Management of Varicose Veins of the Lower Extremities

Publication Date: October 11, 2022
Last Updated: December 15, 2022

Guideline 1


For patients with chronic venous disease of the lower extremities, we recommend duplex ultrasound scanning as the diagnostic test of choice to evaluate for venous reflux. ( 1 – Strong , B)
Implementation Remarks:
Reflux is defined 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. A minimum value >1 second of reversed flow is diagnostic of reflux in the common femoral, femoral, and popliteal veins.

Axial reflux is defined as uninterrupted retrograde venous flow from the groin to the calf. Retrograde flow can occur in the superficial or deep veins, with or without perforating veins. Junctional reflux will be limited to the saphenofemoral or saphenopopliteal junction. Segmental reflux occurs in a portion of a superficial or deep truncal vein.

A definition of “pathologic” perforating veins in patients with varicose veins (CEAP [Clinical Class, Etiology, Anatomy, Pathology] clinical class C2) includes those with an outward flow duration of ≥500 ms and a diameter of ≥3.5 mm on duplex ultrasound.

Guideline 2


For patients with symptomatic varicose veins and axial reflux in the great or small saphenous vein, who are candidates for intervention, we recommend superficial venous intervention over long-term compression stockings. ( 1 – Strong , B)



Management of Varicose Veins of the Lower Extremities - Duplex Scanning and Treatment of Superficial Truncal Reflux

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