It is estimated that 20% to 25% of American adults have varicose veins, and 6% have more advanced chronic venous diseases (CVDs). While varicose veins were once considered a cosmetic problem, they are associated with discomfort, pain, and poor quality of life. Severe CVDs may also lead to loss of limb or life. In response to the rapid improvement in technology and results from recent randomized clinical trials, the Society for Vascular Surgery (SVS) and the American Venous Forum (AVF) jointly released new clinical practice guidelines for the care of patients with varicose veins. The guidelines, published in the May 2011 supplement to the Journal of Vascular Surgery, also provide recommendations for those with more advanced CVDs, including edema, skin changes, or venous ulcers.
As the aging population continues to grow, so too will complications related to varicose veins and associated CVDs. Advancements in technology and surgical techniques have resulted in vast improvements in the prevention and management of varicose veins. “It is critical that surgeons are aware of the latest diagnostic strategies and the less invasive and more effective treatment techniques for treating the disease,” says Peter Gloviczki, MD, who chaired the SVS/AVF Venous Guideline Committee.
New & Modified Recommendations
Numerous recommendations for the management of varicose veins and more advanced CVDs are presented in the SVS/AVF guidelines (Table). The strength of each guideline varies based on the benefits as compared to the risks, burdens, and costs. A key recommendation offered by the new guidelines is duplex scanning of the deep and superficial veins to complement the standard history and physical examination in evaluation of patients with varicose veins or more severe CVDs. “Strong clinical evidence suggests routine use of duplex scanning since it is an accurate, easy-to-use, non-invasive diagnostic technique,” Dr. Gloviczki says.
Another evolution from previous guidelines is the revised CEAP classification system. The classification is based on clinical signs of venous disease (C), etiology (E), anatomy (A), and the underlying pathophysiology (P). Once the venous disease is classified using the CEAP system, the revised Venous Clinical Severity Score (VCSS) is assigned to signify disease severity. “Evaluation and treatment of the various venous conditions are distinctly different,” explains Dr. Gloviczki. “This classification system should improve the quality of care physicians provide. We recommend using the basic CEAP clinical classification along with the revised VCSS.”
The SVS/AVF guidelines continue to recommend compression therapy for treatment of patients with simple varicose veins. “A major modification, which may be of great interest to vascular surgeons, is the recommendation of saphenous vein ablation as the primary treatment versus compression therapy if patients are candidates for intervention,” says Dr. Gloviczki. This recommendation is based on results from a prospective, randomized clinical trial called REACTIV, which showed that treatment with ablation surgery at 2 years provided more symptomatic relief and improvements in quality of life than conservative management with compression.
More Long-Term Data Wanted
Although there is strong clinical evidence to encourage vascular surgeons to use minimally invasive, outpatient techniques to treat CVDs, there is a paucity of long-term data. Less invasive treatments for CVDs are associated with shorter disability and less pain, but only short- and medium-term effective data exist. The only treatment with long-term effectiveness data is open surgery. “We need randomized trials of newer and less invasive therapies—such as laser, radiofrequency ablation, and foam therapy—to compare their durability and efficacy. We also need to assess new treatments like foam therapy to evaluate safety so that it reaches the standard procedure of ligation, stripping, and multiple phlebectomies,” Dr. Gloviczki says. “For now, the scientific evidence must be combined with the clinical experience and patient preferences to select the best diagnostic tests and treatment options for each individual.”
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