The Society for Vascular Surgery (SVS), American Venous Forum (AVF), and American Vein and Lymphatic Society (AVLS) have released the second and final part of new guidelines for the management of varicose veins of the lower extremities. The recommendations, which update the 2011 SVS and AVF guidance on the topic, were published online ahead of print in the Journal of Vascular Surgery: Venous and Lymphatic Disorders (JVS-VL).
The new document focusses on the following topics:
- Evidence supporting the prevention and management of varicose vein patients with compression
- Treatment with drugs and nutritional supplements
- Evaluation and treatment of varicose tributaries
- Superficial venous aneurysms
- The management of complications of varicose veins and their treatment
The publication—authored by Peter Gloviczki (Mayo Clinic, Rochester, USA) and 19 other members of a multispecialty guideline writing committee—follows last year’s release of part one of the guidelines, which addressed duplex scanning and treatment of superficial truncal reflux.
Gloviczki and colleagues outline in their introduction the reason behind the two-part publication of the updated guidelines. They note that all recommendations in part one were based on a new, independent systematic review and meta-analysis that “provided the latest scientific evidence to support updated or completely new guidelines on evaluation with duplex scanning and on the management of superficial truncal reflux in patients with varicose veins”. However, the authors recognised “several additional important clinical issues” needed to be addressed, despite many having varying levels of scientific evidence associated with them. For this reason, when a systematic review was not available, the writing committee based ungraded statements on a comprehensive review of the literature, combined with unanimous consensus of the expert panel.
Alongside a series of recommendations, the writing committee highlight “several” knowledge gaps on the natural history, evaluation, prevention and treatment of patients with varicose veins, highlighting their top 20 recommendations for future research. The most important three they identify are comparative studies of polidocanol endovenous micro-foam versus physician-compounded foam for treatment of varicose tributaries, comparative studies of polidocanol endovenous micro-foam versus other techniques of thermal and non-thermal ablation of incompetent superficial truncal veins, and best metric of axial reflux to determine ablation of superficial truncal veins.
Speaking to Venous News following the publication of these guidelines, Gloviczki commented: “These up-to-date, evidence-based recommendations are made by a 20-member multidisciplinary expert panel of three leading North American societies, dedicated to the care of patients with acute and chronic venous disease. This comprehensive document includes a list of practical recommendations, ungraded consensus statements, implementation remarks, and best practice statements to aid practitioners with the best and most appropriate management of patients with lower extremity varicose veins. It emphasises the superiority of endovenous techniques over conventional surgery, endorses both thermal and non-thermal ablation techniques and defines the role of compression, drugs and nutritional supplements. The guidelines address management of ablation-related thrombus extension (ARTE) after endovenous procedures and recommends best management of superficial thrombophlebitis, bleeding varicose veins and treatment of superficial venous aneurysms. Of special value is the list of projects for future research.”
The guideline document can be accessed in full on the JVS-VL website: https://www.jvsvenous.org/article/S2213-333X(23)00322-0/fulltext
When we know the great value of arterial bypass material of the great saphenous vein, whether competent or incompetent, proven by all the studies, why is this advantage of treatment methods respecting the great saphenous vein not taken into account in the grade of recommendation? Conservative methods do exist, including the CHIVA cure, evaluated by Cochrane as slightly more or as effective as all other methods of treating varicose veins?