclerotherapy.

If you are not symptomatic then an ablation (RF or EVLT) is not necessary.  I would also ask the extent of the reflux.  I would not do an ablation if there is only a short segment of reflux.  However, if the GSV is incompetent (showing reflux) along its length then you are unlikely to get lasting results with sclerotherapy alone.  A good analogy is that if you have a leaky roof and it is ruining the paint on your walls.  Painting the walls will make it look better but it's not going to solve the problem, you have to fix the leak to get lasting results.  Similarly with proximal GSV reflux and sclerotherapy.  Sclerotherapy will work but if the GSV is refluxing into those varicosities then they are likely to recur.  An ablation is treating the source of the problem.   

If you have had a response to sclerotherapy then there is no need to rush into doing an EVLT.  The presence of reflux suggests that most likely veins will worsen with time but, if sclerotherapy has worked for you, then I would recommend continued sclerotherapy until such time that you develop varicose veins or the veins in your leg worsen.

Either RVLT or Radiofrequency Ablation can be done if any symptoms persist. Generally, spider veins are the tip of the iceberg and symptoms are due to larger varicosities which can only be evaluated by ultrasound and are not visible to the naked eye. In short, symptomatic regurgitant great and small saphenous veins should be ablated as a definitive treatment if conservative management doesn't improve symptoms significantly.

If your issues/ concerns are the visible veins, it is fine to keep doing sclerotherapy.  The reflux seen is in larger veins below the surface.  Have reflux means you are more likely to continue to get spider veins, but it only should be treated if you are having symptoms.  Normal symptoms include leg swelling, aching, heaviness, cramps or restless leg, skin discoloration, or sore that do not heal quickly.As mentioned, EVLT, RFA ablation are treatments for the larger veins, as well as Venaseal - using a glue to close the veins, and Clarivein- using sclerotherapy and a mechanical device.Wearing compression socks can also help slow the formation of spider veins as well.  Especially when travelling or standing for long periods of time.Good luck,Dr. Powell