Update on Update on Varicose Veins Varicose Veins

TreatmentTreatment

Abdullah Al-Qudah, MDAbdullah Al-Qudah, MDAssociate Prof. of Thoracic Associate Prof. of Thoracic

and vascular Surgery, Jordan and vascular Surgery, Jordan University Hospital, Amman, University Hospital, Amman,

Jordan.Jordan.

                                                           

Chronic venous diseaseChronic venous disease

Most common vascular disorderMost common vascular disorder 3 Billion US dollars spent a year for 3 Billion US dollars spent a year for

treatmenttreatment 3 % of the total Heath care Budget3 % of the total Heath care Budget 2 million USA work days lost per year2 million USA work days lost per year

DefinitionDefinition TelangiectasiasTelangiectasias - are a confluence of dilated - are a confluence of dilated

intradermal venules less than one millimeter in diameter. intradermal venules less than one millimeter in diameter.

Reticular veinsReticular veins - are dilated bluish subdermal veins, - are dilated bluish subdermal veins, one to three millimeters in diameter. Usually tortuous.one to three millimeters in diameter. Usually tortuous.

Varicose veinsVaricose veins - are subcutaneous dilated veins three - are subcutaneous dilated veins three millimeters or greater in size. They may involve the millimeters or greater in size. They may involve the saphenous veins, saphenous tributaries, or saphenous veins, saphenous tributaries, or nonsaphenous superficial leg veins. nonsaphenous superficial leg veins.

Abnormal VeinsAbnormal Veins

Telangiectasias

Reticular veinsVaricose vein

Common QuestionsCommon Questions

Are they dangerous?Are they dangerous? How do they form?How do they form? Why does it happen? Why does it happen? Did I inherit it?Did I inherit it? What tests can we use?What tests can we use? What treatments are available?What treatments are available?

Fascia, Veins and Cutaneous Fascia, Veins and Cutaneous nerves of the LEnerves of the LE

The subcutaneous tissue of the hip & thigh is The subcutaneous tissue of the hip & thigh is continuous with that of the inferior abdominal continuous with that of the inferior abdominal wall and buttock.wall and buttock.

At the knee the subcutaneous tissue loses its fat At the knee the subcutaneous tissue loses its fat and blends with the deep fasciaand blends with the deep fascia

Deep fascia: strong & inelastic it invests the LE; Deep fascia: strong & inelastic it invests the LE; it limits outward expansion of the contracting it limits outward expansion of the contracting musculature, the increased pressure “pumps” musculature, the increased pressure “pumps” the blood proximally through the veins.the blood proximally through the veins.

Deep fascia of the thigh (fascia lata)Deep fascia of the thigh (fascia lata) The fascia lata attaches to and is The fascia lata attaches to and is

continuous with:continuous with:1.The inguinal ligament, pubic 1.The inguinal ligament, pubic

arch, body of the pubis and arch, body of the pubis and pubic tubercle.pubic tubercle.

2.Scarpa’s fascia of the inferior 2.Scarpa’s fascia of the inferior abdominal wall attaches to abdominal wall attaches to deep LE fascia inferior to the deep LE fascia inferior to the inguinal ligament.inguinal ligament.

3. Iliac crest (lateral & posterior).3. Iliac crest (lateral & posterior).4. Sacrum, coccyx, sacrotuberous 4. Sacrum, coccyx, sacrotuberous

ligament, ischial tuberosity ligament, ischial tuberosity postreiorly.postreiorly.

5. Exposed parts of bones at the 5. Exposed parts of bones at the knee & deep fascia of the leg.knee & deep fascia of the leg.

LE CompartmentsLE Compartments Anterior & Posterior Anterior & Posterior

intermuscular septa – pass intermuscular septa – pass from the deep crural fascia to from the deep crural fascia to attach to the margins of the attach to the margins of the fibula.fibula.

Interosseous membrane Interosseous membrane traverses from tibia to fibulatraverses from tibia to fibula

(4) compartments created.(4) compartments created. Anterior -dorsiflexorsAnterior -dorsiflexors Lateral - fibular (everter) Lateral - fibular (everter)

compartmentcompartment Posterior – plantarflexor Posterior – plantarflexor

compartmentcompartment The transverse The transverse

intermuscular septum intermuscular septum divides this into a deep & divides this into a deep & superficial compartment.superficial compartment.

Crural fasciaCrural fascia Deep fascia to the leg – Deep fascia to the leg –

continuous with the fascia continuous with the fascia lata, attaches to the lata, attaches to the anterior & medial borders anterior & medial borders of the tibia; it is of the tibia; it is continuous with the continuous with the periosteum.periosteum.

Thinner distally but Thinner distally but thickens to form an thickens to form an extensor/flexor extensor/flexor retinaculum both anterior retinaculum both anterior & posterior to the ankle.& posterior to the ankle.

Superficial veinsSuperficial veins

Great saphenousGreat saphenous – formed by the union of the – formed by the union of the dorsal digital vein of the great toe and the dorsal dorsal digital vein of the great toe and the dorsal venous arch.venous arch.

Ascends anterior to the medial malleolus, Ascends anterior to the medial malleolus, posterior to the medial condyle of the femur. It posterior to the medial condyle of the femur. It freely communicates with the small saphenous freely communicates with the small saphenous vein. vein.

Proximally it traverses the saphenous opening in Proximally it traverses the saphenous opening in the fascia to enter the femoral vein.the fascia to enter the femoral vein.

Saphenous openingSaphenous opening NAVELNAVEL This is a gap in the fascia This is a gap in the fascia

lata infero-lateral to the lata infero-lateral to the inguinal ligament, lateral to inguinal ligament, lateral to the pubic tubercle.the pubic tubercle.

Medial margin is smoothMedial margin is smooth Lateral margin is sharp Lateral margin is sharp

forming the falciform forming the falciform ligamentligament

Cribiform fossa – a sleeve Cribiform fossa – a sleeve like membrane covering the like membrane covering the saphenous openingsaphenous opening

Small saphenous veinSmall saphenous vein

Formed by the union of the dorsal digital Formed by the union of the dorsal digital vein of the 5th digit and distal venous arch. vein of the 5th digit and distal venous arch.

Runs posterior to the lateral malleolus, Runs posterior to the lateral malleolus, lateral to the calcaneal tendon. lateral to the calcaneal tendon.

Runs superiorly medial to the fibula and Runs superiorly medial to the fibula and penetrates the deep fascia of the popliteal penetrates the deep fascia of the popliteal fossa, ascends between the heads of the fossa, ascends between the heads of the gastrocnemius muscle to join the popliteal gastrocnemius muscle to join the popliteal vein.vein.

Perforating veins Perforating veins Penetrate the deep Penetrate the deep

fascia, tributaries of the fascia, tributaries of the saphenous veins, valves saphenous veins, valves are located just distal to are located just distal to penetration of the deep penetration of the deep fascia. fascia.

