The care of patients with varicose veins and associated chronic ...

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JOURNAL OF VASCULAR SURGERY Volume 53, Number 16S Gloviczki et al 5S Continued. Guideline No. Guideline title 10.3 For treatment of small saphenous vein incompetence, we recommend high ligation of the vein at the knee crease, about 3 to 5 cm distal to the saphenopopliteal junction, with selective invagination stripping of the incompetent portion of the vein. 10.4 To decrease recurrence of venous ulcers, we recommend ablation of the incompetent superficial veins in addition to compression therapy. 10.5 We suggest preservation of the saphenous vein using the ambulatory conservative hemodynamic treatment of varicose veins (CHIVA) technique only selectively in patients with varicose veins, when performed by trained venous interventionists. 10.6 We suggest preservation of the saphenous vein using the ambulatory selective varicose vein ablation under local anesthesia (ASVAL) procedure only selectively in patients with varicose veins. 10.7 We recommend ambulatory phlebectomy for treatment of varicose veins, performed with saphenous vein ablation, either during the same procedure or at a later stage. If general anesthesia is required for phlebectomy, we suggest concomitant saphenous ablation. 10.8 We suggest transilluminated powered phlebectomy using lower oscillation speeds and extended tumescence as an alternative to traditional phlebectomy for extensive varicose veins. 10.9 For treatment of recurrent varicose veins, we suggest ligation of the saphenous stump, ambulatory phlebectomy, sclerotherapy, or endovenous thermal ablation, depending on the etiology, source, location, and extent of varicosity. 11. Endovenous thermal ablation 11.1 Endovenous thermal ablations (laser and radiofrequency ablations) are safe and effective, and we recommend them for treatment of saphenous incompetence. 11.2 Because of reduced convalescence and less pain and morbidity, we recommend endovenous thermal ablation of the incompetent saphenous vein over open surgery. 12. Sclerotherapy of varicose veins 12.1 We recommend liquid or foam sclerotherapy for telangiectasia, reticular veins, and varicose veins. 12.2 For treatment of the incompetent saphenous vein, we recommend endovenous thermal ablation over chemical ablation with foam. 13. Treatment of perforating veins 13.1 We recommend against selective treatment of incompetent perforating veins in patients with simple varicose veins (CEAP class C 2). 13.2 We suggest treatment of “pathologic” perforating veins that includes those with an outward flow duration of 500 ms, with a diameter of 3.5 mm, located beneath a healed or open venous ulcer (CEAP class C 5-C 6). 13.3 For treatment of “pathologic” perforating veins, we suggest subfascial endoscopic perforating vein surgery, ultrasonographically guided sclerotherapy, or thermal ablations. 14. Treatment of pelvic varicose veins 14.1 We recommend noninvasive imaging with transabdominal and/or transvaginal ultrasonography, computed tomography, or magnetic resonance venography in selected patients with symptoms of pelvic congestion syndrome or symptomatic varices in the distribution of the pubis, labia, perineum, or buttocks. 14.2 We recommend retrograde ovarian and internal iliac venography in patients with pelvic venous disease, confirmed or suspected by noninvasive imaging studies, in whom an intervention is planned. 14.3 We suggest treatment of pelvic congestion syndrome and pelvic varices with coil embolization, plugs, or transcatheter sclerotherapy, used alone or together. 14.4 If less invasive treatment is not available or has failed, we suggest surgical ligation and excision of ovarian veins to treat reflux. GRADE of recommendation 1 B 1 A 2 B 2 C 1 B 2 C 2 C 1 B 1 B 1 B 1 B 1 B 2 B 2 C 1 C 1 C 2 B 2 B Level of evidence
6S Gloviczki et al INTRODUCTION In the United States, an estimated 23% of adults have varicose veins, and 6% have more advanced chronic venous disease (CVD), including skin changes and healed or active venous ulcers. 1 Varicose veins have long been considered a cosmetic problem that only affected emotional well-being but were not the source of disability. Varicosities, however, are frequently the cause of discomfort, pain, loss of working days, disability, and deterioration of health-related quality of life (QOL). 1-3 Severe CVD may also lead to loss of limb or loss of life. 4 Evaluation of varicose veins has greatly progressed in the past 2 decades with the widespread availability of duplex ultrasonography. 5 The treatment of varicose veins has also undergone dramatic changes with the introduction of percutaneous endovenous ablation techniques, including endovenous laser therapy (EVLA), 6,7 radiofrequency ablation (RFA), 8 and liquid or foam sclerotherapy. 