Management of Varicose Veins of the Lower Extremities

Publication Date: October 10, 2022
Last Updated: December 15, 2022

Guideline 1

1.1.

For patients with chronic venous disease of the lower extremities, we recommend duplex ultrasound scanning as the diagnostic test of choice to evaluate for venous reflux. ( 1 – Strong , B)
Implementation Remarks:
1.1.a.
Reflux is defined as a minimum value >500 ms of reversed flow in the superficial truncal veins (great saphenous vein, small saphenous vein, anterior accessory great saphenous vein, posterior accessory great saphenous vein) and in the tibial, deep femoral, and perforating veins. A minimum value >1 second of reversed flow is diagnostic of reflux in the common femoral, femoral, and popliteal veins.

1.1.b.
Axial reflux is defined as uninterrupted retrograde venous flow from the groin to the calf. Retrograde flow can occur in the superficial or deep veins, with or without perforating veins. Junctional reflux will be limited to the saphenofemoral or saphenopopliteal junction. Segmental reflux occurs in a portion of a superficial or deep truncal vein.

1.1.c.
A definition of “pathologic” perforating veins in patients with varicose veins (CEAP [Clinical Class, Etiology, Anatomy, Pathology] clinical class C2) includes those with an outward flow duration of ≥500 ms and a diameter of ≥3.5 mm on duplex ultrasound.
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1.2.1.

We recommend that evaluation of reflux with duplex ultrasound be performed in an Intersocietal Accreditation Commission– or American College of Radiology–accredited vascular laboratory by a credentialed ultrasonographer, with the patient standing whenever possible. A sitting or reverse Trendelenburg position can be used if the patient cannot stand. ( G-U , U)
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1.2.2.

We recommend that for evaluation of reflux with duplex ultrasound, we use either a Valsalva maneuver or distal augmentation to assess the common femoral vein and saphenofemoral junction and distal augmentation with either manual compression or cuff deflation for evaluation of more distal segments. Superficial reflux must be traced to its source, including the saphenous junctions, truncal or perforating veins, or pelvic origin varicose veins. The study should be interpreted by a physician trained in venous duplex ultrasound interpretation. ( G-U , U)
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1.3.1.

We recommend that a complete duplex ultrasound scanning examination for venous reflux in the lower extremities should include transverse grayscale images without and with transducer compression of the common femoral, proximal, mid, and distal femoral and popliteal veins, saphenofemoral junction, and great and small saphenous veins. ( G-U , U)
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1.3.2.

We recommend that a complete duplex ultrasound scanning examination for venous reflux in the lower extremities should include measurement of the spectral Doppler waveform using calipers. Reflux at baseline and in response to a Valsalva maneuver or distal augmentation in the common femoral vein and at the saphenofemoral junction and in response to distal augmentation in the mid-femoral and popliteal vein, the great saphenous vein at the proximal thigh and knee, the anterior accessory great saphenous vein and small saphenous vein, and at saphenopopliteal junction or proximal calf should be documented. ( G-U , U)
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1.3.3.

We recommend that a complete duplex ultrasound scanning examination for venous reflux in the lower extremities should include diameter measurements in patients with the leg in the dependent position, from the anterior to the posterior wall, at the saphenofemoral junction, in the great saphenous vein at the proximal thigh and at the knee, in the anterior accessory great saphenous vein, and in the small saphenous vein at the saphenopopliteal junction or proximal calf. Images of both normal and abnormal findings should be documented in the records of the patient. ( G-U , U)
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1.4.

We recommend the use of the 2020 upgraded CEAP classification system for chronic venous disorders. The clinical or basic CEAP classification can be used for clinical practice, and the full CEAP classification system should be used for clinical research. ( G-U , U)
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Guideline 2

2.1.1.

For patients with symptomatic varicose veins and axial reflux in the great or small saphenous vein, who are candidates for intervention, we recommend superficial venous intervention over long-term compression stockings. ( 1 – Strong , B)
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2.1.2.

For patients with symptomatic varicose veins and axial reflux in the anterior accessory or posterior accessory great saphenous vein, who are candidates for intervention, we suggest superficial venous intervention over compression stockings. ( 2 – Weak , C)
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2.1.3.

For patients with symptomatic varicose veins and axial reflux in the superficial truncal veins, we suggest compression therapy for primary treatment if the patient’s ambulatory status and underlying medical conditions warrant a conservative approach or, if the patient prefers conservative treatment, for either a trial period or definitive management. ( 2 – Weak , C)
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2.2.1.

