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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 Japanese Dermatological Association (JDA 2025), 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 ...
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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
Revised Venous Clinical Severity Score (rVCSS)
Calculator
When to use
Pain or other discomfort, such as aching, heaviness, fatigue, soreness, or burning (presumes venous origin)
None
Occasional, not restricting regular daily activities
Daily, interfering with but not preventing regular daily activities
Daily, limiting most regular daily activities
Varicose veins (≥ 3 mm in diameter)
None
Few: scattered (isolated branch varicosities or clusters); includes corona phlebectatica (ankle flare)
Confined to calf or thigh
Involves calf and thigh
Venous edema (presumes venous origin)
None
Limited to foot and ankle area
Extends above the ankle but below the knee
Extends to knee and above
Skin pigmentation (presumes venous origin); does not include focal pigmentation over varicose veins or pigmentation due to other chronic diseases (vasculitis purpura)
None or focal
Limited to perimalleolar area
Diffuse over the lower third of calf
Wider distribution above the lower third of calf
Inflammation (more than just recent pigmentation, including erythema, cellulitis, venous eczema, and dermatitis)
None
Limited to perimalleolar area
Diffuse over the lower third of calf
Wider distribution above the lower third of calf
Induration (presumes venous origin of secondary skin and subcutaneous changes, such as chronic edema with fibrosis, hypodermitis); includes white atrophy and lipodermatosclerosis
None
Limited to perimalleolar area
Diffuse over the lower third of calf
Wider distribution above the lower third of calf
Active ulcer number
0
1
2
≥ 3
Active ulcer duration (longest active)
< 3 months
3 months to < 1 year
Not healed for > 1 year
Active ulcer diameter (largest active)
< 2 cm
2–6 cm
> 6 cm
Use of compression therapy
Not used
Intermittent use of stockings
Wears stockings most days
Full compliance: stockings
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Diagnostic investigations
Initial assessment
As per JDA 2025 guidelines:
Assess for the possibility of leg ulcers caused by primary or secondary varicose veins, as a majority of leg ulcers are caused by venous circulatory disorders.
B
Obtain Doppler auscultation of the leg veins in a standing position for leg ulcer evaluation.
B
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Duplex ultrasound (indications)
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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Topical agents and dressings
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.
B
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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.
E
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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
Preoperative evaluation: as per JDA 2025 guidelines, confirm the patency of deep veins with Doppler ultrasound, contrast-enhanced CT (venous phase), MRV, leg venography, or similar methods as part of the preoperative examination.
A
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Periprocedural management of anticoagulants
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.
C
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Ambulatory conservative hemodynamic treatment
Ligation and stripping
Surgical debridement
Skin grafting
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