Diagnostic et traitement des varices des membres inférieurs - KCE

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