Home

Search

Pathway AI

Account ⋅ Sign Out

Table of contents

Varicose veins

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 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 2019).
1
2
3
4
5
6
7
8

Guidelines

1.Screening and diagnosis

Definitions: 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.
Show 2 more
Create free account

2.Classification and risk stratification

Classification: as per SVS 2023 guidelines, use the 2020 upgraded CEAP classification for chronic venous disorders. Consider using the clinical or basic CEAP classification for clinical practice. Use the full CEAP classification for clinical research.
E

3.Diagnostic investigations

Duplex ultrasound, indications, AVLS/AVF/SVS: obtain duplex ultrasound as the diagnostic test of choice to evaluate for venous reflux in patients with chronic venous disease of the lower extremities.
B

More topics in this section

  • Duplex ultrasound (technical considerations)

  • Advanced imaging

  • Plethysmography

  • Ankle-brachial index

4.Medical management

Phlebotonics
As per SVS 2023 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

More topics in this section

  • Management of bleeding varicose veins

5.Nonpharmacologic interventions

Exercise: advise exercising to reduce venous symptoms in patients with symptomatic chronic venous disease.
B

More topics in this section

  • Compression therapy (primary/preprocedural)

  • Compression therapy (postprocedural)

6.Therapeutic procedures

Setting of care: as per SVS 2023 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.
E

More topics in this section

  • 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

7.Perioperative care

Periprocedural management of anticoagulants: do not interrupt anticoagulation in patients with chronic venous disease receiving anticoagulants and scheduled to undergo endovenous thermal ablation.
D

More topics in this section

  • Periprocedural thromboprophylaxis

  • Anesthesia

8.Surgical interventions

Ambulatory selective variceal ablation: as per SVS 2023 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.
C

More topics in this section

  • Ambulatory conservative hemodynamic treatment

  • Ligation and stripping

9.Specific circumstances

Patients with superficial vein thrombosis: 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
Show 4 more

More topics in this section

  • Patients with superficial truncal vein aneurysm

  • Patients with pelvic congestion syndrome (evaluation)

  • Patients with pelvic congestion syndrome (management)

10.Preventative measures

Prevention of progression
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

11.Follow-up and surveillance

Postprocedural monitoring: as per SVS 2023 guidelines, use the r-VCSS for assessing treatment outcomes in patients with chronic venous disorder.
E
Show 4 more

More topics in this section

  • 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