Veins cross the deep Veins cross the deep fascia obliquely fascia obliquely

Muscle contraction Muscle contraction causes the valves to causes the valves to close prior to venous close prior to venous compression so blood is compression so blood is forced proximally forced proximally (musculo-venous pump). (musculo-venous pump).

Deep VeinsDeep Veins

Usually paired with named arteries inside a Usually paired with named arteries inside a vascular sheath, this allows arterial pulsation to vascular sheath, this allows arterial pulsation to force blood proximally. force blood proximally.

The popliteal vein joins the femoral vein in the The popliteal vein joins the femoral vein in the popliteal fossapopliteal fossa

Femoral vein is joined by the deep vein of the Femoral vein is joined by the deep vein of the thigh. The femoral vein passes deep to the thigh. The femoral vein passes deep to the inguinal ligament to become the external iliac inguinal ligament to become the external iliac vein.vein.

www.veinsurg.com/.../echodoppler_11.php

Lymphatic drainage of LELymphatic drainage of LE

Superficial LymphaticsSuperficial Lymphatics Superficial lymphatic vessels accompany the saphenous Superficial lymphatic vessels accompany the saphenous

veins (great & small)veins (great & small) Superficial lymphatics end at the superficial inguinal Superficial lymphatics end at the superficial inguinal

nodes most of this lymph drains to the external iliac nodes most of this lymph drains to the external iliac nodes, some drains to the deep inguinal nodes.nodes, some drains to the deep inguinal nodes.

Small lymphatics drain to the popliteal nodesSmall lymphatics drain to the popliteal nodesDeep LymphaticsDeep Lymphatics Deep lymphatics drain to the popliteal nodes which then Deep lymphatics drain to the popliteal nodes which then

drain to the inguinal nodes then to the external iliac drain to the inguinal nodes then to the external iliac nodes.nodes.

Both deep & superficial drain into the lumbar lymphatics.Both deep & superficial drain into the lumbar lymphatics.

Varicose veinsVaricose veins Varicose veins are a common Varicose veins are a common

condition in the United States, condition in the United States, affecting up to 15 percent of affecting up to 15 percent of men and up to 25 percent of men and up to 25 percent of women. women.

For many people, varicose For many people, varicose veins and spider veins a veins and spider veins a common, mild and medically common, mild and medically insignificant variation of insignificant variation of varicose veins — are simply a varicose veins — are simply a cosmetic concern. cosmetic concern.

For other people, varicose For other people, varicose veins can cause aching pain veins can cause aching pain and discomfort. and discomfort.

Sometimes the condition leads Sometimes the condition leads to more serious problems.to more serious problems.

Varicose veins may also signal Varicose veins may also signal a higher risk of other disorders a higher risk of other disorders of the circulatory system.of the circulatory system.

Callam, MJ. Epidemiology of varicose veins. Br J Surg 1994;81:167.

EtiologyEtiology

Reflux 80%Reflux 80% Venous obstruction 18-28%Venous obstruction 18-28%

Resultant edema and skin changes = Resultant edema and skin changes = Postthrombotic syndromePostthrombotic syndrome

Muscle Pump Dysfunction Muscle Pump Dysfunction

Stasis PathophysiologyStasis Pathophysiology

Usually associated with venous Usually associated with venous incompetenceincompetence

Primary and secondary refluxPrimary and secondary reflux Edema Edema Vein wall dilatation Vein wall dilatation Inflammation/Pigmentation (Hemosiderin Inflammation/Pigmentation (Hemosiderin

deposits)deposits) ““Fibrin cuffing”Fibrin cuffing” UlcerationUlceration

Risk factorsRisk factors

Age: Age: Aging causes wear and tear. Eventually, Aging causes wear and tear. Eventually, that wear causes the valves to malfunction. that wear causes the valves to malfunction.

Sex: Sex: Women > Men. Hormonal changes during Women > Men. Hormonal changes during pregnancy or menopause. Progesterone pregnancy or menopause. Progesterone relaxes venous walls. HRT / OCP may increase relaxes venous walls. HRT / OCP may increase the risk of varicose veins. the risk of varicose veins.

GeneticsGenetics Obesity: Obesity: Increases venous HTN. Increases venous HTN. Standing for long periods of time.Standing for long periods of time. Prolonged Prolonged

immobile standing impairs venous return.immobile standing impairs venous return.Fowkes, FG, Lee, AJ, Evans, CJ, et al. Lifestyle risk factors for lower limb venous reflux in the general population: Edinburgh Vein Study. Int J Epidemiol 2001; 30:846. Sadick, NS. Predisposing factors of varicose and telangiectatic leg veins. J Dermatol Surg Oncol 1992; 18:883. Iannuzzi, A, Panico, S, Ciardullo, AV, et al. Varicose veins of the lower limbs and venous capacitance in postmenopausal women: relationship with obesity. J Vasc Surg 2002; 36:965. Evans, CJ, Fowkes, FG, Hajivassiliou, CA, et al. Epidemiology of varicose veins. A review. Int Angiol 1994; 13:263.

Strong familial component Strong familial component

Not well studiedNot well studied Twin studies 75% identical, 52% non Twin studies 75% identical, 52% non

identicalidentical If both parents VVS - 90% of children VVsIf both parents VVS - 90% of children VVs If one parent was affected 25 percent for If one parent was affected 25 percent for

men and 62 percent for womenmen and 62 percent for women

Cornu-Thenard, A, Boivin, P, Baud, JM, et al. Importance of the familial factor in varicose disease. Clinical study of 134 families. J Dermatol Surg Oncol 1994; 20:318.

SymptomsSymptoms

Achy or heavy feeling, Achy or heavy feeling, burning, throbbing, burning, throbbing, muscle cramping and muscle cramping and swelling. swelling.

Prolonged sitting or Prolonged sitting or standing tends to standing tends to intensify symptoms. intensify symptoms.

Pruritis Pruritis Painful skin ulcers Painful skin ulcers

ComplicationsComplications Extremely painful ulcers Extremely painful ulcers

may form on the skin may form on the skin near varicose veins, near varicose veins, particularly near the particularly near the ankles.ankles.

Brownish pigmentation Brownish pigmentation usually precedes the usually precedes the development of an ulcer. development of an ulcer.

Occasionally, veins deep Occasionally, veins deep become enlarged.become enlarged.

