The care of patients with varicose veins and associated chronic venous diseases: Clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum

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The Society for Vascular Surgery (SVS) and the American Venous Forum (AVF) have developed clinical practice guidelines for the care of patients with varicose veins of the lower limbs and pelvis. The document also includes recommendations on the management of superficial and perforating vein incompetence in patients with associated, more advanced chronic venous diseases (CVDs), including edema, skin changes, or venous ulcers. Recommendations of the Venous Guideline Committee are based on the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system as strong (GRADE 1) if the benefits clearly outweigh the risks, burden, and costs. The suggestions are weak (GRADE 2) if the benefits are closely balanced with risks and burden. The level of available evidence to support the evaluation or treatment can be of high (A), medium (B), or low or very low (C) quality. The key recommendations of these guidelines are: We recommend that in patients with varicose veins or more severe CVD, a complete history and detailed physical examination are complemented by duplex ultrasound scanning of the deep and superficial veins (GRADE 1A). We recommend that the CEAP classification is used for patients with CVD (GRADE 1A) and that the revised Venous Clinical Severity Score is used to assess treatment outcome (GRADE 1B). We suggest compression therapy for patients with symptomatic varicose veins (GRADE 2C) but recommend against compression therapy as the primary treatment if the patient is a candidate for saphenous vein ablation (GRADE 1B). We recommend compression therapy as the primary treatment to aid healing of venous ulceration (GRADE 1B). To decrease the recurrence of venous ulcers, we recommend ablation of the incompetent superficial veins in addition to compression therapy (GRADE 1A). For treatment of the incompetent great saphenous vein (GSV), we recommend endovenous thermal ablation (radiofrequency or laser) rather than high ligation and inversion stripping of the saphenous vein to the level of the knee (GRADE 1B). We recommend phlebectomy or sclerotherapy to treat varicose tributaries (GRADE 1B) and suggest foam sclerotherapy as an option for the treatment of the incompetent saphenous vein (GRADE 2C). We recommend against selective treatment of perforating vein incompetence in patients with simple varicose veins (CEAP class C2; GRADE 1B), but we suggest treatment of pathologic perforating veins (outward flow duration ≥500 ms, vein diameter ≥3.5 mm) located underneath healed or active ulcers (CEAP class C5-C6; GRADE 2B). We suggest treatment of pelvic congestion syndrome and pelvic varices with coil embolization, plugs, or transcatheter sclerotherapy, used alone or together (GRADE 2B).

Abbreviations

ACCP
American College of Chest Physicians
ASVAL
ablation sélective des varices sous anesthésie locale (ie, ambulatory selective varicose vein ablation under local anesthesia)
AVF
American Venous Forum
AVVQ
Aberdeen Varicose Vein Questionnaire
CHIVA
cure conservatrice et hémodynamique de l'insuffisance veineuse en ambulatiore (ie, ambulatory conservative hemodynamic treatment of varicose veins)
CI
confidence interval
CT
computed tomography
CVI
chronic venous insufficiency
CVD
chronic venous disease
DVT
deep venous thrombosis
EVLA
endovenous laser ablation
EVLT
endovenous laser therapy
FDA
U.S. Food and Drug Administration
GRADE
Grading of Recommendations, Assessment, Development, and Evaluation
GSV
great saphenous vein
HL/S
high ligation and stripping
ICP
intermittent compression pump
IVC
inferior vena cava
IVUS
intravascular ultrasonography
MPFF
micronized purified flavonoid fraction
MR
magnetic resonance
OR
odds ratio
PAPS
percutaneous ablation of perforators
PE
pulmonary embolism
PIN
perforate invaginate (stripping)
PRO
patient-reported outcome
PTFE
polytetrafluoroethylene
QALY
quality-adjusted life-year
QOL
quality of life
RCT
randomized controlled trial
REVAS
recurrent varicose veins after surgery
RF
radiofrequency
RFA
radiofrequency ablation
RR
relative risk
SEPS
subfascial endoscopic perforator surgery
SF-36
Short-Form 36-Item Health Survey
SFJ
saphenofemoral junction
SSV
small saphenous vein
STS
sodium tetradecyl sulfate
SVS
Society for Vascular Surgery
TIPP
transilluminated powered phlebectomy
VCSS
Venous Clinical Severity Score
VTE
venous thromboembolism

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Competition of interest: none.