Management of Varicose Veins of the Lower Extremities. Part II
Publication Date: August 27, 2023
Last Updated: December 22, 2023
Diagnosis
1. Evaluation of Patients With Varicose Veins
1.1. Classification and grading of clinical severity of chronic venous disorders
Good Practice Statements
1.1.1.
We recommend the use of the 2020 updated Clinical Stage, Etiology, Anatomy, Pathology (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 , )
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1.1.2.
We recommend the use of the revised Venous Clinical Severity Score (VCSS) for patients with chronic venous disorders for grading of clinical severity and for assessment of post treatment outcome. ( G-U , )
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1.2.–1.5. Doppler ultrasound scanning (DUS)
Recommendation
1.2.1.
For patients with chronic venous disease of the lower extremities, we recommend DUS as the diagnostic test of choice to evaluate for venous reflux. ( 1 – Strong , B)
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Implementation Remarks
1.3.1.
Reflux is defined as a minimum value >500 ms of reversed flow in the superficial truncal veins (great saphenous vein [GSV], small saphenous vein [SSV], anterior accessory great saphenous vein [AAGSV], and posterior accessory great saphenous vein [PAGSV]) and in the tibial, deep femoral, and perforating veins. A minimum value of >1 second of reversed flow is diagnostic of reflux in the common femoral, femoral, and popliteal veins. There is no minimum diameter required to have pathologic reflux. (, )
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1.3.2.
Axial reflux of the GSV is defined as uninterrupted retrograde venous flow from the groin to the upper calf. Axial reflux in the SSV is defined as being from the knee to the ankle. Axial reflux in the AAGSV and PAGSV is retrograde flow between two measurements, at least five centimeters (cm) apart. Retrograde flow can occur in the superficial or deep veins, with or without perforating veins. Junctional reflux is limited to the saphenofemoral (SFJ) or saphenopopliteal junction (SPJ). Segmental reflux occurs in only a portion of a superficial or deep truncal vein. (, )
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1.3.3.
A definition of “pathologic” perforating veins in patients with varicose veins CEAP 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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Good Practice Statements
1.4.1.
We recommend that evaluation of reflux with DUS 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 , )
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1.4.2.
We recommend that for evaluation of reflux with DUS, the sonographer use either a Valsalva maneuver or augmentation to assess the common femoral vein and SFJ 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 , )
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1.4.3.
We recommend that a complete DUS examination for venous reflux in the lower extremities include transverse gray scale images without and with transducer compression of the common femoral, proximal, mid, and distal femoral and popliteal veins, SFJ, and at least two segments along the GSV and SSV. ( G-U , )
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1.4.4.
We recommend that a complete DUS examination for venous reflux in the lower extremities 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 should be documented. Reflux in the GSV at the proximal thigh and knee, in the AAGSV or PAGSV at the saphenofemoral junction and at the proximal thigh and in the SSV at SPJ and at the proximal calf should be documented. ( G-U , )
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1.4.5.
We recommend that a complete DUS examination for venous reflux in the lower extremities include diameter measurements in patients with the leg in the dependent position, from the anterior to the posterior wall, in the GSV 1 cm distal to the SFJ, at the proximal thigh and at the knee, in the AAGSV and PAGSV in the proximal thigh, and in the SSV at the SPJ and the proximal calf. Images of both normal and abnormal findings should be documented in the records of the patient. ( G-U , )
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Consensus Statements
1.5.1.
In asymptomatic patients with telangiectasias or reticular veins (CEAP Class C1) DUS evaluation of the lower extremity veins should not be routinely performed, since testing could result in unnecessary saphenous vein ablation procedures. (CS, )
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1.5.2.
In symptomatic CEAP Class C1 patients with bleeding or with severe symptoms of pain or burning due to moderate to severe telangiectasias or reticular veins, DUS evaluation may be performed to exclude associated venous incompetence; however, saphenous ablation for C1 disease without bleeding is rarely required. (CS, )
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1.5.3.
In symptomatic patients with varicose veins (CEAP Class C2) the deep venous system should be routinely evaluated for infrainguinal obstruction or valvular incompetence. (CS, )
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1.5.4.
In symptomatic patients with varicose veins (CEAP Class C2) evaluation for iliofemoral venous obstruction with DUS or with other imaging studies should be performed if suprapubic or abdominal wall varicosities are present and in patients with symptoms of proximal obstruction, including thigh and leg fullness, heaviness, swelling and venous claudication. CEAP Classes 3–6 warrant DUS or other imaging studies to evaluate for iliofemoral obstruction. (CS, )
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1.5.5.