For patients with symptomatic varicose veins and axial reflux in the great saphenous vein, who are candidates for intervention, we recommend treatment with endovenous ablation over high ligation and stripping of the great saphenous vein because of less postprocedure pain and morbidity and an earlier return to regular activity. ( 1 – Strong , B)
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2.2.2.

For patients with symptomatic varicose veins and axial reflux in the small saphenous vein, who are candidates for intervention, we recommend treatment with endovenous ablation over ligation and stripping of the small saphenous vein because of less postprocedure pain and morbidity and an earlier return to regular activity. ( 1 – Strong , C)
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2.2.3.

For patients with symptomatic varicose veins and axial reflux in the anterior accessory or posterior accessory great saphenous vein, who are candidates for intervention, we suggest treatment with endovenous ablation, with additional phlebectomy, if needed, over ligation and stripping of the accessory great saphenous vein because of less postprocedure pain and morbidity and an earlier return to regular activity. ( 2 – Weak , C)
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2.3.1.

For patients with symptomatic varicose veins and axial reflux in the great or small saphenous vein, we recommend treatment with ligation and stripping of the saphenous vein if technology or expertise in endovenous ablation is not available or if the venous anatomy precludes endovenous treatment. ( 1 – Strong , B)
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2.3.2.

For patients with symptomatic varicose veins and axial reflux in the anterior accessory or the posterior accessory great saphenous vein, we suggest treatment with ligation and stripping of the accessory great saphenous vein, with additional phlebectomy, if needed, if technology or expertise in endovenous ablations is not available or if the venous anatomy precludes endovenous treatment. ( 2 – Weak , C)
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2.4.1.

For patients with symptomatic varicose veins and axial reflux in the great saphenous vein who place a high priority on the long-term outcomes of treatment (quality of life and recurrence), we suggest treatment with endovenous laser ablation, radiofrequency ablation, or high ligation and stripping over physician-compounded ultrasound-guided foam sclerotherapy. ( 2 – Weak , B)
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2.4.2.

For patients with symptomatic varicose veins and axial reflux in the small saphenous vein who place a high priority on the long-term outcomes of treatment (quality of life and recurrence), we suggest treatment with laser ablation, radiofrequency ablation, or ligation and stripping from the knee to the upper or mid-calf over physician-compounded ultrasound-guided foam sclerotherapy. ( 2 – Weak , C)
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2.4.3.

For patients with symptomatic varicose veins and axial reflux in the anterior accessory or posterior accessory great saphenous vein who place a high priority on the long-term outcomes of treatment (quality of life and recurrence), we suggest treatment of the refluxing superficial trunk with endovenous laser ablation, radiofrequency ablation, or high ligation and stripping, with additional phlebectomy, if needed, over physician-compounded ultrasound-guided foam sclerotherapy. ( 2 – Weak , C)
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Guideline 3

3.1.1.

For patients with symptomatic axial reflux of the great saphenous vein, we recommend both thermal and nonthermal ablation from the groin to below the knee, depending on the available expertise of the treating physician and the preference of the patient. ( 1 – Strong , B)
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3.1.2.

For patients with symptomatic axial reflux of the small saphenous vein, we recommend both thermal and nonthermal ablation from the knee to the upper or mid-calf, depending on the available expertise of the treating physician and the preference of the patient. ( 1 – Strong , C)
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3.1.3.

For patients with symptomatic axial reflux of the anterior accessory or posterior accessory great saphenous vein, we suggest either thermal or nonthermal ablation, with additional phlebectomy, if needed, depending on the available expertise of the treating physician and the preference of the patient. ( 2 – Weak , C)
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Guideline 4

4.1.1.

For patients with varicose veins (CEAP class C2) who have significant, symptomatic axial reflux of the great or small saphenous vein, we recommend against treatment of incompetent perforating veins concomitant with initial ablation of the superficial truncal veins. ( 1 – Strong , C)
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4.1.2.

For patients with varicose veins (CEAP class C2) who have significant, symptomatic axial reflux of the anterior accessory or posterior accessory great saphenous vein, we suggest against treatment of incompetent perforating veins concomitant with initial ablation of the superficial truncal veins. ( 2 – Weak , C)
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4.2.

For patients with varicose veins (CEAP class C2) and persistent or recurrent symptoms after previous complete ablation of incompetent superficial truncal veins, we suggest treatment of perforating vein incompetence if it is the origin of the symptomatic varicose tributaries. ( 2 – Weak , C)
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Guideline 5

5.1.1.

