Current Best Practice in the Management of Varicose Veins

Abstract

This article outlines the current best practice in the management of varicose veins. “Varicose veins” traditionally means bulging veins, usually seen on the legs, when standing. It is now a general term used to describe these bulging veins, and also underlying incompetent veins that reflux and cause the surface varicose veins. Importantly, “varicose veins” is often used for superficial venous reflux even in the absence of visible bulging veins. These can be simply called “hidden varicose veins”. Varicose veins usually deteriorate, progressing to discomfort, swollen ankles, skin damage, leg ulcers, superficial venous thrombosis and venous bleeds. Patients with varicose veins and symptoms or signs have a significant advantage in having treatment over conservative treatment with compression stockings or venotropic drugs. Small varicose veins or telangiectasia without symptoms or signs can be treated for cosmetic reasons. However, most have underlying venous reflux from saphenous, perforator or local “feeding veins” and so investigation with venous duplex should be mandatory before treatment. Best practice for investigating leg varicose veins is venous duplex ultrasound in the erect position, performed by a specialist trained in ultrasonography optimally not the doctor who performs the treatment. Pelvic vein reflux is best investigated with transvaginal duplex ultrasound (TVS), performed using the Holdstock-Harrison protocol. In men or women unable to have TVS, venography or cross-sectional imaging is needed. Best practice for treating truncal vein incompetence is endovenous thermal ablation. Increasing evidence suggests that significant incompetent perforating veins should be found and treated by thermal ablation using the transluminal occlusion of perforator (TRLOP) approach, and that incompetent pelvic veins refluxing into symptomatic varicose veins in the genital region or leg should be treated by coil embolisation. Bulging varicosities should be treated by phlebectomy at the time of truncal vein ablation. Monitoring and reporting outcomes is essential for doctors and patients; hence, participation in a venous registry should probably be mandatory.

Risk Factors for Bleeding Varicose Veins in Patients with Chronic Venous Disease

“…The main sites of superficial venous system of lower limbs that can be involved in CVD pathophysiology and vein reflux are represented by GSV, small saphenous veins (SSV), anterior accessory saphenous veins (AASVs), SFJ, sapheno-popliteal junction (SPJ), perforators veins, and non-saphenous veins [ 12 ]. In particular, the superficial veins connect to the deep veins at the SFJ, where the GSV joins the common femoral vein, and at the SPJ where the SSV joins the popliteal vein [ 13 ]. Additionally, several perforator veins, such as Dodd’s, Boyd’s, and Cockett’s perforators, connect the deep and the superficial venous system along the lower limb and may be responsible of important vein reflux [ 14 ].…”

“…Vein reflux, in one or more of the aforementioned veins, is the fundamental mechanisms in CVD and is responsible of the formation of bulging VVs, visible on lower limbs’ skin, and of more important signs such as skin changes, leg ulceration, and even bleeding VVs [ 13 ]. Reflux is also responsible of local venous hypertension that determines venous shear stress on the endothelium, which triggers biochemical and cellular events that stimulate inflammation pathways that characterize all stages and complication of CVD [ 15 , 16 , 17 ].…”

Factors Influencing Venous Remodeling in the Development of Varicose Veins of the Lower Limbs

“…In addition to invasive/surgical methods such as sclerotherapy, endovascular laser or radiofrequency ablation, microphlebectomy [156,157], treatment with phlebotonic drugs is used. Venoactive drugs of different mechanisms of action in many cases are effective and safe way of treatment for patients with CVeD (Table 1).…”

Cyanoacrylate adhesive closure in the European and American 2022 clinical practice guidelines

“…Последнее десятилетие ознаменовано появлением нетермических нетумесцентных (НТНТ) методов устранения вертикального рефлюкса при несостоятельности магистральных подкожных вен нижних конечностей [1][2][3]. В настоящее время основными НТНТ-методами являются механохимическая облитерация и цианоакрилатная клеевая облитерация (ЦКО) [4][5][6][7].…”