Aim:
To demonstrate the effectiveness and safety of endovenous laser ablation (EVLA) in the treatment of recurrent varicose veins of the lower extremities complicated by a floating thrombus in the popliteal vein in a patient with severe comorbidities.

Material and methods:
We present a clinical case of a 59-year-old male who complained of varicose veins and a burning sensation in the right lower limb. His medical history included bilateral great saphenous vein (GSV) removal (2003), type 2 diabetes mellitus, stage 4 chronic kidney disease, gout, and arterial hypertension. Duplex ultrasound revealed varicothrombophlebitis of the small saphenous vein (SSV) and a floating thrombus in the popliteal vein. Initial treatment consisted of oral anticoagulation with rivaroxaban, followed by EVLA of the SSV and ultrasound-guided sclerotherapy of tributaries.

Case report:
After anticoagulant therapy, partial recanalization of the SSV and thrombus lysis in the popliteal vein were observed. EVLA of the SSV was performed without complications. Anticoagulant therapy was continued in coordination with a hematologist. At 6-month follow-up, duplex ultrasound showed the SSV as a fibrotic cord (diameter 3–4 mm), with regression of symptoms of chronic venous insufficiency. Despite the patient’s high-risk profile, individualized management and careful monitoring allowed for the successful performance of a minimally invasive procedure.

Summary:
In selected high-risk patients with recurrent varicose disease complicated by thrombosis, EVLA may be considered following appropriate anticoagulant preparation. This case highlights the potential feasibility of an individualized and staged treatment approach in complex clinical settings.