https://repub.eur.nl/pub/78905/Chronic-Venous-Disease.pdf

Editor's Choice - Management of Chronic Venous Disease: Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS).

Aim: Sclerotherapy is the targeted chemical ablation of varicose veins by intravenous injection of a liquid or foamed sclerosing drug. The treated veins may be intradermal, subcutaneous, and/or transfascial as well as superficial and deep in venous malformations. The aim of this guideline is to give evidence-based recommendations for liquid and foam sclerotherapy. Methods: This guideline was drafted on behalf of 23 European Phlebological Societies during a Guideline Conference on 7–10 May 2012 in Mainz. The conference was organized by the German Society of Phlebology. These guidelines review the present state of knowledge as reflected in published medical literature. The regulatory situation of sclerosant drugs differs from country to country but this has not been considered in this document. The recommendations of this guideline are graded according to the American College of Chest Physicians Task Force recommendations on Grading Strength of Recommendations and Quality of Evidence in Clinical Guidelines. Results: This guideline focuses on the two sclerosing drugs which are licensed in the majority of the European countries, polidocanol and sodium tetradecyl sulphate. Other sclerosants are not discussed in detail. The guideline gives recommendations concerning indications, contraindications, side-effects, concentrations, volumes, technique and efficacy of liquid and foam sclerotherapy of varicose veins and venous malformations.

https://journals.sagepub.com/doi/pdf/10.1177/0268355513483280

European guidelines for sclerotherapy in chronic venous disorders

http://www.ejves.com/article/S1078588421009795/pdf

European Society for Vascular Surgery (ESVS) 2022 Clinical Practice Guidelines on the Management of Chronic Venous Disease of the Lower Limbs.

Comparing endovenous laser ablation, foam sclerotherapy, and conventional surgery for great saphenous varicose veins

Background

This was a prospective study of radiofrequency segmental thermal ablation (RFA) for the treatment of incompetent varicose great saphenous veins (GSVs). The present report describes long-term follow-up at 5 years.



Methods

The 5-year follow-up of this multicentre European study included assessment of the Venous Clinical Severity Score (VCSS), and GSV occlusion and reflux on duplex imaging.



Results

A total of 225 patients had 295 GSVs treated by RFA, achieving an initial vein occlusion rate of 100 per cent. With 80·0 per cent compliance, Kaplan–Meier analyses showed a GSV occlusion rate of 91·9 per cent and a reflux-free rate of 94·9 per cent at 5 years. Among the 15 GSVs noted with reflux during follow-up, only three showed full recanalization of the GSV at 1 week, 6 months and 3 years. Of the 12 legs with partial recanalization, reflux originated at the saphenofemoral junction in ten, with a mean length of the patent segment of 5·8 (range 3·2–10) cm; only six patients were symptomatic. Mean(s.d.) VCSS scores improved from 3·9(2·1) at baseline to 0·6(1·2), 0·9(1·3) and 1·3(1·7) at 1, 3 and 5 years.



Conclusion

At 5 years RFA proved to be an efficient endovenous treatment for incompetent GSVs in terms of sustained clinical and anatomical success for the vast majority of treated patients.

Five-year results from the prospective European multicentre cohort study on radiofrequency segmental thermal ablation for incompetent great saphenous veins

Duplex Ultrasound Investigation of the Veins of the Lower Limbs after Treatment for Varicose Veins – UIP Consensus Document

Management strategies for patients with varicose veins (C2-C6): results of a worldwide survey.

Nowadays, various surgical and endovenous methods are available to treat varicose veins. Theoretically, every technique is applicable to treat any kind of patient. However, it seems appropriate to consider the specific indications and limitations of each of the techniques. To choose the most appropriate treatment method, several issues have to be taken into account. The patient's reason for consulting and clinical condition will define the aim of the treatment. Anatomical and hemodynamic characterization of the varicose veins by means of duplex ultrasound will define the technical feasibility. Although a definitive algorithm still remains to be developed, some of the most important questions that should be included in a decision tree can already be proposed: Is high ligation necessary or at least justified? Is stripping or ablation necessary or at least justified, and in that case, what is the most appropriate technique to be used? All this should help us define a reasonable "a la carte" treatment for each patient.

Treatment of Varicose Veins: Does Each Technique Have a Formal Indication?

Postural Diameter Change of the Saphenous Trunk in Chronic Venous Disease.

Recurrent varicose veins remain a common problem after varicose vein treatment. Several etiologies have been recognized: tacticaland technical failure, neovascularisation, and recanalisation of a previously obliterated trunk and progression of the disease. With the widespread use of duplex ultrasound and increasing experience in the field of ultrasound-guided procedures, the impact of both tactical and technical failure is likely to diminish. However this issue still needs our attention, as it may induce early recurrence after all types of intervention. Another etiologic factor is neovascularisation, occurring in particular after surgery at the level of the saphenofemoral junction (SFJ) or saphenopopliteal junction (SPJ). To explain recurrence after endovenous ablation (EVA) the focus has rather been on recanalisation of a previously obliterated trunk. It is well known that such recanalisation occurs more frequently after chemical ablation with sclerosant foam than after thermal ablation. The incidence of neovascularisation at the SFJ or SPJ is much lower after EVA than after surgical procedures. However this does not mean that the junctions are never involved in recurrence after EVA. It is therefore also important to follow the evolution at the level of the SFJ or SPJ by means of duplex ultrasound, as new (or persistent) reflux may be detected sonographically. Progression of the disease cannot be avoided and is an important contributory factor in the pathophysiology of recurrence at long term. Apart from genetic factors, other patient-related factors (BMI ≥ 30, pregnancy after the intervention⋯) have been claimed to be responsible for progression of the disease and hence recurrence. Due to disease progression after several years, tortuous neovascular veins or (newly) refluxing veins at the junction may connect with superficial varicose veins of the thigh or leg, acting as a 'joint venture' and in this way lead to the clinical situation of a full-blown recurrence of varicose veins. To increase our understanding of varicose vein recurrence, future studies are needed, including adequate preoperative duplex ultrasound investigation and long-term follow-up with serial duplex scans, after different forms of varicose vein treatment.

O. Pichot

Papers

Duplex Ultrasound Investigation of the Veins of the Lower Limbs after Treatment for Varicose Veins – UIP Consensus Document

Management strategies for patients with varicose veins (C2-C6): results of a worldwide survey.

Treatment of Varicose Veins: Does Each Technique Have a Formal Indication?

Postural Diameter Change of the Saphenous Trunk in Chronic Venous Disease.

New concepts on recurrence of varicose veins according to the different treatment techniques