Varicose Veins

Perform a focused history and examination for symptom burden, edema, skin injury, prior venous thromboembolism, prior venous procedures, functional limitation, and treatment goals. Classify the clinical component of CEAP at baseline: C0 has no visible or palpable venous signs; C1 has telangiectases or reticular veins; C2 has varicose veins; C3 has edema; C4a has pigmentation or eczema; C4b has lipodermatosclerosis or atrophie blanche; C5 has a healed ulcer; and C6 has an active ulcer.BMJBMJCaVenT - BMJ Open

Obtain duplex ultrasound of the deep and superficial veins for symptomatic varicose veins and for edema, skin changes, or ulceration. The examination should establish whether disease is superficial, deep, perforator, or mixed and whether the dominant physiologic abnormality is reflux, obstruction, or both; these distinctions determine whether isolated superficial treatment is anatomically appropriate.BMJ+2BMJCaVenT - BMJ OpenScienceDirectThe care of patients with varicose veins and associated chronic venous diseases: Clinical practice guidelines of the Society for Vascular Surgery and the American Venous ForumWileyChronic venous insufficiency – a review of pathophysiology ...

A documented example of great saphenous reflux used a reflux time of 1.8 seconds in a 2- to 3-mm segment, whereas contemporary treatment discussions commonly identify retrograde flow exceeding 500 ms as axial reflux. Interpret a reflux study in the context of symptoms, extent of axial disease, and deep-system findings rather than treating an isolated ultrasonographic abnormality.NEJM+1NEJMNonsurgical Management of Chronic Venous InsufficiencyPubMedVenous Insufficiency: Endovascular and Surgical Treatment

Offer compression therapy for symptomatic varicose veins when ambulatory status, comorbidity, patient preference, or procedural unsuitability favors conservative care. Compression is a reasonable symptom-directed strategy, but guideline recommendations advise against using it as the primary treatment solely when a patient is an appropriate candidate for saphenous vein intervention.ScienceDirect+1ScienceDirectThe care of patients with varicose veins and associated chronic venous diseases: Clinical practice guidelines of the Society for Vascular Surgery and the American Venous ForumPubMedVenous Insufficiency: Endovascular and Surgical Treatment

For symptomatic axial superficial reflux in an intervention-eligible patient, select a procedure according to vein anatomy, access feasibility, need for tributary treatment, prior procedures, patient preference, and operator expertise. Thermal endovenous modalities include endovenous laser ablation (EVLA) and radiofrequency ablation (RFA); both aim to occlude the refluxing truncal vein without high ligation and stripping.ScienceDirect+1ScienceDirectA systematic review supporting the Society for Vascular Surgery, the American Venous Forum, and the American Vein and Lymphatic Society guidelines on the management of varicose veinsPubMedPain Outcomes Following Mechanochemical Ablation vs Cyanoacrylate Adhesive for the Treatment of Primary Truncal Saphenous Vein Incompetence: The MOCCA Randomized Clinical Trial - PMC

Discuss treatment durability explicitly when considering foam. In a randomized comparison of primary symptomatic great saphenous reflux, 1-year anatomic success was 88.5% with EVLA, 88.2% with conventional surgery, and 72.2% with ultrasound-guided foam sclerotherapy; complications were low and comparable, while quality-of-life measures improved in all groups.PubMedPubMedComparing endovenous laser ablation, foam sclerotherapy, and conventional surgery for great saphenous varicose veins. - Abstract At 5 years, EVLA and conventional surgery were more effective than foam at great saphenous vein obliteration, and foam was associated with more reflux and lower disease-specific quality-of-life scores.PubMedPubMedFive-year results of a randomized clinical trial of conventional surgery, endovenous laser ablation and ultrasound-guided foam sclerotherapy in patients with great saphenous varicose veins. - Abstract

Do not perform sclerotherapy in a patient with known allergy to the sclerosant, acute venous thromboembolism, local infection in the treatment field, or severe generalized infection. For foam sclerotherapy, known symptomatic right-to-left shunt, including symptomatic patent foramen ovale, is an additional absolute contraindication.PubMedPubMedS2k guidelines: diagnosis and treatment of varicose veins

Treat pregnancy, lactation, severe peripheral arterial occlusive disease, poor general health, high thromboembolic risk, active cancer, long-term immobility, and severe thrombophilia as relative contraindications requiring individualized risk-benefit assessment. If sclerotherapy is urgent during lactation, the guideline advises interruption of lactation for 2 to 3 days.PubMedPubMedS2k guidelines: diagnosis and treatment of varicose veins

For known thrombophilia with high thrombus risk, undertake sclerotherapy only with additional pharmacologic thrombosis prophylaxis. The source does not specify an agent or regimen; individualize prophylaxis to thrombotic risk and bleeding risk rather than applying a uniform dose.PubMedPubMedS2k guidelines: diagnosis and treatment of varicose veins

After thermal ablation, use compression for short-term symptom control when appropriate. Guideline evidence found better pain scores during the first 5 days after endothermal saphenous ablation with compression, but longer use of 3 to 6 weeks did not add benefit over 3 to 10 days after surgery in the cited evidence.PubMedPubMedThe 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 A one-week post-ablation compression course is also described in a recent review.PubMedPubMedVenous Insufficiency: Endovascular and Surgical Treatment

At follow-up, reassess clinical class, symptom response, and residual tributaries; duplex ultrasound is the modality used to determine treated-vein obliteration, patency, and residual reflux. Randomized trials used anatomic success defined by obliteration or absence of the treated vein on ultrasound and tracked changes in CEAP and disease-specific quality of life.BMJ+1BMJCaVenT - BMJ OpenPubMedComparing endovenous laser ablation, foam sclerotherapy, and conventional surgery for great saphenous varicose veins. - Abstract

If clinically important reflux or varicosities persist after foam, anticipate that repeat treatment may be necessary. If durable truncal closure is the priority, revisit EVLA or surgery rather than assuming an initial foam session provides equivalent long-term control.PubMed+2PubMedFive-year results of a randomized clinical trial of conventional surgery, endovenous laser ablation and ultrasound-guided foam sclerotherapy in patients with great saphenous varicose veins. - AbstractPubMedComparing endovenous laser ablation, foam sclerotherapy, and conventional surgery for great saphenous varicose veins. - AbstractPubMedIntroduction - Clinical effectiveness and cost-effectiveness of foam sclerotherapy, endovenous laser ablation and surgery for varicose veins: results from the Comparison of LAser, Surgery and foam Sclerotherapy (CLASS) randomised controlled trial - NCBI Bookshelf