For patients with symptomatic reflux in the great or small saphenous vein and associated varicosities, we recommend ablation of the refluxing venous trunk and concomitant phlebectomy or ultrasound-guided foam sclerotherapy of the varicosities with physician-compounded foam or commercial polidocanol endovenous microfoam. ( 1 – Strong , C)
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5.1.2.

For patients with symptomatic reflux in the anterior accessory or posterior accessory great saphenous vein, we suggest ablation of the refluxing venous trunk and concomitant phlebectomy or ultrasound-guided foam sclerotherapy of the varicosities with physician-compounded foam or commercial polidocanol endovenous microfoam. ( 2 – Weak , C)
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5.2.1.

For patients with symptomatic reflux in the great or small saphenous vein, we suggest ablation of the refluxing venous trunk and staged phlebectomy or ultrasound-guided foam sclerotherapy of the varicosities only if anatomic or medical reasons present. We suggest shared decision-making with the patient. ( 2 – Weak , C)
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5.2.2.

For patients with symptomatic reflux in the anterior accessory great saphenous vein or posterior accessory great saphenous vein, we suggest ablation of the refluxing venous trunk and staged phlebectomy or ultrasound-guided foam sclerotherapy of the varicosities only if anatomic or medical reasons present. We suggest shared decision-making with the patient. ( 2 – Weak , C)
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5.3.

For patients with symptomatic reflux in the major superficial venous trunks and associated varicosities undergoing initial ablation alone, we recommend that patients be followed up for ≥3 months to assess the need for staged phlebectomy or ultrasound-guided sclerotherapy for persistent or recurrent symptoms. Longer follow-up is recommended for patients with recurrent symptoms and for patients who participate in clinical trials. ( G-U , U)
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Recommendation Grading

Overview

Title

Management of Varicose Veins of the Lower Extremities - Duplex Scanning and Treatment of Superficial Truncal Reflux

Authoring Organizations

American Vein & Lymphatic Society

American Venous Forum

Society for Vascular Surgery

Endorsing Organization

Society for Vascular Medicine

Publication Month/Year

October 10, 2022

Last Updated Month/Year

April 1, 2024

Document Type

Guideline

Country of Publication

US

Document Objectives

The Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society collaborated to update the 2011 Society for Vascular Surgery/American Venous Forum clinical practice guidelines and provide new evidence-based recommendations on critical issues affecting the care of patients with varicose veins. Each recommendation is based on a recent, independent systematic review and meta-analysis of the diagnostic tests and treatments options for patients with lower extremity varicose veins. Part I of the guidelines includes evidence-based recommendations for the evaluation of patients with CEAP (Clinical Class, Etiology, Anatomy, Pathology) class 2 varicose vein using duplex ultrasound scanning and other diagnostic tests, open surgical treatment (ligation and stripping) vs endovenous ablation techniques, thermal vs nonthermal ablation of the superficial truncal veins, and management of incompetent perforating veins in CEAP class 2 disease. We have also made recommendations on the concomitant vs staged treatment of varicose tributaries using phlebectomy or liquid or foam sclerotherapy (with physician-compounded foam or commercially prepared polidocanol endovenous microfoam) for patients undergoing ablation of incompetent superficial truncal veins.

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Ambulatory, Outpatient, Operating and recovery room

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Diagnosis, Assessment and screening, Treatment, Management

Diseases/Conditions (MeSH)

D014648 - Varicose Veins

Keywords

varicose veins, duplex scanning, superficial truncal reflux

Source Citation

Gloviczki P, Lawrence PF, Wasan SM, Meissner MH, Almeida J, Brown KR, Bush RL, Di Iorio M, Fish J, Fukaya E, Gloviczki ML, Hingorani A, Jayaraj A, Kolluri R, Murad MH, Obi AT, Ozsvath KJ, Singh MJ, Vayuvegula S, Welch HJ. The 2022 Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society clinical practice guidelines for the management of varicose veins of the lower extremities. Part I. Duplex Scanning and Treatment of Superficial Truncal Reflux: Endorsed by the Society for Vascular Medicine and the International Union of Phlebology. J Vasc Surg Venous Lymphat Disord. 2022 Oct 12:S2213-333X(22)00417-6. doi: 10.1016/j.jvsv.2022.09.004. Epub ahead of print. PMID: 36326210.