Evidence Based Treatment of Superficial Venous Insufficiency

Recent emphasis has been placed on improving quality of care and reducing cost at all levels of health care systems. To this end, there has been expanding creation and implementation of evidence based clinical practice guidelines to provide better standardization of treatment protocols and improved efficacy of care delivery. Evidence based guidelines provide specific recommendations that are the result of a rigorous methodology involving extensive review of literature, grading of the quality of evidence, and assigning strength of recommendations related to harm/benefit ratio of therapy through an analytical process.

For venous care, evidence based guidelines now exist for treatment of superficial venous insufficiency. All practitioners who care for superficial venous disease should be familiar with current recommendations which provide a standard framework for clinical decision making regarding most optimal superficial venous treatment options. This article will review current evidence based guidelines for superficial venous insufficiency as outlined in the 2011 The care of patients with varicose veins and associated chronic venous diseases: Clinical practice guidelines of the Society for Vascular Surgery (SVS) and the American Venous Forum (AVF);1 2013 National Institute for Health and Care Excellence (NICE) - National Clinical Guideline Centre – Varicose veins in the legs: Diagnosis and management of varicose veins – Clinical guidelines;2 and 2014 Management of venous leg ulcers: Clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum.3 Current guidelines will be summarized based on treatment options specific to superficial venous insufficiency including compression, interventions for truncal reflux, varicose vein procedures, and treatment of venous ulcers in the presence of superficial reflux (Table I).

Diagnosis of Superficial Venous Insufficiency

There is general agreement between all guidelines that clinical manifestation consistent with superficial venous insufficiency needs to be documented. A thorough medical history should be performed to identify symptoms potentially related to superficial venous insufficiency, including extremity pain, discomfort, aching, throbbing, cramps, heaviness, itching, tiredness, fatigue and restless legs. Venous complaints are usually exacerbated by limb dependency and relieved with rest or elevation. Additional history should also include venous risk factor assessment such as age, body mass index, prior venous thromboembolism, family history, superficial thrombophlebitis, and spontaneous varicose vein rupture as well as prior compression therapy use and venous operative interventions. Physical examination for signs of superficial venous disease should include inspection for spider veins, varicose veins, edema, chronic venous skin changes (discoloration, inflammation, exzema, hyperpigmentation, malleolar flair, corona phlebectatica, atrophie blanche, lipodermatosclerosis) healed or active venous ulceration.

To confirm the presence of superficial venous insufficiency, all guidelines support use of comprehensive venous duplex ultrasound as the initial diagnostic test. Venous duplex ultrasound should be performed in an accredited vascular lab using standardized technique preferably in the upright position that includes visualization, compressibility, venous flow, measurement of reflux duration and augmentation. Additional documentation should include anatomic distribution of reflux, with a threshold value of one second for reflux in the femoral and popliteal veins, and 500ms for reflux in the great saphenous vein (GSV), small saphenous vein (SSV), tibial veins, deep femoral vein, and perforating veins. Additional testing including venous plethysmography, computed tomography venography, magnetic resonance venography, contrast venography and intravascular ultrasound should be used selectively and mainly reserved for patients with more advanced venous disease than superficial venous insufficiency.

As part of a comprehensive venous evaluation, accurate classification of superficial venous disease is critically important for standardization of treatment, stratification of venous disease severity and outcome assessment of therapy. Classification systems for reporting of venous disease severity are well described and include both patient and physician generated tools. In general, recommendations include use of the Clinical class, Etiology, Anatomy and Pathophysiology (CEAP) classification,4 Venous Clinical Severity Score (VCSS),5 and other venous specific quality of life assessment surveys.

Prescribing Treatment for Chronic Venous Insufficiency

Compression therapy including elastic compression stockings, multi- and single- component, elastic and non-elastic, multi- and single- layer, and intermittent pneumatic devices are available to treat superficial venous insufficiency by reducing ambulatory venous hypertension and associated venous edema. Evidence based guidelines generally support use of compression therapy with moderate pressure (20-30mmHg) for patients with symptomatic varicose vein. In patients who have superficial venous insufficiency and varicose veins and are candidates for saphenous ablation, compression therapy is not recommend as a primary therapy, but can be considered an adjunct to superficial venous treatments, although evidence supporting efficacy after intervention is equivocal beyond seven days. For patients with active venous ulcers, compression over no compression is recommended to increase venous leg ulcer healing rate, with multi-component compression bandage over single-component bandages, and extended compression to prevent recurrence in those with healed venous ulcers. For patients with venous ulcers and concomitant arterial insufficiency, compression bandages or stockings should not be used if the ankle-brachial index is 0.5 or less or if the absolute ankle pressure is less than 60mmHg. Gaps in current compression guidelines include clinical and cost effectiveness of compression versus no compression for the management of symptomatic varicose veins, and duration of use after interventional treatment. However, for patients undergoing superficial venous ablation for active or healed venous ulcer, compression therapy should be continued to assist ulcer healing and prevent recurrence.

