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Review article: Biomedical intelligence

Vol. 146 No. 4546 (2016)

Varicosities of the lower extremity, new approaches: cosmetic or therapeutic needs?

  • Luca Spinedi
  • Heiko Uthoff
  • Sasan Partovi
  • Daniel Staub
DOI
https://doi.org/10.4414/smw.2016.14360
Cite this as:
Swiss Med Wkly. 2016;146:w14360
Published
06.11.2016

Summary

Varicose veins of the lower extremity (VVLE) are a frequently encountered vascular disorder in the general population. The general view that VVLE are a non-serious disease with primarily aesthetic impact is a common misconception, as the disease can have a significant negative impact on generic and disease-specific quality of life. Further, VVLE may be associated with potentially threatening clinical conditions, such as chronic venous ulceration, venous thromboembolism and haemorrhage from ruptured varicose veins.

In the case of symptomatic varicose veins, in the presence of advanced lower limb skin changes or when venous complications occur, a referral for dedicated evaluation by the vascular medicine specialist is recommended. The initial diagnostic test of choice to detect the extent of the varicose disease and to plan treatment is duplex ultrasound.

Traditionally, compression therapy, surgical high ligation and stripping of the truncal veins have been considered standard of care for VVLE. Driven by the aim to reduce surgical trauma and improve the long-term effectiveness, minimally invasive treatment options have been developed in the last two decades, namely endovascular vein ablation techniques (EVA). Endovenous laser ablation and radiofrequency ablation have been established as first-line treatments for varicose veins associated with axial reflux on the basis of the most recent international guidelines. For practical purposes and depending on the concrete clinical situation, the various EVA and surgical techniques are often combined, leading to multimodal varicose vein therapy management. Knowledge of the different techniques is of utmost importance for the vascular medicine specialist.

The purpose of this article is to provide an overview of the new EVA techniques and to elucidate the different therapeutic strategies for VVLE.

