Evidence-Based Summary of Guidelines From the Society for Vascular Surgery and the American Venous Forum

Abstract

Abstract This chapter summarizes the most important current guidelines on evaluation and management of patients with chronic venous disease adopted by our two major vascular societies, SVS and AVF. The best evidence is usually provided by systematic reviews and meta-analyses of prospective randomized trials. The approach developed by the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) working group has been adopted by the Society for Vascular Surgery and the American Venous Forum in developing practice guidelines. Evaluation of the patient with venous disease should include a thorough history, focusing on the underlying etiology (congenital, primary, or secondary), symptoms, and risk factors for venous disease. Duplex ultrasonography, including an evaluation of reflux in the upright position, should be the initial diagnostic test in patients with suspected venous disease. Compression is considered first-line therapy for chronic venous disorders. A systematic review of 44 randomized, placebo-controlled trials evaluating oral phlebotonics suggested efficacy for some signs such as edema, although the global evidence for their efficacy was insufficient to recommend routine use. During the past 2 decades, an array of endovenous techniques have emerged and have largely replaced high ligation and stripping for the management of saphenous vein reflux. The potential value of interruption of pathologic perforators (>3.5\xa0mm, reflux ≥ 0.5 second, located near the ulcer bed) in C5–C6 disease cannot be excluded. Because of lack of controlled prospective studies, the quality of evidence to support iliac vein stenting remains weak.