Bleeding Bleeding Superficial Superficial

thrombophlebitis thrombophlebitis

CEAP classification CEAP classification

1994 AVF Meeting

Patient AssessmentPatient Assessment

HistoryHistory History of symptoms and onsetHistory of symptoms and onset History of venous complicationsHistory of venous complications Desire for treatmentDesire for treatment ComorbiditiesComorbidities Rule out secondary cause including DVT and HEART FailureRule out secondary cause including DVT and HEART Failure

ExaminationExamination Patient in generalPatient in general Pedal pulsesPedal pulses GroinsGroins VeinsVeins

Trendelenburg TestTrendelenburg TestVenous claudicationVenous claudication

InvestigationInvestigation

All get a Duplex scan All get a Duplex scan ExaminesExamines

– – Deep veinsDeep veins

– – Superficial veinsSuperficial veins

– – Incompetence and Incompetence and patencypatency

Other TestsPhysiologic testingPhlebographyIntravascular Ultrasound

Duplex scanDuplex scan

Vast majority have superficial Vast majority have superficial incompetence only.incompetence only.

Sensitivity 95 % for identifying the Sensitivity 95 % for identifying the competence of the saphenofemoral and competence of the saphenofemoral and saphenopopliteal junctions. saphenopopliteal junctions.

Less sensitive for identifying incompetent Less sensitive for identifying incompetent perforators (40 to 60 percent) perforators (40 to 60 percent)

Lin, JC, Iafrati, MD, O'Donnell, TF Jr, et al. Correlation of duplex ultrasound scanning-derived valve closure time and clinical classification in patients with small saphenous vein reflux: Is lesser saphenous vein truly lesser?. J Vasc Surg 2004; 39:1053. Jutley, RS, Cadle, I, Cross, KS. Preoperative assessment of primary varicose veins: a duplex study of venous incompetence. Eur J Vasc Endovasc Surg 2001; 21:370.

TreatmentTreatment

ConservativeConservative

Leg elevationLeg elevation

ExerciseExercise

Compression stockings Compression stockings

Treatment of other underlying Treatment of other underlying conditionsconditions

Nothing Nothing

Vein ablation therapies Vein ablation therapies

Classified by method of vein destruction:Classified by method of vein destruction:

1. Chemical (sclerotherapy)1. Chemical (sclerotherapy)

2. Thermal (laser or endovenous ablation)2. Thermal (laser or endovenous ablation)

3. Mechanical (surgical excision or 3. Mechanical (surgical excision or stripping) stripping)

Who gets sclerotherapy Who gets sclerotherapy

Small non-saphenous varicose veins (less Small non-saphenous varicose veins (less than 5 mm), than 5 mm),

Perforator veinsPerforator veins Residual or recurrent varicosities following Residual or recurrent varicosities following

surgery surgery TelangiectasiaTelangiectasia Reticular veinsReticular veins

Who gets SclerotherapyWho gets Sclerotherapy

Who elseWho else

– – Good control with TrendelenburgGood control with Trendelenburg

– – Recurrent veinsRecurrent veins

– – Frail with resistant/healed ulcersFrail with resistant/healed ulcers

O'Donnell, TF Jr. The present status of surgery of the superficial venous system in the management of venous ulcer and the evidence for the role of perforator interruption. J Vasc Surg 2008; 48:1044.

Galland, RB, Magee, TR, Lewis, MH. A survey of current attitudes of British and Irish vascular surgeons to venous sclerotherapy. Eur J Vasc Endovasc Surg 1998; 16:43.

Sclerosing AgentsSclerosing Agents

Sodium tetradecyl sulfateSodium tetradecyl sulfate Hypertonic SalineHypertonic Saline PolidocanolPolidocanol Monoethanolamine oleateMonoethanolamine oleate Glucose combinationsGlucose combinations

Damage endothelium leading to thrombosis of Damage endothelium leading to thrombosis of the vein.the vein.

Pressure to try and reduce the amount of Pressure to try and reduce the amount of thrombus.thrombus.

Tessari, L, Cavezzi, A, Frullini, A. Preliminary experience with a new sclerosing foam in the treatment of varicose veins. Dermatol Surg 2001; 27:58.

MicrosclerotherapyMicrosclerotherapy

30 g butterfly needle30 g butterfly needle 0.2% STS0.2% STS Several courses requiredSeveral courses required

benefit compressionbenefit compression

TelangiectasiasTelangiectasias

Foam SclerotherapyFoam Sclerotherapy

1:4 Sclerosant (1% or 1:4 Sclerosant (1% or 3%): Air3%): Air

Why foam?Why foam?

– – Induces spasmInduces spasm

– – Disperses furtherDisperses further

– – Enhanced Enhanced sclerosissclerosis

Breu, FX, Guggenbichler, S. European Consensus Meeting on Foam Sclerotherapy, April, 4-6, 2003, Tegernsee, Germany. Dermatol Surg 2004; 30:709.

Spider veinsSpider veins

Foam Sclerotherapy:Foam Sclerotherapy:ComplicationsComplications

PhlebitisPhlebitis Skin stainingSkin staining FailureFailure Residual lumpsResidual lumps MattingMatting Embolus (CVA)Embolus (CVA) DVTDVT Ulceration (rare)Ulceration (rare) Anaphylaxis (very rare)Anaphylaxis (very rare)

Foam Sclerotherapy ResultsFoam Sclerotherapy Results

Variable depending on seriesVariable depending on series Long-term recurrence rates are as high as Long-term recurrence rates are as high as

65 percent in five years, however, patients 65 percent in five years, however, patients can also be retreated when veins recurcan also be retreated when veins recur

Large veins can be a problemLarge veins can be a problem Currently randomized trialCurrently randomized trial Part of the arsenalPart of the arsenal

Belcaro, G, Nicolaides, AN, Ricci, A, et al. Endovascular sclerotherapy, surgery, and surgery plus sclerotherapy in superficial venous incompetence: a randomized, 10-year follow-up trial--final results. Angiology 2000; 51:529.

Catheter-based TreatmentsCatheter-based Treatments

Endovenous laser EVLAEndovenous laser EVLA Radiofrequency ablation RFARadiofrequency ablation RFA Primarily to treat saphenous insufficiency Primarily to treat saphenous insufficiency

(great or small)(great or small) EVLA and RFA, are equally efficacious & EVLA and RFA, are equally efficacious &

have similar recanalization rates. have similar recanalization rates.

Boros, MJ, O'Brien, SP, McLaren, JT, Collins, JT. High ligation of the saphenofemoral junction in endovenous obliteration of varicose veins. Vasc Endovascular Surg 2008; 42:235.

Radiofrequency ablationRadiofrequency ablation

Radiofrequency ablation devices (ClosureFast™, RFiTT®, ClosureRFS™) generate a high frequency alternating current in the radio range of frequency.

Weiss, RA, Weiss, MA. Controlled radiofrequency endovenous occlusion using a unique radiofrequency catheter under duplex guidance to eliminate saphenous varicose vein reflux: a 2-year follow-up. Dermatol Surg 2002; 28:38. Rautio, T, Ohinmaa, A, Perala, J, et al. Endovenous obliteration versus conventional stripping operation in the treatment of primary varicose veins: a randomized controlled trial with comparison of the costs. J Vasc Surg 2002; 35:958.

