New Guidelines

New guidelines released for the evaluation and treatment of varicose veins

Wednesday, 11 May 2011

New guidelines for the management of varicose veins and associated chronic venous disease (CVD) were recently published in a supplement to Journal of Vascular Surgery (J Vasc Surg 2011;53(5 Suppl):2S-48S), journal of the Society for Vascular Surgery. The guidelines, which focus on evaluation and treatment of varicose veins of the lower limbs and pelvis, were developed by a joint Venous Guideline Committee of the Society for Vascular Surgery and the American Venous Forum. An estimated 23% of the adult population in the USA has varicose veins, and 6% has more advanced chronic venous disease, including skin changes and healed or active venous ulcers. Long considered a cosmetic problem, varicose veins are now known to cause more serious disability, ranging from discomfort and pain that cause lost work days and decreased quality of life to, in the most serious cases of chronic venous disease and venous ulcers, loss of limb or loss of life. “Improved technology and new surgical techniques, many of which can be done in an office setting, have led to dramatic changes in the treatment of varicose veins,” said Peter Gloviczki, professor of surgery, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, USA, who chaired the Venous Guideline Committee and is the vice- president of the Society for Vascular Surgery and past president of the American Venous Forum. “The new treatment options can significantly improve patient outcomes. They can experience less discomfort, improved quality of life and earlier return to work than was previously possible.”   Key recommendations The guidelines feature nine key recommendations. The strength of each guideline varies based on the benefits as compared to the risks, burdens and costs. We recommend that in patients with varicose veins or more severe chronic venous disease, a complete history and detailed physical examination are complemented by duplex scanning of the deep and superficial veins. We recommend that the CEAP (clinical, etiologic, anatomic, pathophysiologic) classification is used for patients with chronic venous disease and that the revised venous clinical severity score is used to assess treatment outcome. We suggest compression therapy for patients with symptomatic varicose veins but recommend against compression therapy as the primary treatment if the patient is a candidate for saphenous vein ablation. We recommend compression therapy as the primary treatment to aid healing of venous ulceration. To decrease recurrence of venous ulcers, we recommend ablation of the incompetent superficial veins in addition to compression therapy. For treatment of the incompetent great saphenous vein we recommend endovenous thermal ablation (laser) over high ligation and inversion stripping of the saphenous vein to the level of the knee. We recommend phlebectomy or sclerotherapy to treat varicose tributaries and suggest foam sclerotherapy as an option for treatment of the incompetent saphenous vein. We recommend against selective treatment of perforating vein incompetence in patients with simple varicose veins (CEAP class C2), but we suggest treatment of pathologic perforating veins (outward flow 500 ms duration, vein diameter 3.5 mm) located underneath healed or active ulcers (CEAP class C5-C6). We suggest treatment of pelvic congestion syndrome and pelvic varices with coil embolization, plugs, or transcatheter sclerotherapy, used alone or in combination. The abstract can be found on http://www.jvascsurg.org/article/S0741-5214(11)00327-2/abstract