Chronic Venous Disease

Risk factors:

The pathophysiology of CVD is characterized by reflux, obstruction, or a combination of both. This results in reduced ability to empty the leg veins efficiently during exercise, which means the AVP remains high and this eventually leads to all the clinical features of venous hypertension. Most pats with uncomplicated varicose veins (C2) have normal venous pressure. All those with more advanced stages of CVD progressively develop venous hypertension, characterized by symptoms and signs of CVI (C3-6). The clinical manifestations of CVI are oedema and skin changes, from hyperpigmentation, eczema, atrophie blanche and lipodermatosclerosis to venous ulcers.

In incompetent superficial veins, reflux is primarily caused by vein wall abnormalities. Perforator incompetence has proven to be a significant factor in the determination of CVD severity.

Clinical presentation

Patients present with heaviness, tiredness, itching of the skin, nocturnal cramps, and throbbing and aching of the legs, which is exacerbated by prolonged standing. These symptoms can interfere with day to day activities and work, particularly in patients who need to stand for prolonged periods of time. Symptoms are worse at the end of the day, and symptomatic relief may be achieved by leg elevation, mobilization, and exercise.

Superficial veins can thrombose, resulting in painful thrombophlebitis and localized cellulitis.

Uncommonly, bleeding can be a presentation of CVD.

There is evidence suggesting that clinical signs of disease also correlate with GSV vein diameter, with increasing diameter being associated with greater disease severity.

QoL scores also correlate with disease severity. Patients with more severe signs and symptoms report worse QoL scores.

Clinical Etiological Anatomical Pathophysiological (CEAP) classification

1. Use of CEAP classification is recommended. (I/B)

History taking

Possible thromboembolic antecedents should be investigated, together with any allergy, medication (oral contraceptives primarily), and concomitant relevant diseases including heart and renal failure, which may influence CVD

6. specific symptoms, thromboembolic event, FH, relevant drug history taking is recommended (I/C)

Physical exam

7. mapping varicose veins, oedema, skin changes are recommended physical examinations (I/C)

Imaging

9. duplex is recommended to assess the incompetence of perforator veins and truncal junctions (I/B)

11. The five major components that define a complete DUS examination are: anatomical information, flow visualization (presence or absence of reflux), provocation manoeuvre for flow augmentation, morphology (patency or obliteration), and compressibility (thrombosis diagnosis). (I/A)

13. DUS is recommended for assessment of recurrence (I/C)

Treatment of CVD

1. dressing for venous ulcers: a kotszerekkel kapcsolatos vizsgalati eredmenyek meglehetosen ellentmondasosak

21. wound dressing may be considered to promote healing of venous ulceration (IIb/A)

2. compression therapy:

23. elastic stocking is recommended as an effective treatment for signs and symptoms of CVD (I/B)

25. compression bandaging and walking exercises is recommended as initial treatment to promote healing of venous ulcers (I/A)

27. Compression bandages are good for initial treatment of venous leg ulcers, but active treatment should be explored and offered to maintain healing (I/B)

28. intermittent pneumatic compression is recommended to provide symptomatic relief in C3-6 disease if standard method is not available or failed

30. one week long post-procedural compression is recommended after superficial venous surgery (I/A)

32. leg elevation may be considered if compression is not feasible or as an adjunct to compression (IIb/C)

Medical treatment

Venoactive drugs decrease capillary permeability and release of inflammatory mediators and improve venous tone

pentoxiphyllin (Trental 400 2×1 VK) reduces white cell activaton

acetyl-salicylic acid prevent platelet function and has anti-inflammatory effect

34. venotonic drugs should be considered for swelling and pain in CVD (IIb/A)

35. sulodexide (Vessel Due F 2×1 VK) and MPFF (Detralex 500 2×1) should be considered as adjuvant to compression in venous ulcers (IIb/A)

36. routine use of ABx, horse chestnut seed extract and pentoxifyllin is NOT recommended in pats with venous ulcers (III/B)

Sclerotherapy

Post-procedural compression is an integral part of this type of treatment, which can be used to treat the entire spectrum of refluxing superficial veins, including the saphenous veins, and telangiectasias with a great degree of efficacy and safety. Patients should be informed of possible side effects (such as skin necrosis, telangiectatic matting, hyperpigmentation, and also allergic reactions) and complications (such as deep vein thrombosis and PE). Cochrane reviews: there is no evidence suggesting superior efficacy of any one sclerosant over another. Lower concentrations of the sclerosant agent are used for smaller veins. Varicose vein recurrence, as high as 90% after 6 years if the source of incompetence has not been eliminated. On the other hand, good long-term results in the primary treatment of isolated varicose veins, not associated with saphenous vein incompetence have been demonstrated. Treatment of recurrent varicose veins following surgery is another indication. Foam sclerotherapy, usually guided by DUS (ultrasound guided foam sclerotherapy, UGFS), has been shown to be more effective than liquid sclerotherapy because of the enhanced sclerosing properties of the foam form of the sclerosant. UGFS is characterized by a higher recanalization rate when treating veins larger than 5-7 mm in diameter.

38. sclerotherapy is NOT recommended as a first choice for C2-6 due to saphenous vein incompetence. (III/A)

39. foam sclerotherapy is recommended as a second choice in C2 disease. (I/A)

40-41. foam sclerotherapy should be considered for C1 and as primary treatment for recurrent varicose veins (IIa/B)

Transcutaneous laser treatment is less effective than sclerotherapy at managing legtelangiectasias, requires more treatment sessions and is more expensive.