Radiofrequency ablationRadiofrequency ablation

Heats the tissue surrounding the catheter Heats the tissue surrounding the catheter electrode to a specified temperature. electrode to a specified temperature. Radiofrequency works well on tissue Radiofrequency works well on tissue composed primarily of collagencomposed primarily of collagen

Special probes have been designed for the Special probes have been designed for the radiofrequency device to manage non-radiofrequency device to manage non-saphenous and perforator veins.saphenous and perforator veins.

Varicose veinsVaricose veins

Endovenous Laser Endovenous Laser

Endovenous LaserEndovenous Laser

Devices (EVLT®, ClosurePlus™) Devices (EVLT®, ClosurePlus™) Use a bare tipped optical fiber which Use a bare tipped optical fiber which

applies laser light energy to the vein.applies laser light energy to the vein. Therapy based on photothermolysis (light Therapy based on photothermolysis (light

induced thermal damage). induced thermal damage). Laser light heats the target tissue inducing Laser light heats the target tissue inducing

thermal injurythermal injury Wavelength of light is chosen based on Wavelength of light is chosen based on

the target structure's chromophore.the target structure's chromophore.Bush, RG, Shamma, HN, Hammond, K. Histological changes occurring after endoluminal ablation with two diode lasers (940 and 1319 nm) from acute changes to 4 months. Lasers Surg Med 2008; 40:676.

Wavelengths of light used for Wavelengths of light used for venous laser therapy venous laser therapy

Mozes, G, Kalra, M, Carmo, M, et al. Extension of saphenous thrombus into the femoral vein: a potential complication of new endovenous ablation techniques. J Vasc Surg 2005; 41:130

.

Surface laser therapySurface laser therapy

Telangiectasias, Telangiectasias, reticular veins and reticular veins and small varicose veins small varicose veins <5mm<5mm

Not used for larger Not used for larger varicose veins varicose veins

Post op carePost op care

Graduated compression stockings are Graduated compression stockings are worn following the procedure.worn following the procedure.

F/U duplex ultrasound is performed within F/U duplex ultrasound is performed within one week to evaluate for thrombus in the one week to evaluate for thrombus in the common femoral vein.common femoral vein.

Pt recovery averages two and four daysPt recovery averages two and four days Significantly shorter interval than is seen Significantly shorter interval than is seen

with surgical ligation and stripping with surgical ligation and stripping Mozes, G, Kalra, M, Carmo, M, et al. Extension of saphenous thrombus into the femoral vein: a potential complication of new endovenous ablation techniques. J Vasc Surg 2005; 41:130. Darwood, RJ, Theivacumar, N, Dellagrammaticas, D, et al. Randomized clinical trial comparing endovenous laser ablation with surgery for the treatment of primary great saphenous varicose veins. Br J Surg 2008; 95:294.

Endovenous complicationsEndovenous complications

Pain, bruising, hematoma Pain, bruising, hematoma Skin changes: burns, induration, Skin changes: burns, induration,

pigmentation, matting, dysesthesia, & pigmentation, matting, dysesthesia, & superficial thrombophlebitis.superficial thrombophlebitis.

Nerve injury Nerve injury DVT DVT Wound infection Wound infection

Mozes, G, Kalra, M, Carmo, M, et al. Extension of saphenous thrombus into the femoral vein: a potential complication of new endovenous ablation techniques. J Vasc Surg 2005; 41:130.

VAN DEN Bos, RR, Neumann, M, DE Roos, SP, Nijsten, T. Endovenous laser ablation-induced complications: Review of the literature and new cases. Dermatol Surg 2009;

SurgerySurgery

Thermal ablation techniques are limited by Thermal ablation techniques are limited by an upper limit of vein diameter (>1.5 cm) an upper limit of vein diameter (>1.5 cm)

Procedure is performed under general or Procedure is performed under general or spinal anesthesia spinal anesthesia

Indications include management of Indications include management of superficial thrombophlebitis, and venous superficial thrombophlebitis, and venous hemorrhage hemorrhage

Perala, J, Rautio, T, Biancari, F, et al. Radiofrequency endovenous obliteration versus stripping of the long saphenous vein in the management of primary varicose veins: 3-year outcome of a randomized study. Ann Vasc Surg 2005; 19:669.

SurgerySurgery

Saphenous vein strippingSaphenous vein stripping Cryostripping Cryostripping High saphenous ligationHigh saphenous ligation Ambulatory phlebectomy Ambulatory phlebectomy Stab/avulsion phlebectomy Stab/avulsion phlebectomy Transilluminated phlebectomy TIPP Transilluminated phlebectomy TIPP Perforator ligation Perforator ligation Subfascial endoscopic perforator vein ligation Subfascial endoscopic perforator vein ligation

(SEPS) (SEPS)

Dwerryhouse, S, Davies, B, Harradine, K, Earnshaw, JJ. Stripping the long saphenous vein reduces the rate of reoperation for recurrent varicose veins: five-year results of a randomized trial. J Vasc Surg 1999; 29:589. Menyhei, G, Gyevnar, Z, Arato, E, et al. Conventional stripping versus cryostripping: a prospective randomised trial to compare improvement in quality of life and complications. Eur J Vasc Endovasc Surg 2008; 35:218.

Saphenous vein strippingSaphenous vein stripping

Traditional surgical approachTraditional surgical approach Involves first ligation then division of either Involves first ligation then division of either

the great saphenous (incision in the groin) the great saphenous (incision in the groin) or small saphenous vein. or small saphenous vein.

Duplex ultrasound to identify the Duplex ultrasound to identify the saphenopopliteal junction. saphenopopliteal junction.

CryostrippingCryostripping

Variation of traditional saphenous stripping Variation of traditional saphenous stripping Limited to Great Saphenous veinLimited to Great Saphenous vein Vein freezes adhering to the device and Vein freezes adhering to the device and

the vein is strippedthe vein is stripped Less postoperative bruising than Less postoperative bruising than

conventional strippingconventional stripping Requires specialized instrumentation Requires specialized instrumentation

High saphenous ligation High saphenous ligation

Ligation of the saphenous vein at the Ligation of the saphenous vein at the saphenofemoral junction onlysaphenofemoral junction only

Uncommonly performed in treating saphenous Uncommonly performed in treating saphenous incompetence b/c of higher varicose vein incompetence b/c of higher varicose vein recurrence rates. recurrence rates.