References

  1. Eklof B, Perrin M, Delis KT, Rutherford RB, Gloviczki P; American Venous Forum; European Venous Forum; International Union of Phlebology; American College of Phlebology; International Union of Angiology. Updated terminology of chronic venous disorders: the VEIN-TERM transatlantic interdisciplinary consensus document. J Vasc Surg. 2009;49(2):498–501.
  2. Eklöf B, Rutherford RB, Bergan JJ, Carpentier PH, Gloviczki P, Kistner RL, et al.; American Venous Forum International Ad Hoc Committee for Revision of the CEAP Classification. Revision of the CEAP classification for chronic venous disorders: consensus statement. J Vasc Surg. 2004;40(6):1248–52.
  3. Gloviczki P, Comerota AJ, Dalsing MC, Eklof BG, Gillespie DL, Gloviczki ML, et al.; Society for Vascular Surgery; American Venous Forum. The care of patients with varicose veins and associated chronic venous diseases: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg. 2011;53(5, Suppl):2S–48S.
  4. Criqui MH, Jamosmos M, Fronek A, Denenberg JO, Langer RD, Bergan J, et al. Chronic venous disease in an ethnically diverse population: the San Diego Population Study. Am J Epidemiol. 2003;158(5):448–56.
  5. Rabe E, Guex JJ, Puskas A, Scuderi A, Fernandez Quesada F; VCP Coordinators. Epidemiology of chronic venous disorders in geographically diverse populations: results from the Vein Consult Program. Int Angiol. 2012;31(2):105–15.
  6. Evans CJ, Fowkes FG, Ruckley CV, Lee AJ. Prevalence of varicose veins and chronic venous insufficiency in men and women in the general population: Edinburgh Vein Study. J Epidemiol Community Health. 1999;53(3):149–53.
  7. Beebe-Dimmer JL, Pfeifer JR, Engle JS, Schottenfeld D. The epidemiology of chronic venous insufficiency and varicose veins. Ann Epidemiol. 2005;15(3):175–84.
  8. Rabe E, Pannier-Fischer F, Bonner BK. Venenstudie der Deutschen Gesellschaft für Phlebologie.Epidemiologische Untersuchung zur Frage der Häufigkeit und Ausprägung von chronischen Venenkrankheiten in der städtischen und ländlichen Wohnbevölkerung. Phlebologie. 2003;32:1–14.
  9. Chiesa R, Marone EM, Limoni C, Volontè M, Petrini O. Chronic venous disorders: correlation between visible signs, symptoms, and presence of functional disease. J Vasc Surg. 2007;46(2):322–30.
  10. Eberhardt RT, Raffetto JD. Chronic venous insufficiency. Circulation. 2014;130(4):333–46.
  11. McCarthy WJ, Dann C, Pearce WH, Yao JS. Management of sudden profuse bleeding from varicose veins. Surgery. 1993;113(2):178–83.
  12. Guex JJ. Thrombotic complications of varicose veins. A literature review of the role of superficial venous thrombosis. Dermatol Surg. 1996;22(4):378–82.
  13. Bradbury A, Evans C, Allan P, Lee A, Ruckley CV, Fowkes FG. What are the symptoms of varicose veins? Edinburgh vein study cross sectional population survey. BMJ. 1999;318(7180):353–6.
  14. Wrona M, Jöckel KH, Pannier F, Bock E, Hoffmann B, Rabe E. Association of Venous Disorders with Leg Symptoms: Results from the Bonn Vein Study 1. Eur J Vasc Endovasc Surg. 2015;50(3):360–7.
  15. Van der Velden SK, Shadid NH, Nelemans PJ, Sommer A. How specific are venous symptoms for diagnosis of chronic venous disease? Phlebology. 2014;29(9):580–6.
  16. Goldmann MP, Guex J-J, Weiss RA. Sclerotherapy Treatment of Varicose and Teleangiectatic Leg Veins, in Sclerotherapy Treatment of Varicose and Teleangiectatic Leg Veins, S. Elsevier, Editor. 2011. p. 30–43.
  17. Smith JJ, Garratt AM, Guest M, Greenhalgh RM, Davies AH. Evaluating and improving health-related quality of life in patients with varicose veins. J Vasc Surg. 1999;30(4):710–9.
  18. Kaplan RM, Criqui MH, Denenberg JO, Bergan J, Fronek A. Quality of life in patients with chronic venous disease: San Diego population study. J Vasc Surg. 2003;37(5):1047–53.
  19. Darvall KA, Bate GR, Adam DJ, Bradbury AW. Generic health-related quality of life is significantly worse in varicose vein patients with lower limb symptoms independent of CEAP clinical grade. Eur J Vasc Endovasc Surg. 2012;44(3):341–4.
  20. Gandhi A, Froghi F, Shepherd AC, Shalhoub J, Lim CS, Gohel MS, et al. A study of patient satisfaction following endothermal ablation for varicose veins. Vasc Endovascular Surg. 2010;44(4):274–8.
  21. Michaels JA, Brazier JE, Campbell WB, MacIntyre JB, Palfreyman SJ, Ratcliffe J. Randomized clinical trial comparing surgery with conservative treatment for uncomplicated varicose veins. Br J Surg. 2006;93(2):175–81.
  22. Sam RC, MacKenzie RK, Paisley AM, Ruckley CV, Bradbury AW. The effect of superficial venous surgery on generic health-related quality of life. Eur J Vasc Endovasc Surg. 2004;28(3):253–6.
  23. Sam RC, Darvall KA, Adam DJ, Silverman SH, Bradbury AW. A comparison of the changes in generic quality of life after superficial venous surgery with those after laparoscopic cholecystectomy. J Vasc Surg. 2006;44(3):606–10.
