management of varicose veins and associated chronic venous disease (CVD) were just published in a supplement to the Journal of Vascular Surgery® (J Vasc Surg 2011;53(5 Suppl):2S-48S). 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® (SVS) and the American Venous Forum (AVF). The Journal of Vascular Surgery is published by the SVS.
An estimated 23 percent of the adult population of the U.S. has varicose veins, and six percent has more advanced CVD, 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, MD, Professor of Surgery, Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, who chaired the SVS/AVF Venous Guideline Committee and is the vice- president of the SVS and past president of the AVF. "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."
The guidelines feature nine key recommendations. Note that 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 CVD, 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 CVD 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 (GSV) we recommend endovenous thermal ablation (radiofrequency or 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 authors assert that "under no circumstance should these guidelines be construed in practice or legal terms as defining 'standards of care' which is solely determined by the condition of the individual patient, treatment setting and other factors." They go on to note that individual patient factors may dictate a different approach that is outlines in the supplement.
Treatment Review Highlights; Meta-Analysis Points to the Need for More Research
The guidelines were based on evidence gained from prospective randomized studies, large case-series and a systematic review and meta-analysis of the treatments for varicose veins, led by M. Hassan Murad, MD, MPH, et al., from Mayo Clinic. These authors summarized the best available evidence about the benefits and harms of the different available treatments. The review compared results of liquid and foam sclerotherapy, laser, radiofrequency ablation and surgery of varicose veins.
The reviewers concluded that the available treatments for varicose veins appear to be safe with rare side effect, but they noted that the only treatment with long-term effectiveness data is still open surgery. The other less invasive treatments are associated with shorter disability and less pain, but only short and medium term effective data exists.
In addition, the reviewers noted that there is an "apparent need for randomized trials of newer and less invasive therapies, such as laser, radiofrequency ablation and foam therapy to compare their durability, efficacy and safety to that of the standard procedure of ligation, stripping and multiple phlebectomies." They also noted that additional studies should stratify patients by the severity of their symptoms in order to obtain the most useful results and that they should focus on cost and long term benefit.