Technique for patients who develop superficial Technique for patients who develop superficial phlebitis (idiopathic or iatrogenic from phlebitis (idiopathic or iatrogenic from endovenous therapies) w/ extension of clot to endovenous therapies) w/ extension of clot to the saphenofemoral junctionthe saphenofemoral junction

Performed if PT cannot be anticoagulatedPerformed if PT cannot be anticoagulated

Other TechniquesOther Techniques

Ambulatory Ambulatory phlebectomy phlebectomy

Stab/avulsion Stab/avulsion phlebectomy phlebectomy

Transilluminated Transilluminated phlebectomy TIPP phlebectomy TIPP

Perforator ligation Perforator ligation Subfascial Subfascial

endoscopic perforator endoscopic perforator vein ligation (SEPS)vein ligation (SEPS)

Subfascial endoscopic perforator Subfascial endoscopic perforator vein ligation (SEPS) vein ligation (SEPS)

Indicated for pts with refractory symptoms, Indicated for pts with refractory symptoms, ulceration, recurrent ulceration. Pt who failed ulceration, recurrent ulceration. Pt who failed Cath based treatmentCath based treatment

Two ports each placed subfasciallyTwo ports each placed subfascially Perforators divided electrocautery, harmonic Perforators divided electrocautery, harmonic

scalpel or clippedscalpel or clipped 20 studies involving 1140 limbs in total, found 20 studies involving 1140 limbs in total, found

overall ulcer healing in 88 percent of treated overall ulcer healing in 88 percent of treated limbslimbs

Repeat SEPS if perforators persistRepeat SEPS if perforators persist

Kalra, M, Gloviczki, P. Surgical treatment of venous ulcers: role of subfascial endoscopic perforator vein ligation. Surg Clin North Am 2003; 83:671.

Subfascial endoscopic perforator Subfascial endoscopic perforator vein ligation (SEPS)vein ligation (SEPS)

ContraindicationsContraindications

Systemic illnessSystemic illness Tortuous veinTortuous vein Hypercoagulable stateHypercoagulable state PregnancyPregnancy Obstructed Deep veinsObstructed Deep veins

Which is Better ???Which is Better ???

Endoluminal thermal ablation versus Endoluminal thermal ablation versus stripping of the saphenous vein: Meta-stripping of the saphenous vein: Meta-analysis of recurrence of reflux.analysis of recurrence of reflux.

ES Xenos, G Bietz, DJ Minion, et alES Xenos, G Bietz, DJ Minion, et al

Endoluminal thermal ablation versus stripping of Endoluminal thermal ablation versus stripping of the saphenous vein: Meta-analysis of recurrence the saphenous vein: Meta-analysis of recurrence

of refluxof reflux..

Method: Systematic search of Method: Systematic search of Medline/Pubmed, OVID, EMBASE, Medline/Pubmed, OVID, EMBASE, CINAHL, Clinicaltrials.gov and Cochrane CINAHL, Clinicaltrials.gov and Cochrane central registercentral register 1966-2009 in all lanuages1966-2009 in all lanuages

MethodMethod

Randomized prospective clinical trials with Randomized prospective clinical trials with > 365 days f/u.> 365 days f/u.

Analyzed outcomes included recurrence of Analyzed outcomes included recurrence of varicosities and reflux, as documented by varicosities and reflux, as documented by duplex ultrasound, and recurrence of signs duplex ultrasound, and recurrence of signs and symptomsand symptoms

ResultsResults

8 randomized controlled trials were 8 randomized controlled trials were includedincluded

497 patients total497 patients total 226 L/S226 L/S 271 endoluminal thermal ablation271 endoluminal thermal ablation F/U 584 SD182 days.F/U 584 SD182 days.

ConclusionConclusion Catheter-based treatments and traditional Catheter-based treatments and traditional

venous stripping with high ligation have similar venous stripping with high ligation have similar long-term resultslong-term results

Catheter-based treatments have a decreased Catheter-based treatments have a decreased post op pain, shorter recovery time to work post op pain, shorter recovery time to work and normal activity.and normal activity.

Poster Presented at American Venous Form Poster Presented at American Venous Form 2121stst Annual Meeting Phoenix, Arizona Feb Annual Meeting Phoenix, Arizona Feb 20092009

Questions ?Questions ?

Which is Better ???Which is Better ??? RFA & laser ablation are highly successful in achieving vein closure and have high RFA & laser ablation are highly successful in achieving vein closure and have high

patient satisfaction rates as well.patient satisfaction rates as well. Laser>RFA treating perforator veins.Laser>RFA treating perforator veins. A meta analysis evaluating stripping, foam sclerotherapy, and endovenous therapies A meta analysis evaluating stripping, foam sclerotherapy, and endovenous therapies

in the treatment of the saphenous vein concluded that minimally invasive therapies in the treatment of the saphenous vein concluded that minimally invasive therapies were as effective as surgical stripping with long term success rates of 78 to 84 were as effective as surgical stripping with long term success rates of 78 to 84 percent [percent [72].].

Endovenous laser therapy was found to be significantly more effective than stripping, Endovenous laser therapy was found to be significantly more effective than stripping, foam sclerotherapy and radiofrequency ablation. However, the early technical foam sclerotherapy and radiofrequency ablation. However, the early technical success rates for radiofrequency ablation were inferior to laser ablation and newer success rates for radiofrequency ablation were inferior to laser ablation and newer radiofrequency catheter technology (ClosureFast®) achieving higher temperatures radiofrequency catheter technology (ClosureFast®) achieving higher temperatures has achieved improved results [has achieved improved results [77].].

Endovenous ablation (EVLA, RFA) is associated with less perioperative pain Endovenous ablation (EVLA, RFA) is associated with less perioperative pain compared to surgical vein stripping, with patients requiring fewer days out of work compared to surgical vein stripping, with patients requiring fewer days out of work and less pain medication [and less pain medication [67-69]. Radiofrequency ablation compared to laser ablation ]. Radiofrequency ablation compared to laser ablation is associated with greater improvement in these periprocedural recovery parameters [is associated with greater improvement in these periprocedural recovery parameters [77]. Laser ablation is consistently associated with more pain and bruising than ]. Laser ablation is consistently associated with more pain and bruising than radiofrequency ablation and continued evaluation of varying radiofrequency ablation and continued evaluation of varying

EVLAEVLA

The key to success with EVLA is making theThe key to success with EVLA is making the correct diagnosis and careful patientcorrect diagnosis and careful patient selection.selection. The straighter the vein the easier it will be toThe straighter the vein the easier it will be to pass the laser fibre across the length of thepass the laser fibre across the length of the segment which requires therapy.segment which requires therapy. Large diameter veinsLarge diameter veins