EVTA

Endovenous techniques in the treatment of saphenous vein incompetence have become very popular as a minimally invasive alternative to classical surgery (HL and stripping). In countries where reimbursement is available, the vast majority of patients are treated endovenously. The two most frequently used techniques are endovenous laser ablation (EVLA) and radiofrequency ablation (RFA). Another endovenous thermal ablation (EVTA) technique is steam ablation. Other more recently introduced techniques are mechanochemical ablation (MOCA)  and injection of cyanoacrylate glue. The use of EVTA (EVLA, RFA, Steam) techniques requires injection of tumescent liquid around the target vein. The purpose of this is to protect the perivenous tissue from the heat created during treatment. A very dilute solution of local anaesthetic combined with bicarbonate and epinephrine is used for this purpose. The new non-thermal ablation techniques (MOCA and glue injection) can be performed without injection of tumescence during the ablation. It is important to empty the vein of blood as much as possible. Compression post intervention is recommended, but the duration of compression is not clearly defined.

Thrombo-prophylaxis can be prescribed for high risk patients (previous venous thromboembolism, documented thrombophilia, obesity, immobilized patients, patients with neoplasm, and older patients).

Patients can be treated in an outpatient setting under local tumescent anaesthesia, which permits early ambulation reducing the risk of possible thromboembolic complications.

Compared with EVTA, surgically treated patients more frequently develop complications, such as wound infection (2- 6% for surgery vs. 0% for EVTA) and haematomas (5% for surgery vs. 2% for EVTA). Patients treated with EVTA have, on average, less pain compared with patients treated surgically. Post EVTA as opposed to surgery, swelling and bruising is reduced. This results in quicker recovery and faster return to normal activities. 

43-44. For the treatment of symptomatic VSM reflux EVTA techniques are recommended to prefer to surgery and foam sclerotherapy (I/A)

Treatment of SSV

Access at the lateral malleolus results in a higher paresthesia rate compared with mid-calf access, because of the proximity of the sural nerve to the SSV in the distal part of the calf. SPJ ligation and stripping of the SSV often fails because of the complex anatomy. UGFS for the treatment of SSV incompetence can be an alternative to EVTA and surgery. There are no RCTs comparing foam sclerotherapy with surgery or EVTA in treatment of SSV incompetence.

In the REACTIV trial, the results of surgery were compared with results of compression alone in 246 patients with uncomplicated varicose veins, the surgical treatment comprising high ligation/stripping (HL/ S) of the GSV and multiple phlebectomies. At 2-year follow up the results showed more symptomatic relief, better cosmetic results, and much improved QoL for surgery compared with conservative management by compression.

A non-comparative prospective study showed that the use of isotonic sodium bicarbonate as excipient for tumescent anaesthesia reduced intraoperative pain and improved cost-effectiveness of surgery.

As endovenous procedures have shown good results without HL, stripping of the saphenous vein has also been described without HL. The conclusion was that beyond a higher pain score in the post-operative period and a higher total cost for HL/S and EVLA, the efficiency of the four modalities was not significantly different.

46. For (non-complicated CVD) C2-3 surgery is recommended to conservative treatment (I/B)

47. In surgery of refluxing GSV HL/S is recommended to HL only (I/A)

50. The use of tumescent anaesthesia should be considered to reduce post-op pain (IIa/C)

A randomized study showed that ambulatory phlebectomy compared with liquid sclerotherapy plus compression for accessory vein incompetence caused significantly fewer recurrences at 1 and 2 years of follow up. Some publications advocate limiting the treatment to thermal ablation of the SV without treating the tributary varicose veins.

51. when performing EVTA for refluxing saphenous trunk adding concomittant phlebectomy should be considered (IIa/B)

52. to treat tributary varicose veins ambulatory phlebectomy should be considered (IIa/C)

Anatomical, DUS examination, and morphological information confirmed the theory that the reflux begins at the saphenous junctions and progresses downwards through the saphenous axis leading to venous hypertension, wall dilatation, and dilatation of tributaries which become varicose veins. Cooper assessed in a retrospective analysis of venous DUS examinations that the incompetence of the SFJ has a major influence on the extension of the reflux and that the venous incompetence was most commonly proximal in presence of varicose veins. The evolution of CVD, whether ascending or descending, remains largely unknown, as prospective longitudinal studies with a lengthy period of observation and a large sample size, are missing and RCTs are needed.

Recurrent varicose veins

Whether after open surgery or endovenous intervention, mid-term recurrence rates remain in the region of up to 35% at 2 year follow up, and 65% at 11 year follow up.

Causes of recurrent varicose veins:

– Tactical error 4% (Tactical error refers to errors in pre-operative planning). Persistent venous reflux in a saphenous vein secondary to inadequate preoperative evaluation and inappropriate surgery

– Technical error 5.3% (Technical error refers to inaccurate treatment at the time of surgery or endovenous intervention. There is evidence suggesting that human, or technical error, plays a lesser role in the development of recurrence compared with neovascularization and disease progression.) Persistent venous reflux due to inadequate or incomplete surgical technique

– Neovascularisation 13% (Neovascularization refers to the formation of new veins, typically at the site of the previous ligation of the GSV or SSV. This results in reconnection of the deep vein with a residual main saphenous trunk (if not stripped) or with superficial tributaries, eventually resulting in clinical recurrence.) Presence of reflux in a previously ligated SFJ or SPJ caused by development of incompetent tortuous veins linked to thigh (or calf) varicosities. After GSV stripping, revascularization of the saphenectomy track has been observed, seen as multiple tortuous venous channels in the track of the previously stripped GSV.

– Disease progression 15%. Development of venous reflux secondary to the natural evolution of the disease

64. extensive redo surgery is not recommended as a first choice in patients with recurrent varicose veins (III/B)

Forrás: Management of Chronic Venous Disease.
Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg (2015) 49, 678-737

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