In patients with medial thigh or vulvar varicosities evaluation of pelvic venous pathology with DUS or other imaging studies is not indicated if they have no symptoms of pelvic venous disease. (CS, )
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Treatment
2. Compression Therapy
2.1. Compression therapy vs. intervention
Recommendations
2.1.1.
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/or 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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2.1.2.
For patients with symptomatic varicose veins and axial reflux in the GSV or SSV who are candidates for intervention, we recommend superficial venous intervention over long-term compression stockings. ( 1 – Strong , B)
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2.1.3.
For patients with symptomatic varicose veins and axial reflux in the AAGSV or PAGSV, who are candidates for intervention, we suggest superficial venous intervention over long-term compression stockings. ( 2 – Weak , C)
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2.1.4.
In patients with symptomatic varicose veins who are candidates for endovenous therapy and wish to proceed with treatment, we suggest against a 3-month trial of compression therapy before intervention. ( 2 – Weak , B)
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2.2. Compression therapy after intervention
2.2.1.
In patients undergoing thermal ablation for saphenous incompetence, with or without concomitant phlebectomy, we suggest post-procedure compression therapy for a minimum of 1 week for pain reduction. ( 2 – Weak , B)
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3. Pharmacological Treatment
Recommendations
3.1.
In symptomatic patients with varicose veins who are not candidates for intervention, or who are waiting for intervention or have symptoms after intervention, we suggest Micronized Purified Flavonoid Fraction (MPFF) or Ruscus extracts for treatment of vein related pain, leg heaviness and/or sensation of swelling.a ( 2 – Weak , B)
a These products are not approved drugs by the U.S. Food and Drug Administration (FDA). FDA does not approve medical food or nutritional supplements (https://www.fda.gov/).
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3.2.
In symptomatic patients with varicose veins who are not candidates for intervention, or who are waiting for intervention or have symptoms after intervention, we suggest hydroxyethylrutosides (HR), calcium dobesilate, horse chestnut extract (HCSE), red vine leaf extract, or sulodexide for treatment of vein-related pain, leg heaviness, night cramps and/or sensation of swelling.a ( 2 – Weak , C)
a These products are not approved drugs by the U.S. Food and Drug Administration (FDA). FDA does not approve medical food or nutritional supplements (https://www.fda.gov/).
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4. Interventions for Superficial Truncal Reflux
4.1. Endovenous ablation vs. high ligation and stripping (HL&S)
Recommendations
4.1.1.
For patients with symptomatic varicose veins and axial reflux in the GSV, who are candidates for intervention, we recommend treatment with endovenous ablation over HL&S of the GSV. ( 1 – Strong , B)
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4.1.2.
For patients with symptomatic varicose veins and axial reflux in the SSV, who are candidates for intervention, we recommend treatment with endovenous ablation over ligation and stripping of the SSV. ( 1 – Strong , C)
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4.1.3.
For patients with symptomatic varicose veins and axial reflux in the AAGSV or PAGSV, who are candidates for intervention, we suggest treatment with endovenous ablation, with additional phlebectomy, if needed, over ligation and stripping of the accessory vein. ( 2 – Weak , C)
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4.1.4.
For patients with symptomatic varicose veins and axial reflux in the GSV or SSV, we recommend treatment with HL&S 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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4.1.5.
For patients with symptomatic varicose veins and axial reflux in the AAGSV or PAGSV, we suggest treatment with ligation and stripping of the accessory 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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4.1.6.
For patients with symptomatic varicose veins and axial reflux in the GSV who place a high priority on the long-term outcomes of treatment (quality of life and recurrence), we suggest treatment with endovenous laser ablation (EVLA), radiofrequency ablation (RFA), or HL&S over physician-compounded ultrasound-guided foam sclerotherapy because of long-term improvement of quality of life and reduced recurrence. ( 2 – Weak , B)
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4.1.7.
For patients with symptomatic varicose veins and axial reflux in the SSV, we suggest treatment with endovenous laser ablation, RFA, or ligation and stripping from the knee to the upper or mid-calf over physician-compounded ultrasound-guided foam sclerotherapy because of long-term improvement of quality of life and reduced recurrence. ( 2 – Weak , C)
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4.1.8.