Early technical successEarly technical successRFA & foam scleroRFA & foam sclero

http://www.sawma.org.au/documenhttp://www.sawma.org.au/documents/2009_endovenous_laser_ablatiots/2009_endovenous_laser_ablatio

n.pdfn.pdf

Discussion thoughtsDiscussion thoughts For both the radiofrequency and endovenous devices, the endovenous catheter is placed For both the radiofrequency and endovenous devices, the endovenous catheter is placed

percutaneously with local anesthesia via a sheath typically placed at the level of the knee and percutaneously with local anesthesia via a sheath typically placed at the level of the knee and advanced with ultrasound guidance to the proximal vein. After additional local anesthesia is advanced with ultrasound guidance to the proximal vein. After additional local anesthesia is injected along the vein, the device is activated. Energy transferred to the blood and vein wall injected along the vein, the device is activated. Energy transferred to the blood and vein wall results in immediate intimal loss and subsequent thrombosis of the vein [results in immediate intimal loss and subsequent thrombosis of the vein [69]. Vein wall ]. Vein wall thickening, inflammatory change and ultimately fibrotic closure of the vein occurs over time thickening, inflammatory change and ultimately fibrotic closure of the vein occurs over time

Saphenous vein stripping - The traditional surgical approach involves first ligation then division of Saphenous vein stripping - The traditional surgical approach involves first ligation then division of either the great saphenous (incision in the groin) or small saphenous vein (incision based upon either the great saphenous (incision in the groin) or small saphenous vein (incision based upon duplex ultrasound to identify the saphenopopliteal junction). The procedure is performed under duplex ultrasound to identify the saphenopopliteal junction). The procedure is performed under general or spinal anesthesia, and the patient typically goes home the same day [general or spinal anesthesia, and the patient typically goes home the same day [78]. ].

Cryostripping is a variation of traditional saphenous stripping and is limited to the treatment of the Cryostripping is a variation of traditional saphenous stripping and is limited to the treatment of the great saphenous vein. It involves the placement of a special instrument to the level of the great saphenous vein. It involves the placement of a special instrument to the level of the previously ligated and divided saphenous junction and supercooled. The vein freezes, adhering previously ligated and divided saphenous junction and supercooled. The vein freezes, adhering to the device and the vein is stripped. The advantage of this method is less postoperative to the device and the vein is stripped. The advantage of this method is less postoperative bruising compared to conventional stripping but it requires specialized instrumentation [bruising compared to conventional stripping but it requires specialized instrumentation [79].].

High saphenous ligation - Ligation of the saphenous vein at the saphenofemoral junction alone High saphenous ligation - Ligation of the saphenous vein at the saphenofemoral junction alone without additional treatment of the saphenous vein is uncommonly performed in treating without additional treatment of the saphenous vein is uncommonly performed in treating saphenous incompetence because of higher varicose vein recurrence rates. saphenous incompetence because of higher varicose vein recurrence rates.

Efficacy of endovenous techniquesEfficacy of endovenous techniques — Both radiofrequency and laser ablation are highly successful in achieving vein closure and have high patient satisfaction rates as well [ — Both radiofrequency and laser ablation are highly successful in achieving vein closure and have high patient satisfaction rates as well [60-62,74,75,75]. Success rates in treating perforator veins (RFA) are worse compared to ]. Success rates in treating perforator veins (RFA) are worse compared to the treatment of the saphenous vein [the treatment of the saphenous vein [76].].

A meta analysis evaluating stripping, foam sclerotherapy, and endovenous therapies in the treatment of the saphenous vein concluded that minimally invasive therapies were as effective as surgical stripping with long term success rates of 78 to 84 percent [A meta analysis evaluating stripping, foam sclerotherapy, and endovenous therapies in the treatment of the saphenous vein concluded that minimally invasive therapies were as effective as surgical stripping with long term success rates of 78 to 84 percent [72].]. Endovenous laser therapy was found to be significantly more effective than stripping, foam sclerotherapy and radiofrequency ablation. However, the early technical success rates for radiofrequency ablation were inferior to laser ablation and newer radiofrequency Endovenous laser therapy was found to be significantly more effective than stripping, foam sclerotherapy and radiofrequency ablation. However, the early technical success rates for radiofrequency ablation were inferior to laser ablation and newer radiofrequency

catheter technology (ClosureFast®) achieving higher temperatures has achieved improved results [catheter technology (ClosureFast®) achieving higher temperatures has achieved improved results [77].]. Endovenous ablation (EVLA, RFA) is associated with less perioperative pain compared to surgical vein stripping, with patients requiring fewer days out of work and less pain medication [Endovenous ablation (EVLA, RFA) is associated with less perioperative pain compared to surgical vein stripping, with patients requiring fewer days out of work and less pain medication [67-69]. Radiofrequency ablation compared to laser ablation is associated with ]. Radiofrequency ablation compared to laser ablation is associated with

greater improvement in these periprocedural recovery parameters [greater improvement in these periprocedural recovery parameters [77]. Laser ablation is consistently associated with more pain and bruising than radiofrequency ablation and continued evaluation of varying laser parameters (wavelength, fluence) is needed to ]. Laser ablation is consistently associated with more pain and bruising than radiofrequency ablation and continued evaluation of varying laser parameters (wavelength, fluence) is needed to determine optimal settings.determine optimal settings.

SurgerySurgery — Surgical methods have largely been supplanted by the lesser invasive ablation therapies discussed above. However, patients with very large veins are best treated with surgical therapy. Thermal ablation techniques are limited by an upper limit of vein  — Surgical methods have largely been supplanted by the lesser invasive ablation therapies discussed above. However, patients with very large veins are best treated with surgical therapy. Thermal ablation techniques are limited by an upper limit of vein diameter (>1.5 cm) that can be treated effectively and endovenous treatment of these larger veins is associated with a higher incidence of venous thromboembolism. Surgerical options are limited in patients with a high risk for anesthesia.diameter (>1.5 cm) that can be treated effectively and endovenous treatment of these larger veins is associated with a higher incidence of venous thromboembolism. Surgerical options are limited in patients with a high risk for anesthesia.

