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Varicose veins

What's new

Added 2023 SVS/AVF/AVLS, 2022 ESVS, and 2019 AAFP guidelines for the diagnosis and management of varicose veins.

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of varicose veins are prepared by our editorial team based on guidelines from the American Vein and Lymphatic Society (AVLS/SVS/AVF 2024,2023), the European Society for Vascular Surgery (ESVS 2022), the Society for Vascular Surgery (SVS/AVF 2021,2011), the American Academy of Family Physicians (AAFP 2019,2013), and the Society for Vascular Medicine (SVM/SVS/ACP/AVF/IUP ...
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Screening and diagnosis

Definitions: as per AVF/AVLS/SVS 2023 guidelines, define reflux as a minimum value > 500 ms of reversed flow in the superficial truncal veins (great saphenous vein, small saphenous vein, anterior accessory great saphenous vein, posterior accessory great saphenous vein) and in the tibial, deep femoral, and perforating veins. Use a minimum value of > 1 second of reversed flow to diagnose reflux in the common femoral, femoral, and popliteal veins.
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Classification and risk stratification

Classification: as per AVF/AVLS/SVS 2024 guidelines, use the r-VCSS for grading clinical severity in patients with chronic venous disorder.
E

Diagnostic investigations

Duplex ultrasound, indications: as per AVF/AVLS/SVS 2024 guidelines, do not obtain routine duplex ultrasound of the lower extremity veins in asymptomatic patients with telangiectasias or reticular veins (CEAP class C1), since testing could lead to unnecessary saphenous vein ablation procedures.
D
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  • Duplex ultrasound (technical considerations)

  • Advanced imaging

  • Plethysmography

  • Ankle-brachial index

Medical management

Phlebotonics
As per AVF/AVLS/SVS 2024 guidelines:
Consider offering micronized purified flavonoid fraction or Ruscus aculeatus extract for the treatment of vein-related pain, leg heaviness, and/or sensation of swelling in symptomatic patients with varicose veins ineligible for intervention, waiting for intervention, or having symptoms after an intervention.
C
Consider offering hydroxyethylrutosides, calcium dobesilate, horse chestnut extract, red vine leaf extract, or sulodexide for the treatment of vein-related pain, leg heaviness, night cramps, and/or sensation of swelling in symptomatic patients with varicose veins ineligible for intervention, waiting for intervention, or having symptoms after an intervention.
C

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  • Management of bleeding varicose veins

Nonpharmacologic interventions

Exercise: as per ESVS 2022 guidelines, advise exercising to reduce venous symptoms in patients with symptomatic chronic venous disease.
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  • Compression therapy (primary/preprocedural)

  • Compression therapy (postprocedural)

Therapeutic procedures

Setting of care: as per AVF/AVLS/SVS 2024 guidelines, consider performing interventions for varicose veins in an office-based setting, surgery center, or hospital operating room at the discretion of the physician specialized in vein care. Perform procedures in an office-based setting for better patient experience and lower cost.
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  • Indications for intervention

  • Choice of intervention

  • Endovenous ablation (indications for thermal ablation)

  • Endovenous ablation (indications for non-thermal ablation)

  • Endovenous ablation (additional considerations)

  • Management of foot and ankle varicose veins

  • Management of varicose tributaries

  • Management of incompetent perforating veins

  • Management of telangiectasias and reticular veins

Perioperative care

Periprocedural management of anticoagulants: as per ESVS 2022 guidelines, do not interrupt anticoagulation in patients with chronic venous disease receiving anticoagulants and scheduled to undergo endovenous thermal ablation.
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  • Periprocedural thromboprophylaxis

  • Anesthesia

Surgical interventions

Ambulatory selective variceal ablation: as per AVF/AVLS/SVS 2024 guidelines, consider performing ambulatory selective variceal ablation under local anesthesia, performed by a physician familiar with the technique, to preserve the great saphenous vein in patients with the early stages of symptomatic varicose veins.
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  • Ambulatory conservative hemodynamic treatment

  • Ligation and stripping

Specific circumstances

Patients with superficial vein thrombosis: as per AVF/AVLS/SVS 2024 guidelines, administer fondaparinux 2.5 mg SC daily for 45 days in patients with superficial vein thrombosis of the main saphenous trunks and tributaries above the knee > 3 cm from the saphenofemoral junction and > 5 cm in length, whether associated with varicose veins or not. Consider administering rivaroxaban 10 mg/day for 45 days as an alternative in patients unwilling or unable to administer subcutaneous injections.
B
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  • Patients with superficial truncal vein aneurysm

  • Patients with pelvic congestion syndrome (evaluation)

  • Patients with pelvic congestion syndrome (management)

Preventative measures

Prevention of progression
As per AVF/AVLS/SVS 2024 guidelines:
Consider offering weight control, compression stockings, and avoidance of prolonged standing for the prevention of venous disease progression.
E
Do not perform prophylactic intervention for the prevention of venous disease progression in asymptomatic patients with C2 disease.
D

Follow-up and surveillance

Postprocedural monitoring: as per AVF/AVLS/SVS 2024 guidelines, use the r-VCSS for assessing treatment outcomes in patients with chronic venous disorder.
E
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  • Management of postprocedural DVT

  • Management of endothermal heat-induced thrombosis (prevention)

  • Management of endothermal heat-induced thrombosis (classification)

  • Management of endothermal heat-induced thrombosis (treatment)

  • Management of recurrent varicose veins