For patients with symptomatic varicose veins and axial reflux in the AAGSV or PAGSV 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, RFA, or HL&S, with additional phlebectomy, if needed, over physician-compounded ultrasound-guided foam sclerotherapy because of long-term improvement of quality of life and reduced recurrence. ( 2 – Weak , C)
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4.2. Thermal vs. non-thermal ablation of superficial truncal veins
Recommendations
4.2.1.
For patients with symptomatic axial reflux of the GSV, we recommend either thermal or non-thermal 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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4.2.2.
For patients with symptomatic axial reflux of the SSV, we recommend either thermal or non-thermal 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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4.2.3.
For patients with symptomatic axial reflux of the AAGSV or PAGSV, we suggest either thermal or non-thermal 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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5. Factors Affecting Choice of Superficial Truncal Ablation and Outcome
Recommendation
5.1.1.
In symptomatic patients with C2 disease we suggest against using truncal vein diameter to determine which patients need venous ablation. ( 2 – Weak , B)
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Consensus Statements
5.2.1.
In asymptomatic patients with C2 disease, prophylactic intervention does not prevent progression of venous disease. Weight control, compression stockings and avoiding prolonged standing may be beneficial. (CS, )
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5.2.2.
Interventions to treat varicose veins can be performed in an office-based setting, surgery center, or hospital operating room, at the discretion of the physician, who is specialized in vein care. Better patient experience and lower cost was reported for procedures performed in an office-based setting. (CS, )
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5.2.3.
In patients with symptomatic C2 disease, isolated SFJ incompetence does not justify ablation of an otherwise competent GSV. (CS, )
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5.2.4.
In patients with symptomatic C2 disease, ablation of the incompetent GSV may be indicated, even if the axial reflux is not complete and the SFJ is competent. Ablation of isolated refluxing GSV segments, in the presence of competent segments proximally and distally, is rarely indicated. Shared decision making with the patient is warranted. (CS, )
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5.2.5.
In patients with reflux in the below-knee GSV, ablation to the lowest point of reflux resulted in better early outcome. Non-thermal techniques are better for ablation of refluxing distal calf saphenous veins, to avoid thermal nerve injury. (CS, )
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5.2.6.
In patients with an epifascial or superficial saphenous vein, thermal ablation may result in skin burns, hyperpigmentation, or induration, while non-thermal techniques may cause hyperpigmentation or induration. Mini-phlebectomy or limited stripping is safe and effective if the saphenous vein is close to the skin (<0.5 cm). (CS, )
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5.2.7.
For patients with large (>10 mm), non-aneurysmal saphenous veins, thermal ablation with EVLA or RFA should be performed rather than using non-thermal ablation techniques. (CS, )
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5.2.8.
The incidence of superficial thrombophlebitis has been reported to be similar for thermal and non-thermal ablations. (CS, )
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5.2.9.
In patients with uncomplicated C2 disease (no venous claudication, thigh swelling, suprapubic or abdominal wall varicosities) due to concurrent superficial incompetence and iliac or iliofemoral venous obstruction, treatment of superficial incompetence first is indicated. (CS, )
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6. Interventions to Preserve the GSV
Recommendations
6.1.1.
For patients with the early stages of symptomatic varicose veins we suggest preserving the GSV using the ambulatory selective variceal ablation under local anesthesia (ASVAL) technique, if performed by a physician who is familiar with the technique. ( 2 – Weak , B)
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6.1.2.
For patients with symptomatic varicose veins, we suggest preserving the GSV using the Ambulatory Conservative Hemodynamic Correction of Venous Insufficiency (CHIVA) technique, if performed by physician who is familiar with the technique. ( 2 – Weak , B)
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7. Treatment of Venous Tributaries
7.1. Telangiectasias and reticular veins
Recommendations
7.1.1.
For patients with symptomatic telangiectasias and reticular veins, we recommend sclerotherapy with liquid or foam. ( 1 – Strong , B)
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7.1.2.
For patients with symptomatic telangiectasias or reticular veins, we suggest transcutaneous laser treatment if the patient has sclerosant allergy, needle phobia, sclerotherapy failure or small veins (<1 mm) with telangiectatic matting. ( 2 – Weak , B)
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7.2. Varicose tributaries
Recommendations
7.2.1.
