Treatment of Superficial Venous Disease of the Lower Leg
Publication Date: February 1, 2016
Last Updated: March 14, 2022
Guidelines for Treatment of Venous Disease
Indications for Treatment
Compression therapy is an effective method for the management of symptoms related to superficial disease but it does not correct the source of reflux. When patients have a correctable source of reflux definitive treatment should also be offered unless it is contraindicated or unwanted. (1A)
315340
We recommend against compression therapy as a prerequisite therapy for symptomatic venous reflux disease when other definitive treatments such as endovenous ablation are appropriate. (1A)
315340
After interventional treatment, we recommend the use of a compression garment in the postoperative period. There is extra benefit to the patient in the form of reduced pain after use of compression. The compression dosage and duration is at the discretion and clinical judgment of the treating physician. (2B)
315340
Superficial venous insufficiency is a chronic disease and as such we recommend that patients with this disease be counseled to wear a compression garment even after definite treatment has been provided. The compression dosage is at the discretion and clinical judgment of the treating physician. (2C)
315340
We suggest the treatment of some CEAP C2 patients with isolated varices, by medical compression hose alone may be an acceptable form of treatment. A short 1-2 week trial of compression hose may be appropriate where an alternative etiology of symptoms is considered, e.g. musculoskeletal pain or neuropathy (spinal stenosis, sciatica, hip or knee arthritis, diabetic neuropathy etc). (2C)
315340
Indications for treatment include pain or other discomfort (ie, aching, heaviness, fatigue, soreness, burning), edema, varix hemorrhage, recurrent superficial phlebitis, stasis dermatitis or ulceration. We recommend patients should be evaluated using the CEAP classification and the Venous Clinical Severity Score (VCSS). We would define medically necessary as a CEAP classification of C2 or higher. (1A)
315340
In addition
We recommend all patients being considered for treatment must have a duplex ultrasound of the superficial venous system and, at a minimum, evaluation of the common femoral vein and popliteal vein for patency and competence. The exam should ideally be done in the standing position. (1A)
315340
We suggest all noninvasive vascular diagnostic studies be per formed by a qualified physician or by a qualified technologist under the general supervision of a qualified physician. (1C)
315340
We recommend that named veins (Great Saphenous Vein (GSV), Small Saphenous Vein (SSV), Anterior Accessory of the Great Saphenous Vein (AAGSV), Posterior Accessory of the Great Saphenous Vein (PAGSV ), Intersaphenous Vein (Vein of Giacomini)) must have a reflux time > 500 msec, regardless of the reported vein diameter. (1A)
315340
Treatment of Named Saphenous Veins
We recommend endovenous thermal ablation (laser and radiofrequency) is the preferred treatment for saphenous and accessory saphenous (GSV, SSV, AAGSV, PAGSV) vein incompetence. (1B)
315340
We suggest Mechanical/chemical ablation (Clarivein Device) may also be used to treat truncal venous reflux. (2B)
315340
We recommend open surgery is appropriate in veins not amenable to endovenous procedures but otherwise is not recommended because of increased pain, convalescent time, and morbidity. (1B)
315340
We suggest when open surgery of the great saphenous vein is performed it should include high ligation and invagination stripping to the level of the knee. (2B)
315340
We recommend when open surgery of the small saphenous vein is performed it include high ligation and selective invagination of the proximal portion. (1B)
315340
Treatment of Circumflex Veins and Other Non-Truncal Veins
The treatment of other non-truncal, tributary varicose vein reflux (circumflex veins anterior and posterior thigh) is more complex. The medical record should reflect that these veins are incompetent and note their size, presence or absence of tortuosity, and depth relationship to the skin, i.e. accessible or not accessible by phlebectomy.
We recommend varicose (visible) symptomatic tributary veins can be treated by stab phlebectomy, liquid sclerotherapy or foam chemical ablation. (1B)
315340
We recommend (non visible) symptomatic tributary veins be treated by ultrasound-guided liquid sclerotherapy or foam chemical ablation. (1B)
315340
Treatment of Perforator Veins
We suggest treatment of incompetent perforating veins located beneath a healed or open venous ulcer. They should have outward flow of 500 ms, with a diameter of 3.5 mm. (2B)
315340
We suggest, in patients with perforator reflux as the primary or only source of disease, treatment of the perforator with endovenous thermal ablation, ligation or ultrasound guided sclerotherapy. Subsequent or simultaneous treatment of symptomatic varicosities arising from the incompetent perforator is also considered best practice. (2B)
315340
Recommendation Grading
Overview
Title
Treatment of Superficial Venous Disease of the Lower Leg
Authoring Organization
American Vein & Lymphatic Society
Endorsing Organizations
American Venous Forum
Society for Vascular Surgery
Publication Month/Year
February 1, 2016
Last Updated Month/Year
August 1, 2023
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Inclusion Criteria
Female, Adult, Older adult
Health Care Settings
Ambulatory, Hospital, Operating and recovery room
Intended Users
Surgical technologist, physician, physical therapist, nurse, nurse practitioner, physician assistant
Scope
Assessment and screening, Diagnosis, Prevention, Management, Treatment
Diseases/Conditions (MeSH)
D020246 - Venous Thrombosis
Keywords
Superfecial Venous Disease, Lower Leg, Saphenous Veins, Circumflex veins, Non-Truncal veins, Perforator Veins