9,10 Open surgical treatment with stripping of the varicose veins performed under general anesthesia, with the associated pain, potential for wound complications, and loss of working days, has been largely replaced by percutaneous office-based procedures that can be performed under local or tumescent anesthesia with similar early and midterm results but with less discomfort to the patient, improved early QOL, and earlier return to work. 11-13 The purpose of this document is to report recently formulated current recommendations for the evaluation and treatment of patients with varicose veins of the lower limbs and pelvis. These Guidelines also include recommendations for management of superficial and perforating vein incompetence in patients with associated, more advanced CVDs, such as venous edema, skin changes, or ulcerations. To accomplish this task, a joint Venous Guideline Committee of the Society for Vascular Surgery (SVS) and the American Venous Forum (AVF) was established. Under no circumstance should these Guidelines be construed in practice or legal terms as defining the “standard of care,” which is solely determined by the condition of the individual patient, treatment setting, and other factors. Individual factors in a given patient, such as symptom variance or combinations, comorbidities, work, and socioeconomic factors may dictate a different approach than that described in the Guidelines. Because technology and disease knowledge is rapidly expanding, new approaches may supersede these recommendations. As important new information on management of varicose veins and related CVD becomes available, these recommendations will be revised without delay. METHODOLOGY OF GUIDELINES Evidence-based medicine is the conscientious, explicit, and judicious use of the current best evidence in making decisions about the care of individual patients. 14 Guidelines for the care of patients with varicose veins, as recommended in this report, are based on scientific evidence. The need for adopting evidence-based guidelines and reporting stan- JOURNAL OF VASCULAR SURGERY May Supplement 2011 dards for venous diseases has long been recognized by international experts 15 and by leaders of the SVS 16 and AVF. 17-20 To define current guidelines, members of the Venous Guideline Committee reviewed the relevant literature, including previously published consensus documents and guidelines, 21-31 meta-analyses, 6-12,32-42 the AVF reports on the Venous Summit at the 2006 and 2009 Pacific Vascular Symposiums 13,43-46 and considered the recommendations published in the third edition of the Handbook of Venous Disorders, Guidelines of the American Venous Forum. 47 The guidelines in this publication are based on the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system, as it was described by Guyatt et al (Table I). 48 For each guideline, the letter A, B, or C marks the level of current evidence. The grade of recommendation of a guideline can be strong (1) or weak (2), depending on the risk and burden of a particular diagnostic test or a therapeutic procedure to the patient vs the expected benefit. The words “we recommend” are used for GRADE 1—strong recommendations—if the benefits clearly outweigh risks and burdens, or vice versa; the words “we suggest” are used for GRADE 2—weak recommendations—when the benefits are closely balanced with risks and burdens. DEFINITIONS In this document, the updated terminology for superficial, perforating, and deep veins of the leg and pelvis are used. 49,50 Definitions of varicose and spider veins as well as other manifestations of CVD follow recommendations of the CEAP classification and the recent update on venous terminology of the International Committee of the AVF. 51,52 Varicose veins of the lower limbs are dilated subcutaneous veins that are 3 mm in diameter measured in the upright position. 53 Synonyms include varix, varices, and varicosities. Varicosity can involve the main axial superficial veins—the great saphenous vein (GSV) or the small saphenous vein (SSV)—or any other superficial vein tributaries of the lower limbs. Most varicose veins are due to primary venous disease. The most frequent cause is likely an intrinsic morphologic or biochemical abnormality in the vein wall, although the etiology can also be multifactorial. Labropoulos et al 54 proposed that the origin of venous reflux in patients with primary varicose veins can be local or multifocal structural weakness of the vein wall and that this can occur together or independently of proximal saphenous vein valvular incompetence. Varicosities can also develop as a result of secondary causes, such as previous deep vein thrombosis (DVT), deep venous obstruction, superficial thrombophlebitis, or arteriovenous fistula. Varicose veins may also be congenital and present as a venous malformation. Varicosities are manifestations of CVD. 51,52 CVD includes various medical conditions of long duration, all involving morphologic and functional abnormalities of the venous system manifested by symptoms or signs (or both),
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