For treatment of symptomatic varicose tributaries, we recommend mini-phlebectomy or ultrasound guided sclerotherapy using physician-compounded foam (PCF) or polidocanol endovenous microfoam (PEM). ( 1 – Strong , B)
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7.2.2.
For treatment of symptomatic varicose tributaries, we suggest transilluminated powered phlebectomy as an alternative treatment for patients with clusters of varicosities by a physician who is trained in the procedure. ( 2 – Weak , C)
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Consensus Statements
7.2.3.
For patients with symptomatic varicose tributaries, treatment of the tributaries should be performed, even if the superficial trunks are competent. (CS, )
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7.2.4.
There is no clinical evidence that foam sclerotherapy using room air is less safe and effective than using CO2 gas mixture. (CS, )
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7.2.5.
There is currently no clinical study of sclerotherapy with PCF, prepared using the Tessari method, that shows that it is less safe or effective than PEM. (CS, )
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8. Treatment of Varicose Tributaries Concomittant or Staged With Superficial Truncal Ablation
Recommendations
8.1.1.
For patients with symptomatic reflux in the GSV or SSV and associated varicosities, we recommend ablation of the refluxing venous trunk and concomitant phlebectomy or ultrasound-guided foam sclerotherapy of the varicosities with PCF or PEM. ( 1 – Strong , C)
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8.1.2.
For patients with symptomatic reflux in the AAGSV or PAGSV, we suggest simultaneous ablation of the refluxing venous trunk and phlebectomy or ultrasound-guided foam sclerotherapy of the varicosities with PCF or PEM. ( 2 – Weak , C)
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8.1.3.
For patients with symptomatic reflux in the GSV or SSV, we suggest ablation of the refluxing venous trunk and staged phlebectomy or ultrasound-guided foam sclerotherapy of the varicosities only if anatomical or medical reasons are present. We suggest shared decision-making with the patient regarding the timing of the procedure. ( 2 – Weak , C)
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8.1.4.
For patients with symptomatic reflux in the AAGSV or PAGSV, we suggest ablation of the refluxing venous trunk and staged phlebectomy or ultrasound-guided foam sclerotherapy of the varicosities only if anatomical or medical reasons present. We suggest shared decision-making with the patient regarding the timing of the procedure. ( 2 – Weak , C)
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Good Clinical Practice Statement
8.2.
For patients with symptomatic reflux in the major superficial venous trunks and associated varicosities undergoing initial ablation alone, we recommend follow-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 those with recurrence or more advanced CEAP class. ( G-U , )
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9. Management of Recurrent Varicosities
Consensus Statements
9.1.1.
For patients with symptomatic recurrent varicosities, clinical evaluation and DUS should be performed before treatment to determine the potential source of recurrence. (CS, )
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9.1.2.
For patients with symptomatic recurrent varicosities due to persistent or recurrent reflux of the GSV or AAGSV, treatment either with open surgical or endovascular techniques may be performed, with good outcomes expected. (CS, )
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9.1.3.
For patients with symptomatic recurrent varicosities due to persistent or recurrent reflux at the groin, either EVLA or RFA can be used if there is a straight GSV stump, long enough for thermal ablation. Sclerotherapy or phlebectomy should be performed for recurrence due to neovascularization.
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9.1.4.
For patients with symptomatic recurrent varicosities due to persistent or recurrent reflux of the SSV, ultrasound-guided foam sclerotherapy should be performed. (CS, )
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9.1.5.
For patients with residual or recurrent varicosities due to incompetent perforator veins, treatment with both open and endovascular techniques may be used depending on the physician’s experience, patient choice and availability of technology. (CS, )
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10. Ablation of Incompetent Perforating Veins
Recommendations
10.1.1.
For patients with varicose veins (CEAP class C2) who have significant, symptomatic axial reflux of the GSV or SSV, we recommend against treatment of incompetent perforating veins concomitant with initial ablation of the saphenous veins. ( 1 – Strong , C)
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10.1.2.
For patients with varicose veins (CEAP class C2) who have significant, symptomatic axial reflux of the AAGSV or PAGSV, we suggest against treatment of incompetent perforating veins concomitant with initial ablation of the superficial truncal veins. ( 2 – Weak , C)
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Consensus Statement
10.2.