  24. Marsden G, Perry M, Kelley K, Davies AH; Guideline Development Group. Diagnosis and management of varicose veins in the legs: summary of NICE guidance. BMJ. 2013;347:f4279.
  25. Cavezzi A, Labropoulos N, Partsch H, Ricci S, Caggiati A, Myers K, et al. Duplex ultrasound investigation of the veins in chronic venous disease of the lower limbs--UIP consensus document. Part II. Anatomy. Eur J Vasc Endovasc Surg. 2006;31(3):288–99.
  26. Coleridge-Smith P, Labropoulos N, Partsch H, Myers K, Nicolaides A, Cavezzi A. Duplex ultrasound investigation of the veins in chronic venous disease of the lower limbs--UIP consensus document. Part I. Basic principles. Eur J Vasc Endovasc Surg. 2006;31(1):83–92.
  27. Spinedi L, Broz P, Baldi T, Imfeld S, Staub D, Jaeger K, et al. Evaluation of Varicose Veins of the Lower Extremity: the Value of the Duplex Ultrasound (Part 1). Ultraschall Med. 2016;37(4):348–65.
  28. Wittens C, Davies AH, Bækgaard N, Broholm R, Cavezzi A, Chastanet S, et al.; European Society for Vascular Surgery. Editor’s Choice - Management of Chronic Venous Disease: Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg. 2015;49(6):678–737.
  29. Stirling M, Shortell CK. Endovascular treatment of varicose veins. Semin Vasc Surg. 2006;19(2):109–15.
  30. Malskat WS, Poluektova AA, van der Geld CW, Neumann HA, Weiss RA, Bruijninckx CM, et al. Endovenous laser ablation (EVLA): a review of mechanisms, modeling outcomes, and issues for debate. Lasers Med Sci. 2014;29(2):393–403.
  31. der Kinderen DJ, Disselhoff BC, Koten JW, de Bruin PC, Seldenrijk CA, Moll FL. Histopathologic studies of the below-the-knee great saphenous vein after endovenous laser ablation. Dermatol Surg. 2009;35(12):1985–8.
  32. Bush RG, Shamma HN, Hammond KA. 940-nm laser for treatment of saphenous insufficiency: histological analysis and long-term follow-up. Photomed Laser Surg. 2005;23(1):15–9.
  33. Doganci S, Demirkilic U. Comparison of 980 nm laser and bare-tip fibre with 1470 nm laser and radial fibre in the treatment of great saphenous vein varicosities: a prospective randomised clinical trial. Eur J Vasc Endovasc Surg. 2010;40(2):254–9.
  34. Schwarz T, von Hodenberg E, Furtwängler C, Rastan A, Zeller T, Neumann FJ. Endovenous laser ablation of varicose veins with the 1470-nm diode laser. J Vasc Surg. 2010;51(6):1474–8.
  35. Pannier F, Rabe E, Rits J, Kadiss A, Maurins U. Endovenous laser ablation of great saphenous veins using a 1470 nm diode laser and the radial fibre--follow-up after six months. Phlebology. 2011;26(1):35–9.
  36. von Hodenberg E, Zerweck C, Knittel M, Zeller T, Schwarz T. Endovenous laser ablation of varicose veins with the 1470 nm diode laser using a radial fiber - 1-year follow-up. Phlebology. 2015;30(2):86–90.
  37. Hirokawa M, Kurihara N. Comparison of Bare-Tip and Radial Fiber in Endovenous Laser Ablation with 1470 nm Diode Laser. Ann Vasc Dis. 2014;7(3):239–45.
  38. Ahn SH, Gill G, Prince EA, Soares G, Van Zandt B, Dubel G et al. Endovenous laser Ablation (EVLA) performed with 1470 nm laser: Long term outcomes and comparison with 980 nm laser [Abstract]. J Vasc Interv Radiol. 2013;24(S144): Abstract No. 333.
  39. Malskat WS, Giang J, De Maeseneer MG, Nijsten TE, van den Bos RR. Randomized clinical trial of 940- versus 1470-nm endovenous laser ablation for great saphenous vein incompetence. Br J Surg. 2016;103(3):192–8.
  40. Van Den Bos RR, Neumann M, De Roos KP, Nijsten T. Endovenous laser ablation-induced complications: review of the literature and new cases. Dermatol Surg. 2009;35(8):1206–14.
  41. Pavlović MD, Schuller-Petrović S, Pichot O, Rabe E, Maurins U, Morrison N, et al. Guidelines of the First International Consensus Conference on Endovenous Thermal Ablation for Varicose Vein Disease--ETAV Consensus Meeting 2012. Phlebology. 2015;30(4):257–73.
  42. van Eekeren RR, Boersma D, de Vries JP, Zeebregts CJ, Reijnen MM. Update of endovenous treatment modalities for insufficient saphenous veins--a review of literature. Semin Vasc Surg. 2014;27(2):118–36.
  43. Proebstle TM, Vago B, Alm J, Göckeritz O, Lebard C, Pichot O. Treatment of the incompetent great saphenous vein by endovenous radiofrequency powered segmental thermal ablation: first clinical experience. J Vasc Surg. 2008;47(1):151–6.
  44. Calcagno D, Rossi JA, Ha C. Effect of saphenous vein diameter on closure rate with ClosureFAST radiofrequency catheter. Vasc Endovascular Surg. 2009;43(6):567–70.
  45. Creton D, Pichot O, Sessa C, Proebstle TM; ClosureFast Europe Group. Radiofrequency-powered segmental thermal obliteration carried out with the ClosureFast procedure: results at 1 year. Ann Vasc Surg. 2010;24(3):360–6.
