Management of Varicose Veins of the Lower Extremities. Part II

We recommend the use of the 2020 updated Clinical Stage, Etiology, Anatomy, Pathology (CEAP) classification system for chronic venous disorders. The clinical or basic CEAP classification can be used for clinical practice, and the full CEAP classification system should be used for clinical research. ( G-U , )

We recommend the use of the revised Venous Clinical Severity Score (VCSS) for patients with chronic venous disorders for grading of clinical severity and for assessment of post treatment outcome. ( G-U , )

For patients with chronic venous disease of the lower extremities, we recommend DUS as the diagnostic test of choice to evaluate for venous reflux. ( 1 – Strong , B)

Reflux is defined as a minimum value >500 ms of reversed flow in the superficial truncal veins (great saphenous vein [GSV], small saphenous vein [SSV], anterior accessory great saphenous vein [AAGSV], and posterior accessory great saphenous vein [PAGSV]) and in the tibial, deep femoral, and perforating veins. A minimum value of >1 second of reversed flow is diagnostic of reflux in the common femoral, femoral, and popliteal veins. There is no minimum diameter required to have pathologic reflux. (, )

Axial reflux of the GSV is defined as uninterrupted retrograde venous flow from the groin to the upper calf. Axial reflux in the SSV is defined as being from the knee to the ankle. Axial reflux in the AAGSV and PAGSV is retrograde flow between two measurements, at least five centimeters (cm) apart. Retrograde flow can occur in the superficial or deep veins, with or without perforating veins. Junctional reflux is limited to the saphenofemoral (SFJ) or saphenopopliteal junction (SPJ). Segmental reflux occurs in only a portion of a superficial or deep truncal vein. (, )

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

We recommend that evaluation of reflux with DUS be performed in an Intersocietal Accreditation Commission or American College of Radiology accredited vascular laboratory by a credentialed ultrasonographer, with the patient standing whenever possible. A sitting or reverse Trendelenburg position can be used if the patient cannot stand. ( G-U , )

We recommend that for evaluation of reflux with DUS, the sonographer use either a Valsalva maneuver or augmentation to assess the common femoral vein and SFJ and distal augmentation with either manual compression or cuff deflation for evaluation of more distal segments. Superficial reflux must be traced to its source, including the saphenous junctions, truncal or perforating veins, or pelvic origin varicose veins. The study should be interpreted by a physician trained in venous duplex ultrasound interpretation. ( G-U , )

We recommend that a complete DUS examination for venous reflux in the lower extremities include transverse gray scale images without and with transducer compression of the common femoral, proximal, mid, and distal femoral and popliteal veins, SFJ, and at least two segments along the GSV and SSV. ( G-U , )

We recommend that a complete DUS examination for venous reflux in the lower extremities include measurement of the spectral Doppler waveform using calipers. Reflux at baseline and in response to a Valsalva maneuver or distal augmentation in the common femoral vein and at the saphenofemoral junction and in response to distal augmentation in the mid-femoral and popliteal vein should be documented. Reflux in the GSV at the proximal thigh and knee, in the AAGSV or PAGSV at the saphenofemoral junction and at the proximal thigh and in the SSV at SPJ and at the proximal calf should be documented. ( G-U , )

We recommend that a complete DUS examination for venous reflux in the lower extremities include diameter measurements in patients with the leg in the dependent position, from the anterior to the posterior wall, in the GSV 1 cm distal to the SFJ, at the proximal thigh and at the knee, in the AAGSV and PAGSV in the proximal thigh, and in the SSV at the SPJ and the proximal calf. Images of both normal and abnormal findings should be documented in the records of the patient. ( G-U , )

In asymptomatic patients with telangiectasias or reticular veins (CEAP Class C1) DUS evaluation of the lower extremity veins should not be routinely performed, since testing could result in unnecessary saphenous vein ablation procedures. (CS, )

In symptomatic CEAP Class C1 patients with bleeding or with severe symptoms of pain or burning due to moderate to severe telangiectasias or reticular veins, DUS evaluation may be performed to exclude associated venous incompetence; however, saphenous ablation for C1 disease without bleeding is rarely required. (CS, )

In symptomatic patients with varicose veins (CEAP Class C2) the deep venous system should be routinely evaluated for infrainguinal obstruction or valvular incompetence. (CS, )

In symptomatic patients with varicose veins (CEAP Class C2) evaluation for iliofemoral venous obstruction with DUS or with other imaging studies should be performed if suprapubic or abdominal wall varicosities are present and in patients with symptoms of proximal obstruction, including thigh and leg fullness, heaviness, swelling and venous claudication. CEAP Classes 3–6 warrant DUS or other imaging studies to evaluate for iliofemoral obstruction. (CS, )

In patients with medial thigh or vulvar varicosities evaluation of pelvic venous pathology with DUS or other imaging studies is not indicated if they have no symptoms of pelvic venous disease. (CS, )

For patients with symptomatic varicose veins and axial reflux in the superficial truncal veins, we suggest compression therapy for primary treatment if the patient’s ambulatory status and/or underlying medical conditions warrant a conservative approach, or if the patient prefers conservative treatment for either a trial period or definitive management. ( 2 – Weak , C)

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

For patients with symptomatic varicose veins and axial reflux in the AAGSV or PAGSV, who are candidates for intervention, we suggest superficial venous intervention over long-term compression stockings. ( 2 – Weak , C)

In patients with symptomatic varicose veins who are candidates for endovenous therapy and wish to proceed with treatment, we suggest against a 3-month trial of compression therapy before intervention. ( 2 – Weak , B)