For patients with incompetent pathologic perforators associated with symptomatic residual, recurrent, and rarely primary varicosities, without associated saphenous incompetence, either open or endovascular techniques can be used to treat the perforator veins. (CS, )
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11. Management of Ablation-related Thrombus Extension (ARTE) And Deep Vein Thrombosis (DVT) After Endovenous Ablations
11.1. Post-procedure DUS
Recommendation
11.1.1.
In an average-risk patient who is asymptomatic following thermal ablation of the saphenous vein, we recommend against routine early post-procedural DUS to detect ARTE (formally known as Endovenous Heat Induced Thrombosis, EHIT) or DVT. ( 1 – Strong , B)
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Consensus Statements
11.1.2.
In an average-risk patient who is asymptomatic following non-thermal ablation of the saphenous vein, routine early post-procedural DUS may be performed to detect ARTE or DVT. (CS, )
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11.1.3.
In a high-risk patient who is asymptomatic following thermal or non-thermal saphenous ablation early DUS to exclude ARTE or DVT should be performed. (CS, )
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Recommendation
11.1.4.
In patients who are symptomatic following thermal or non-thermal ablation, we recommend early DUS to exclude ARTE or DVT. ( 1 – Strong , A)
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11.2. Pharmacological thromboprophylaxis
Recommendation
11.2.1.
For high-risk patients undergoing endovenous ablation we suggest pharmacological thromboprophylaxis. ( 2 – Weak , C)
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Consensus Statement
11.2.2.
For patients undergoing endovenous ablation routine risk stratification should be performed to assess the need for peri-procedural thromboprophylaxis. (CS, )
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11.3. Treatment of varicose vein procedure related DVT and ARTE
Recommendationsb
11.3.1.
For patients with acute isolated distal DVT after varicose vein procedure, without symptoms or risk factors for extension, we suggest serial imaging of the deep veins for 2 weeks. ( 2 – Weak , B)
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11.3.2.
For patients with isolated distal DVT after varicose vein procedure and symptoms or risk factors for extension we suggest anticoagulation. ( 2 – Weak , C)
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11.3.3.
For patients with acute proximal DVT after varicose vein procedure, we recommend anticoagulation with a direct oral anticoagulant (over a vitamin K antagonist). ( 1 – Strong , B)
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11.3.4.
For patients with symptomatic ARTE after endovenous ablation, we recommend anticoagulation with a direct oral anticoagulant (over a vitamin K antagonist). ( 1 – Strong , C)
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b We endorsed the recommendations of Stevens SM, Woller SC, Kreuziger LB, Bounameaux H, Doerschug K, Geersing GJ, et al. Antithrombotic Therapy for VTE Disease: Second Update of the CHEST Guideline and Expert Panel Report. Chest. 2021;160(6):e545-e608. The evidence base for these guidelines was adopted without review.
Consensus Statements
11.4.1.
For patients with asymptomatic ARTE III and IV after endovenous ablation, anticoagulation with a direct oral anticoagulant (over a vitamin K antagonist) should be performed. (CS, )
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11.4.2.
For patients who receive anticoagulation for ARTE following endovenous ablation, treatment should be continued until the thrombus retracts. (CS, )
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12. Management of Superficial Vein Thrombosis (SVT)
Recommendation 12 addresses the management of SVT in patients who have not recently undergone superficial venous interventions. The management of ARTE and other thrombotic complications of superficial venous interventions are addressed in Recommendation 11.
Recommendation
12.1.1.
For patients with SVT of the main saphenous trunks and tributaries above the knee >3 cm from the SFJ and >5 cm in length, whether associated with varicose veins or not, we recommend fondaparinux 2.5 mg subcutaneously daily for 45 days. Alternatively, rivaroxaban 10 mg daily for 45 days may be appropriate for patients unwilling or unable to perform subcutaneous injections. ( 1 – Strong , A)
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Consensus Statement
12.1.2
For patients with SVT of the main saphenous trunks ≤3 cm from the SFJ, treatment with full anticoagulation for a minimum of 6 weeks should be continued. (CS, )
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Recommendations
12.1.3.
For patients with SVT of the main saphenous trunks we recommend against using prophylactic or therapeutic dose low molecular weight heparin (LMWH) and nonsteroidal anti-inflammatory drugs (NSAIDs). Although both have been found to reduce SVT pain and extension, they have failed to prevent venous thromboembolic events (VTE). If NSAIDs are used for treatment of short segment distal SVT, surveillance with DUS for VTE extension is recommended due to the high prevalence of concomitant DVT ( 1 – Strong , A)
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12.1.4.