  46. Rasmussen LH, Lawaetz M, Bjoern L, Vennits B, Blemings A, Eklof B. Randomized clinical trial comparing endovenous laser ablation, radiofrequency ablation, foam sclerotherapy and surgical stripping for great saphenous varicose veins. Br J Surg. 2011;98(8):1079–87.
  47. Zuniga JM, Hingorani A, Ascher E, Shiferson A, Jung D, Jimenez R, et al. Short-term outcome analysis of radiofrequency ablation using ClosurePlus vs ClosureFast catheters in the treatment of incompetent great saphenous vein. J Vasc Surg. 2012;55(4):1048–51.
  48. Harlander-Locke M, Jimenez JC, Lawrence PF, Derubertis BG, Rigberg DA, Gelabert HA. Endovenous ablation with concomitant phlebectomy is a safe and effective method of treatment for symptomatic patients with axial reflux and large incompetent tributaries. J Vasc Surg. 2013;58(1):166–72.
  49. Tolva VS, Cireni LV, Bianchi PG, Lombardo A, Keller GC, Casana RM. Radiofrequency ablation of the great saphenous vein with the ClosureFAST™ procedure: mid-term experience on 400 patients from a single centre. Surg Today. 2013;43(7):741–4.
  50. Avery J, Kumar K, Thakur V, Thakur A. Radiofrequency ablation as first-line treatment of varicose veins. Am Surg. 2014;80(3):231–5.
  51. Merchant RF, Pichot O; Closure Study Group. Long-term outcomes of endovenous radiofrequency obliteration of saphenous reflux as a treatment for superficial venous insufficiency. J Vasc Surg. 2005;42(3):502–9, discussion 509.
  52. Proebstle TM, Alm BJ, Göckeritz O, Wenzel C, Noppeney T, Lebard C, et al. Five-year results from the prospective European multicentre cohort study on radiofrequency segmental thermal ablation for incompetent great saphenous veins. Br J Surg. 2015;102(3):212–8.
  53. van den Bos RR, Milleret R, Neumann M, Nijsten T. Proof-of-principle study of steam ablation as novel thermal therapy for saphenous varicose veins. J Vasc Surg. 2011;53(1):181–6.
  54. Milleret R, Huot L, Nicolini P, Creton D, Roux AS, Decullier E, et al. Great saphenous vein ablation with steam injection: results of a multicentre study. Eur J Vasc Endovasc Surg. 2013;45(4):391–6.
  55. Jia X, Mowatt G, Burr JM, Cassar K, Cook J, Fraser C. Systematic review of foam sclerotherapy for varicose veins. Br J Surg. 2007;94(8):925–36.
  56. Rabe E, Breu FX, Cavezzi A, Coleridge Smith P, Frullini A, Gillet JL, et al.; Guideline Group. European guidelines for sclerotherapy in chronic venous disorders. Phlebology. 2014;29(6):338–54.
  57. Biemans AA, Kockaert M, Akkersdijk GP, van den Bos RR, de Maeseneer MG, Cuypers P, et al. Comparing endovenous laser ablation, foam sclerotherapy, and conventional surgery for great saphenous varicose veins. J Vasc Surg. 2013;58(3):727–34.e1.
  58. Mueller RL, Raines JK. ClariVein mechanochemical ablation: background and procedural details. Vasc Endovascular Surg. 2013;47(3):195–206.
  59. van Eekeren RR, Hillebrands JL, van der Sloot K, de Vries JP, Zeebregts CJ, Reijnen MM. Histological observations one year after mechanochemical endovenous ablation of the great saphenous vein. J Endovasc Ther. 2014;21(3):429–33.
  60. Tal MG, Dos Santos SJ, Marano JP, Whiteley MS. Histologic findings after mechanochemical ablation in a caprine model with use of ClariVein. J Vasc Surg Venous Lymphat Disord. 2015;3(1):81–5.
  61. Bishawi M, Bernstein R, Boter M, Draughn D, Gould CF, Hamilton C, et al. Mechanochemical ablation in patients with chronic venous disease: a prospective multicenter report. Phlebology. 2014;29(6):397–400.
  62. van Eekeren RRJP, Boersma D, Holewijn S, Werson DA, de Vries JP, Reijnen MM. Mechanochemical endovenous ablation for the treatment of great saphenous vein insufficiency. J Vasc Surg Venous Lymphat Disord. 2014;2(3):282–8.
  63. Vun SV, Rashid ST, Blest NC, Spark JI. Lower pain and faster treatment with mechanico-chemical endovenous ablation using ClariVein®. Phlebology. 2015;30(10):688–92.
  64. Linfante I, Wakhloo AK. Brain aneurysms and arteriovenous malformations: advancements and emerging treatments in endovascular embolization. Stroke. 2007;38(4):1411–7.
  65. Almeida JI, Javier JJ, Mackay E, Bautista C, Proebstle TM. First human use of cyanoacrylate adhesive for treatment of saphenous vein incompetence. J Vasc Surg Venous Lymphat Disord. 2013;1(2):174–80.
  66. Proebstle T, et al. Twelve-month follow-up of the European multicenter study on cyanoacrylate embolization of incompetent great saphenous veins. J Vasc Surg Venous Lymphat Disord. 2014;2:105–6.
  67. Morrison N, Gibson K, McEnroe S, Goldman M, King T, Weiss R, et al. Randomized trial comparing cyanoacrylate embolization and radiofrequency ablation for incompetent great saphenous veins (VeClose). J Vasc Surg. 2015;61(4):985–94.

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