Last updated March 15, 2022

Treatment of Superficial Venous Disease of the Lower Leg

Guidelines for Treatment of Venous Disease

Indications for Treatment

Compression therapy is an effective method for the management of symptoms related to superficial disease but it does not correct the source of reflux. When patients have a correctable source of reflux definitive treatment should also be offered unless it is contraindicated or unwanted. (1A)
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We recommend against compression therapy as a prerequisite therapy for symptomatic venous reflux disease when other definitive treatments such as endovenous ablation are appropriate. (1A)
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After interventional treatment, we recommend the use of a compression garment in the postoperative period. There is extra benefit to the patient in the form of reduced pain after use of compression. The compression dosage and duration is at the discretion and clinical judgment of the treating physician. (2B)
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Superficial venous insufficiency is a chronic disease and as such we recommend that patients with this disease be counseled to wear a compression garment even after definite treatment has been provided. The compression dosage is at the discretion and clinical judgment of the treating physician. (2C)
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We suggest the treatment of some CEAP C2 patients with isolated varices, by medical compression hose alone may be an acceptable form of treatment. A short 1-2 week trial of compression hose may be appropriate where an alternative etiology of symptoms is considered, e.g. musculoskeletal pain or neuropathy (spinal stenosis, sciatica, hip or knee arthritis, diabetic neuropathy etc). (2C)
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Indications for treatment include pain or other discomfort (ie, aching, heaviness, fatigue, soreness, burning), edema, varix hemorrhage, recurrent superficial phlebitis, stasis dermatitis or ulceration. We recommend patients should be evaluated using the CEAP classification and the Venous Clinical Severity Score (VCSS). We would define medically necessary as a CEAP classification of C2 or higher. (1A)
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In addition

We recommend all patients being considered for treatment must have a duplex ultrasound of the superficial venous system and, at a minimum, evaluation of the common femoral vein and popliteal vein for patency and competence. The exam should ideally be done in the standing position. (1A)
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We suggest all noninvasive vascular diagnostic studies be per formed by a qualified physician or by a qualified technologist under the general supervision of a qualified physician. (1C)
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We recommend that named veins (Great Saphenous Vein (GSV), Small Saphenous Vein (SSV), Anterior Accessory of the Great Saphenous Vein (AAGSV), Posterior Accessory of the Great Saphenous Vein (PAGSV ), Intersaphenous Vein (Vein of Giacomini)) must have a reflux time > 500 msec, regardless of the reported vein diameter. (1A)
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Treatment of Named Saphenous Veins

We recommend endovenous thermal ablation (laser and radiofrequency) is the preferred treatment for saphenous and accessory saphenous (GSV, SSV, AAGSV, PAGSV) vein incompetence. (1B)
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We suggest Mechanical/chemical ablation (Clarivein Device) may also be used to treat truncal venous reflux. (2B)
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We recommend open surgery is appropriate in veins not amenable to endovenous procedures but otherwise is not recommended because of increased pain, convalescent time, and morbidity. (1B)
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We suggest when open surgery of the great saphenous vein is performed it should include high ligation and invagination stripping to the level of the knee. (2B)
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We recommend when open surgery of the small saphenous vein is performed it include high ligation and selective invagination of the proximal portion. (1B)
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Treatment of Circumflex Veins and Other Non-Truncal Veins

The treatment of other non-truncal, tributary varicose vein reflux (circumflex veins anterior and posterior thigh) is more complex. The medical record should reflect that these veins are incompetent and note their size, presence or absence of tortuosity, and depth relationship to the skin, i.e. accessible or not accessible by phlebectomy.

We recommend varicose (visible) symptomatic tributary veins can be treated by stab phlebectomy, liquid sclerotherapy or foam chemical ablation. (1B)
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We recommend (non visible) symptomatic tributary veins be treated by ultrasound-guided liquid sclerotherapy or foam chemical ablation. (1B)
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Treatment of Perforator Veins

We suggest treatment of incompetent perforating veins located beneath a healed or open venous ulcer. They should have outward flow of 500 ms, with a diameter of 3.5 mm. (2B)
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We suggest, in patients with perforator reflux as the primary or only source of disease, treatment of the perforator with endovenous thermal ablation, ligation or ultrasound guided sclerotherapy. Subsequent or simultaneous treatment of symptomatic varicosities arising from the incompetent perforator is also considered best practice. (2B)
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Recommendation Grading

Overview

Title

Treatment of Superficial Venous Disease of the Lower Leg

Authoring Organization

Endorsing Organizations

Publication Month/Year

February 1, 2016

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Female, Adult, Older adult

Health Care Settings

Ambulatory, Hospital, Operating and recovery room

Intended Users

Surgical technologist, physician, physical therapist, nurse, nurse practitioner, physician assistant

Scope

Assessment and screening, Diagnosis, Prevention, Management, Treatment

Diseases/Conditions (MeSH)

D020246 - Venous Thrombosis

Keywords

Superfecial Venous Disease, Lower Leg, Saphenous Veins, Circumflex veins, Non-Truncal veins, Perforator Veins