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8 Varicose Veins <strong>KCE</strong> Reports 164<br />
1.3.2 Second research question: effectiveness and safety of treatments<br />
1.3.2.1 Patient population<br />
Publications had to include adult patients with a confirmed diagnosis of varicose veins of<br />
<strong>the</strong> lower limbs. Exclusion criteria were <strong>the</strong> criteria described in 1.3.1.1 and venous<br />
abnormalities.<br />
1.3.2.2 Interventions<br />
The interventions and comparators considered for inclusion are listed in Table 2.<br />
Interventions that specifically targeted venous ulcers were excluded (e.g. dressings,<br />
dressings, laser <strong>the</strong>rapy).<br />
1.3.2.3 Comparators<br />
The comparators considered for inclusion are usual care, no intervention or <strong>the</strong><br />
treatments listed in Table 2.<br />
1.3.2.4 Outcomes<br />
The effect on “hard” outcomes were included i.e. clinically relevant symptoms,<br />
complications, quality of life, reoperations and adverse events. The occlusion and<br />
recurrence rates are mentioned as intermediate outcomes.<br />
1.3.3 Third research question: type of anaes<strong>the</strong>tic for each intervention<br />
The patient population and outcomes are similar to those described under 1.3.2.<br />
The types of interventions considered were general, spinal, regional and tumescent local<br />
anaes<strong>the</strong>sia.<br />
Tumescent local anaes<strong>the</strong>sia is a procedure commonly used in varicose vein treatment<br />
with two objectives. The first one is pain control of <strong>the</strong> treated area. The second one is<br />
<strong>the</strong> injection of liquid around <strong>the</strong> vein to protect <strong>the</strong> surrounding tissue and to facilitate<br />
<strong>the</strong> intervention. Tumescent solution can vary according to <strong>the</strong> clinician's preference<br />
but usually consists of a saline solution with added lidocaine, epinephrine and sodium<br />
bicarbonate. Using ultrasound guidance, this solution is infused under pressure in <strong>the</strong><br />
saphenous compartment around <strong>the</strong> vein: at <strong>the</strong> conclusion of anaes<strong>the</strong>sia infiltration<br />
<strong>the</strong> vein is maximally compressed and appears on duplex ultrasound to be floating in a<br />
'sea' of anaes<strong>the</strong>tic solution 22 .<br />
1.4 DIAGNOSIS OF VARICOSE VEINS<br />
The diagnosis and treatment of varicose veins are generally guided by an assessment of<br />
patient’s risk factors and symptoms as part of a clinical examination. However,<br />
according to expert clinicians, clinical tests such as <strong>the</strong> cough test, <strong>the</strong> tap test,<br />
Trendelenbergs’ test and Per<strong>the</strong>s’ test, are not used anymore in modern practice.<br />
Several studies 23 24 have validated <strong>the</strong> inaccuracy of <strong>the</strong>se tests and <strong>the</strong>y will not be<br />
discussed fur<strong>the</strong>r.<br />
The paragraph below briefly outlines <strong>the</strong> choice of <strong>the</strong> diagnostic tests selected for this<br />
<strong>report</strong>, based on <strong>the</strong> feedback of <strong>the</strong> expert clinicians consulted for this study.<br />
• Colour Duplex ultrasound is used as <strong>the</strong> ‘gold standard’ reference test for<br />
<strong>the</strong> diagnosis of varicose veins and to assess <strong>the</strong> severity of <strong>the</strong> disease 3 25 ,<br />
also to locate <strong>the</strong> insufficient perforators or <strong>the</strong> junction of <strong>the</strong> small<br />
saphenous vein (SSV). In Belgium this procedure is increasingly performed by<br />
<strong>the</strong> surgeon him/herself, also preoperatively 1 . Performing colour duplex<br />
ultrasound (with <strong>the</strong> patient standing) in each leg of an individual patient with<br />
varicose veins leads to a full understanding of haemodynamics and anatomy,<br />
namely <strong>the</strong> so called ‘duplex anatomy’ (which specifically addresses <strong>the</strong> role<br />
of refluxing saphenous trunks, great saphenous vein (GSV), anterior<br />
accessory saphenous vein, SSV, on one hand and <strong>the</strong> role of <strong>the</strong> tributaries<br />
on <strong>the</strong> o<strong>the</strong>r hand). This will determine which treatment should be<br />
performed in each patient 26 .