Truncal Superficial Venous Reflux

For patients with documented truncal superficial venous reflux involving the saphenous system, there are several treatment options addressed in current guidelines including high ligation and stripping, endothermal ablation, and ultrasound guided foam sclerotherapy. In general, all techniques are acceptable, but the strength of the recommendation of one option over another has different weighting in the SVS/AVF guidelines favoring endothermal ablation over sclerotherapy and over surgery. Based on the evidence, a reasonable clinical decision algorithm for patients with varicose veins and truncal reflux is proposed by the NICE Guidelines: Offer endothermal ablation (either radiofrequency or laser) first. If endothermal ablation is unsuitable, then offer ultrasound guided foam sclerotherapy. If ultrasound guided foam sclerotherapy is unsuitable, then offer surgery. Since publication of current guidelines, there are additional techniques of thermal and non-thermal endovenous ablation that are under investigation including steam, mechanical occlusion chemically assisted (MOCA), cyanoacrylate adhesive, polidocanol injectable microfoam, and V Block. While current guidelines do not support these newer techniques yet, there may be future evolution of clinical practice guidelines for superficial venous treatments to include these options for truncal reflux as more evidence comes forward.

Treatment for Varicose Veins with Truncal Venous Reflux

For primary treatment of tributary varicose veins, phlebectomy is recommend and preferred over sclerotherapy, although both are acceptable options. When varicose veins are present in conjunction with truncal reflux, saphenous endothermal ablation should be performed either separately or in combination with phlebectomy or sclerotherapy options. However, there is no clear consensus regarding clinical and cost effectiveness on either staged or combined approach, and no guidelines regarding optimal timing for staged approach. For extensive varicose veins, transilluminated powered phlebectomy may also be a considered as an alternative technique. For patients with recurrent varicosities, ligation of the saphenous stump, ambulatory phlebectomy, sclerotherapy, or endovenous thermal ablation are all considerations depending on the etiology, source, location and extent of varicosities.

Venous Ulcers in Relation to Varicose Veins

Clinical practice guidelines for venous ulcers are more complex than those for varicose veins alone in that they include direct wound care recommendations, additional compression options depending on extent of wound and venous dysfunction, endovascular/operative treatment of deep venous obstruction/reflux and perforator reflux in addition to superficial venous insufficiency when present, ancillary medical options, and preventative measures. Practitioners who care for patients with venous ulcers should be familiar with the full breadth of the SVS / AVF clinical practice guidelines for venous ulcers. Within the scope of this review, for patients with venous ulcers (active – C6, healed – C5, or skin changes at risk for venous ulcers – C4b) and superficial axial venous reflux directed to the bed of the ulcer, endothermal ablation is preferred over operative ligation and stripping, and are recommended over compression alone both to help venous ulcer healing and prevent recurrence.

In conclusion, clinical practice guidelines for treatment of superficial venous insufficiency provide a standardized framework for clinical decision making based on strength of evidence as rated through strict methodology. While all practitioners caring for patients with superficial venous disease need to be familiar with and incorporate these guidelines into their clinical practice, it is still important to weigh current recommendations within the context of individual patient venous care needs. Because evidence based guidelines represent a dynamic process, as technology and evidence gaps change, these guidelines for superficial venous treatments will continue to evolve over time.

TABLE I. Summary of selected SVS/AVF clinical practice guidelines for treatment of superficial venous insufficiency

COMPRESSION

We suggest compression therapy using moderate pressure (20 to 30 mm Hg) for patients with symptomatic varicose veins. (GRADE 2C)1

We recommend against compression therapy as the primary treatment of symptomatic varicose veins in patients who are

candidates for saphenous vein ablation. (GRADE 1B) 1

Postoperative - To reduce hematoma formation, pain, and swelling, we recommend postoperative compression. The recommended period of

compression in C2 patients is one week. (GRADE 1B) 1

In a patient with a venous leg ulcer, we recommend compression therapy over no compression therapy to increase venous leg ulcer healing rate. (GRADE 1A)2

In a patient with a healed venous leg ulcer, we suggest compression therapy to decrease the risk of ulcer recurrence. (GRADE 2B) 2