Additional indications for surgical management include management of superficial thrombophlebitis, and venous hemorrhage. (Additional indications for surgical management include management of superficial thrombophlebitis, and venous hemorrhage. (See "Varicose vein complications" above).). Several surgical techniques are available and are chosen based upon the location, size, and extent of the patient's varicosities and reflux.Several surgical techniques are available and are chosen based upon the location, size, and extent of the patient's varicosities and reflux. Saphenous vein stripping - The traditional surgical approach involves first ligation then division of either the great saphenous (incision in the groin) or small saphenous vein (incision based upon duplex ultrasound to identify the saphenopopliteal junction). The Saphenous vein stripping - The traditional surgical approach involves first ligation then division of either the great saphenous (incision in the groin) or small saphenous vein (incision based upon duplex ultrasound to identify the saphenopopliteal junction). The

procedure is performed under general or spinal anesthesia, and the patient typically goes home the same day [procedure is performed under general or spinal anesthesia, and the patient typically goes home the same day [78]. ]. Cryostripping is a variation of traditional saphenous stripping and is limited to the treatment of the great saphenous vein. It involves the placement of a special instrument to the level of the previously ligated and divided saphenous junction and supercooled. The vein Cryostripping is a variation of traditional saphenous stripping and is limited to the treatment of the great saphenous vein. It involves the placement of a special instrument to the level of the previously ligated and divided saphenous junction and supercooled. The vein

freezes, adhering to the device and the vein is stripped. The advantage of this method is less postoperative bruising compared to conventional stripping but it requires specialized instrumentation [freezes, adhering to the device and the vein is stripped. The advantage of this method is less postoperative bruising compared to conventional stripping but it requires specialized instrumentation [79].]. High saphenous ligation - Ligation of the saphenous vein at the saphenofemoral junction alone without additional treatment of the saphenous vein is uncommonly performed in treating saphenous incompetence because of higher varicose vein recurrence rates. High saphenous ligation - Ligation of the saphenous vein at the saphenofemoral junction alone without additional treatment of the saphenous vein is uncommonly performed in treating saphenous incompetence because of higher varicose vein recurrence rates. Some advocate this technique for patients who develop superficial phlebitis (idiopathic or iatrogenic from endovenous therapies) with extension of clot to the saphenofemoral junction, and who cannot be anticoagulated.Some advocate this technique for patients who develop superficial phlebitis (idiopathic or iatrogenic from endovenous therapies) with extension of clot to the saphenofemoral junction, and who cannot be anticoagulated. Ambulatory phlebectomy - Various methods of vein excision and/or ligation are applied to non-saphenous veins. Ambulatory phlebectomy - Various methods of vein excision and/or ligation are applied to non-saphenous veins. Stab/avulsion phlebectomy removes varicose vein segments through very small (<5 mm) incisions often with the use of special fine surgical hooks (eg, Muller). Incisions (only as large as needed to remove the vein) are made along its course. The veins are avulsed Stab/avulsion phlebectomy removes varicose vein segments through very small (<5 mm) incisions often with the use of special fine surgical hooks (eg, Muller). Incisions (only as large as needed to remove the vein) are made along its course. The veins are avulsed

and removed and pressure is applied to the incisions to control bleeding. This technique is used to treat non-saphenous varicose veins or residual varicose veins following saphenous ablation.and removed and pressure is applied to the incisions to control bleeding. This technique is used to treat non-saphenous varicose veins or residual varicose veins following saphenous ablation. Transilluminated powered phlebectomy (TIPP) is a minimally invasive technique which uses an illuminator (light source) placed subcutaneously through a stab incision enhancing the visualization of the veins. Non-saphenous veins targeted for removal are suction Transilluminated powered phlebectomy (TIPP) is a minimally invasive technique which uses an illuminator (light source) placed subcutaneously through a stab incision enhancing the visualization of the veins. Non-saphenous veins targeted for removal are suction

aspirated with a separate device with rotating blade and suction port [aspirated with a separate device with rotating blade and suction port [80,81]. The only advantage identified with this device was the need for fewer incisions []. The only advantage identified with this device was the need for fewer incisions [82,83].]. Perforator ligation - Endovenous perforator ablation and subfascial perforator ligation are preferred over a direct incisional technique. Perforator ligation - Endovenous perforator ablation and subfascial perforator ligation are preferred over a direct incisional technique. Open perforator ligation is uncommonly used in the treatment of severe venous skin changes or ulcer because it necessitates placing an incision in a region of venous stasis. The surgical wound is often a source of secondary ulceration if perforator ligation is not Open perforator ligation is uncommonly used in the treatment of severe venous skin changes or ulcer because it necessitates placing an incision in a region of venous stasis. The surgical wound is often a source of secondary ulceration if perforator ligation is not

successful in reducing venous pressures in the skin. (successful in reducing venous pressures in the skin. (See "Liquid and foam sclerotherapy" above and and see "Endovenous catheter ablation" above).). Subfascial endoscopic perforator vein ligation (SEPS) - Subfascial endoscopic perforator vein ligation is indicated for patients with refractory symptoms or ulceration, or recurrent ulceration associated with venous incompetence in patients who have failed minimally Subfascial endoscopic perforator vein ligation (SEPS) - Subfascial endoscopic perforator vein ligation is indicated for patients with refractory symptoms or ulceration, or recurrent ulceration associated with venous incompetence in patients who have failed minimally

invasive approaches [invasive approaches [37,84-87]. ]. SEPS is performed through two ports each placed subfascially via skin incisions in a location away from areas of active skin change or ulceration [SEPS is performed through two ports each placed subfascially via skin incisions in a location away from areas of active skin change or ulceration [85]. Insufflation with carbon dioxide and balloon dissection of the subfascial space helps visualize calf perforators, which ]. Insufflation with carbon dioxide and balloon dissection of the subfascial space helps visualize calf perforators, which

are divided (electrocautery, harmonic scalpel) or clipped.are divided (electrocautery, harmonic scalpel) or clipped. A systematic review of 20 studies involving 1140 limbs in total, found overall ulcer healing in 88 percent of treated limbs, with a 13 percent recurrence rate at a mean of 21 months [A systematic review of 20 studies involving 1140 limbs in total, found overall ulcer healing in 88 percent of treated limbs, with a 13 percent recurrence rate at a mean of 21 months [86]. Risk factors for nonhealing and ulcer recurrence were similar and included the ]. Risk factors for nonhealing and ulcer recurrence were similar and included the

presence of postoperative incompetent perforators, larger ulcer size (>2 cm), and secondary venous insufficiency (eg, postthrombotic).presence of postoperative incompetent perforators, larger ulcer size (>2 cm), and secondary venous insufficiency (eg, postthrombotic). Patients with recurrent ulcers following SEPS should have a duplex scan and repeat SEPS if perforators persist. [Patients with recurrent ulcers following SEPS should have a duplex scan and repeat SEPS if perforators persist. [87].]. Postoperative care and complicationsPostoperative care and complications — Postoperative pain is common and typically relieved with  — Postoperative pain is common and typically relieved with acetaminophen with with codeine. Patients are encouraged to ambulate immediately after surgery. Bruising along the tract of the excised or stripped veins is common . Patients are encouraged to ambulate immediately after surgery. Bruising along the tract of the excised or stripped veins is common

and can last for up to six weeks following surgery. Regardless of the surgical method used, the application of compression therapy in the form of elastic wraps (eg, Ace) or graduated compression stockings helps limit bruising and swelling (and can last for up to six weeks following surgery. Regardless of the surgical method used, the application of compression therapy in the form of elastic wraps (eg, Ace) or graduated compression stockings helps limit bruising and swelling (show table 3). (). (See "Medical management of lower extremity chronic venous disease", section on Compression stockings)., section on Compression stockings).