For selected patients with isolated thrombosis of varicose tributaries or limited involvement of the GSV, we suggest phlebectomy as a safe alternative. ( 2 – Weak , B)
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Consensus Statement
12.1.5.
In patients with saphenous thrombophlebitis, ablation should be performed once the inflammation has resolved if there is evidence of pathologic reflux on DUS. (CS, )
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13. Management of Bleeding Varicose Veins
Consensus Statements
13.1.
For patients presenting with acute bleeding from varicose veins, leg elevation, direct compression and sclerotherapy should be attempted before suture ligation to control bleeding. (CS, )
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13.2.
For patients with bleeding due to varicose veins, prompt referral to a venous specialist should be done. (CS, )
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13.3.
For patients who presented with bleeding from varicose veins, after the bleeding has been controlled, evaluation for superficial venous incompetence and appropriate intervention on the responsible veins should be done to control venous hypertension and reduce the risk of recurrent hemorrhage. (CS, )
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13.4.
Patients with varicose veins or venous ulcerations should be counseled on the possibility of venous bleeding and their families, caregivers, or friends educated regarding leg elevation and simple compression techniques to control severe bleeding. (CS, )
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14. Management of Superficial Vein Aneurysms
Consensus Statements
14.1.
For patients with superficial truncal vein aneurysm, located within 3 cm of the SFJ or SPJ, open surgical excision, with high proximal and distal ligations should be performed. If symptomatic saphenous reflux is present, endovenous or open surgical ablation (phlebectomy or limited stripping) of the distal saphenous vein should be performed. (CS, )
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14.2.
For patients with an asymptomatic superficial truncal vein aneurysm, located >3 cm distal to the SFJ, endovenous ablation alone should be performed. Thrombo-prophylaxis in these patients reduces the risk of VTE. (CS, )
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14.3.
Patients with symptomatic, thrombosed or large (>3 cm) aneurysms in the superficial veins are best treated with surgical excision. (CS, )
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Recommendation Grading
Disclaimer
The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.
Overview
Title
Management of Varicose Veins of the Lower Extremities. Part II
Authoring Organizations
American Vein & Lymphatic Society
American Venous Forum
Society for Vascular Surgery
Publication Month/Year
August 27, 2023
Last Updated Month/Year
November 21, 2024
Supplemental Implementation Tools
Document Type
Guideline
Country of Publication
US
Document Objectives
The Society for Vascular Surgery (SVS), the American Venous Forum (AVF), and the American Vein and Lymphatic Society (AVLS) recently published Part I of the 2022 clinical practice guidelines on varicose veins. Recommendations were based on the latest scientific evidence researched following an independent systematic review and meta-analysis of five critical issues affecting the management of patients with lower extremity varicose veins, using the PICO (patients, interventions, comparators, and outcome) system to answer critical questions. Part I discussed the role of duplex ultrasound scanning (DUS) in the evaluation of varicose veins and treatment of superficial truncal reflux. Part II focuses on evidence supporting the prevention and management of varicose vein patients with compression, on treatment with drugs and nutritional supplements, on evaluation and treatment of varicose tributaries, on superficial venous aneurysms, and on the management of complications of varicose veins and their treatment. All Guidelines were based on systematic reviews, and they were graded according to the level of evidence and the strength of recommendations, using the GRADE method. All ungraded Consensus Statements were supported by an extensive literature review and the unanimous agreement of an expert, multidisciplinary panel. Ungraded Good Practice Statements are recommendations that are supported only by indirect evidence. The topic, however, is usually non-controversial and agreed upon by most stakeholders. The Implementation Remarks contain technical information that supports the implementation of specific recommendations. This comprehensive document includes a list of all recommendations (Part I-II), ungraded consensus statements, implementation remarks, and best practice statements to aid practitioners with appropriate, up-to-date management of patients with lower extremity varicose veins.
Target Patient Population
Patients with lower extremity varicose 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, Venous insufficiency
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 2023 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 II. J Vasc Surg Venous Lymphat Disord. 2023 Aug 29:S2213-333X(23)00322-0. doi: 10.1016/j.jvsv.2023.08.011. Epub ahead of print. PMID: 37652254.
Methodology
Number of Source Documents
317
Literature Search Start Date
December 5, 2020
Literature Search End Date
January 29, 2023