We suggest the use of multicomponent compression bandage over single-component bandages for the treatment of venous leg ulcers. (GRADE 2B) 2

In a patient with a venous leg ulcer and underlying arterial disease, we do not suggest compression bandages or stockings if the ankle-brachial index is 0.5 or less or if absolute ankle pressure is less than 60 mm Hg. (GRADE 2C) 2

TRUNCAL REFLUX[pi1]

For treatment of the incompetent great saphenous vein, we suggest high ligation and inversion stripping of the saphenous vein to the

level of the knee. (GRADE 2B) 1

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. (GRADE 1B) 1

Endovenous thermal ablations (laser and radiofrequency ablations) are safe and effective, and we recommend them for treatment of

saphenous incompetence. (GRADE 1B) 1

Because of reduced convalescence and less pain and morbidity, we recommend endovenous thermal ablation of the incompetent

saphenous vein over open surgery. (GRADE 1B) 1

For treatment of the incompetent saphenous vein, we recommend endovenous thermal ablation over chemical ablation with foam. (GRADE 1B) 1

VARICOSE VEINS

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. (GRADE 1B) 1

We suggest transilluminated powered phlebectomy using lower oscillation speeds and extended tumescence as an alternative to

traditional phlebectomy for extensive varicose veins.(GRADE 2C) 1

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. (GRADE 2C) 1

We recommend liquid or foam sclerotherapy for telangiectasia, reticular veins, and varicose veins. (GRADE 1B) 1

VENOUS ULCERS

In a patient with a venous leg ulcer (C6) and incompetent superficial veins that have axial reflux directed to the bed of the ulcer, we suggest ablation of the incompetent veins in addition to standard compressive therapy to improve ulcer healing. (GRADE 2C) 2

In a patient with a venous leg ulcer (C6) and incompetent superficial veins that have axial reflux directed to the bed of the ulcer, we suggest ablation of the incompetent veins in addition to standard compressive therapy to improve ulcer healing. (GRADE 1B) 2

In a patient with a healed venous leg ulcer (C5) and incompetent superficial veins that have axial reflux directed to the bed of the ulcer, we recommend ablation of the incompetent veins in addition to standard compressive therapy to prevent recurrence. (GRADE 2C) 2

In a patient with skin changes at risk for venous leg ulcer (C4b) and incompetent superficial veins that have axial reflux directed to the bed of the affected skin, we suggest ablation of the incompetent superficial veins in addition to standard compressive therapy to prevent ulceration. (GRADE 2C) 2

In a patient with a venous leg ulcer (C6) and incompetent superficial veins that have reflux to the ulcer bed in addition to pathologic perforating veins (outward flow of >500 ms duration, with a diameter of >3.5 mm) located beneath or associated with the ulcer bed, we suggest ablation of both the incompetent superficial veins and perforator veins in addition to standard compressive therapy to aid in ulcer healing and to prevent recurrence. (Grade 2C)2

Adapted From:

1 Gloviczki P, Comerota AJ, Dalsing MC, Eklof BG, Gillespie DL, Gloviczki ML, et al. 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. J Vasc Surg 2011; 53:2S-48S.

3 O’Donnell TF, Passman MA, Marston WA, et al. Clinical practice guidelines of the Society for Vascular Surgery (SVS) and the American Venous Forum (AVF): Management of venous leg ulcers. J Vasc Surg. 2014; 60: 1S-90S.



1 Gloviczki P, Comerota AJ, Dalsing MC, Eklof BG, Gillespie DL, Gloviczki ML, et al. 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. J Vasc Surg 2011; 53:2S-48S.

2 National Institute for Health and Care Excellence (NICE). National Clinical Guideline Centre – Varicose veins in the legs: Diagnosis and management of varicose veins – Clinical guideline. July 2013.

3 O’Donnell TF, Passman MA, Marston WA, et al. Clinical practice guidelines of the Society for Vascular Surgery (SVS) and the American Venous Forum (AVF): Management of venous leg ulcers. J Vasc Surg. 2014; 60: 1S-90S.

4 Eklöf B, Rutherford RB, Bergan JJ, et al. Revision of the CEAP classification for chronic venous disorders: consensus statement. J Vasc Surg 2004;40:1248-52.

5 Vasquez MA, Rabe E, McLafferty RB, et al. Revision of the venous clinical severity score: Venous outcomes consensus statement: Special communication of the American Venous Forum Ad Hoc Outcomes Working Group. J Vasc Surg 2010;52:1387-96.

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