Time off work varies between one and three weeks depending upon the patient's job requirements and the magnitude of the operation.Time off work varies between one and three weeks depending upon the patient's job requirements and the magnitude of the operation. The most common complications of vein ablation surgery are bruising and hematoma formation. The use of a tourniquet during surgery helps to limit blood loss [88]. Other complications include wound infection, hyperpigmentation, telangiectatic matting, phlebitis The most common complications of vein ablation surgery are bruising and hematoma formation. The use of a tourniquet during surgery helps to limit blood loss [88]. Other complications include wound infection, hyperpigmentation, telangiectatic matting, phlebitis

(superficial or deep) and saphenous nerve injury (frequency 10 percent) [89].(superficial or deep) and saphenous nerve injury (frequency 10 percent) [89]. Post-surgical telangiectatic matting and hyperpigmentation typically improve over time, however, can be treated with surface laser therapy if persistent [90].Post-surgical telangiectatic matting and hyperpigmentation typically improve over time, however, can be treated with surface laser therapy if persistent [90]. Efficacy of surgeryEfficacy of surgery — Surgical therapy is the standard to which the more minimally invasive techniques are compared. — Surgical therapy is the standard to which the more minimally invasive techniques are compared. Surgical intervention improves symptoms, and the overwhelming majority of patients are satisfied with their procedure. As an example, 150 symptomatic patients who underwent varicose vein surgery in Britain were found at six months after surgery to have significant Surgical intervention improves symptoms, and the overwhelming majority of patients are satisfied with their procedure. As an example, 150 symptomatic patients who underwent varicose vein surgery in Britain were found at six months after surgery to have significant

improvements in pain, energy, physical function, and mental health compared with preoperative levels [18]. Symptoms resolved completely in 22 percent and most patients felt their surgery was successful (64 percent). Disease-specific and general quality of life improvements in pain, energy, physical function, and mental health compared with preoperative levels [18]. Symptoms resolved completely in 22 percent and most patients felt their surgery was successful (64 percent). Disease-specific and general quality of life improvements persisted for at least two years [91].improvements persisted for at least two years [91].

The traditional surgical technique is associated with vein recurrence rates of at least 20 percent [26] and is even higher if great saphenous ablation is not performed [89]. The cause of recurrences is not clear and may include surgical technique, development of new The traditional surgical technique is associated with vein recurrence rates of at least 20 percent [26] and is even higher if great saphenous ablation is not performed [89]. The cause of recurrences is not clear and may include surgical technique, development of new veins (neovascularization), or progression of the underlying disease. In randomized trials, ligation plus stripping was found to have lower recurrence rates than high ligation alone and is the preferred surgical technique for patients with saphenofemoral reflux and veins (neovascularization), or progression of the underlying disease. In randomized trials, ligation plus stripping was found to have lower recurrence rates than high ligation alone and is the preferred surgical technique for patients with saphenofemoral reflux and extensive great saphenous disease [78,92].extensive great saphenous disease [78,92].

The cost-effectiveness of surgery for patients with severe varicose veins and reflux, compared to conservative management, was evaluated in a randomized trial of 250 patients [93]. Surgery provided improved outcomes (quality of life, symptomatic relief and The cost-effectiveness of surgery for patients with severe varicose veins and reflux, compared to conservative management, was evaluated in a randomized trial of 250 patients [93]. Surgery provided improved outcomes (quality of life, symptomatic relief and anatomical extent) and was cost-effective at two years, with projected continued cost benefit at 10 years.anatomical extent) and was cost-effective at two years, with projected continued cost benefit at 10 years.

SUMMARY AND RECOMMENDATIONSSUMMARY AND RECOMMENDATIONS Varicose veins are palpable, dilated subcutaneous veins, due to genetic and environmental factors. They may be associated with aching, cramping, itching and fatigue, though are often asymptomatic. (See "Clinical evaluation" above). Varicose veins are palpable, dilated subcutaneous veins, due to genetic and environmental factors. They may be associated with aching, cramping, itching and fatigue, though are often asymptomatic. (See "Clinical evaluation" above). Varicose veins may predispose to superficial thrombophlebitis and venous hemorrhage. Venous ulcers are associated with presence of venous incompetence. (See "Varicose vein complications" above). Varicose veins may predispose to superficial thrombophlebitis and venous hemorrhage. Venous ulcers are associated with presence of venous incompetence. (See "Varicose vein complications" above). The goals of treatment are improved symptoms and appearance. Initial treatment for varicose veins is conservative including leg elevation, exercise and graduated compression stockings. (See "Clinical management" above). The goals of treatment are improved symptoms and appearance. Initial treatment for varicose veins is conservative including leg elevation, exercise and graduated compression stockings. (See "Clinical management" above). Symptomatic patients should be sent for duplex ultrasonography to assess the extent of venous involvement and the location and severity of any reflux. (See "Duplex ultrasound" above). Symptomatic patients should be sent for duplex ultrasonography to assess the extent of venous involvement and the location and severity of any reflux. (See "Duplex ultrasound" above). Patients found to have significant venous reflux, as well as patients who develop complications (including ulceration, hemorrhage, or recurrent superficial thrombophlebitis) should be referred to a vein specialist for further evaluation and management. (See "Clinical Patients found to have significant venous reflux, as well as patients who develop complications (including ulceration, hemorrhage, or recurrent superficial thrombophlebitis) should be referred to a vein specialist for further evaluation and management. (See "Clinical

management" above). management" above). Injection liquid sclerotherapy is typically reserved for patients with small varicose veins (less than 5 mm), without evidence of venous incompetence, and for residual or recurrent varicosities following surgery. Foam sclerotherapy is an alternate method available. (See Injection liquid sclerotherapy is typically reserved for patients with small varicose veins (less than 5 mm), without evidence of venous incompetence, and for residual or recurrent varicosities following surgery. Foam sclerotherapy is an alternate method available. (See

"Liquid and foam sclerotherapy" above). "Liquid and foam sclerotherapy" above). Endovenous ablation techniques (radiofrequency ablation and endovenous laser ablation) are highly successful in achieving vein closure and have high patient satisfaction rates. (See "Endovenous catheter ablation" above). Endovenous ablation techniques (radiofrequency ablation and endovenous laser ablation) are highly successful in achieving vein closure and have high patient satisfaction rates. (See "Endovenous catheter ablation" above). Traditional surgical techniques include ligation/stripping of the great or short saphenous vein, ambulatory phlebectomy, perforator ligation and SEPS. (See "Surgery" above and see "Endovenous catheter ablation" above). Traditional surgical techniques include ligation/stripping of the great or short saphenous vein, ambulatory phlebectomy, perforator ligation and SEPS. (See "Surgery" above and see "Endovenous catheter ablation" above).