A Systematic Review Supporting the Society for Vascular Surgery, the American Venous Forum and the American Vein and Lymphatic Society Guidelines on the Management of Varicose Veins.

Abstract

BACKGROUND\nSeveral diagnostic tests and treatment options for patients with lower extremities varicose veins have existed for decades. The purpose of this systematic review was to summarize the latest evidence of the diagnostic and treatments options to support the forthcoming updates of the clinical practice guidelines on the management of varicose veins for the Society for Vascular Surgery (SVS), the American Venous Forum (AVF) and the American Vein and Lymphatic Society (AVLS).\n\n\nMETHODS\nWe searched multiple databases for studies that addressed four clinical questions identified by the AVF and the SVS guideline committee about evaluating and treating patients with varicose veins. Studies were selected and appraised by pairs of independent reviewers. Meta-analysis was conducted when feasible.\n\n\nRESULTS\nWe included 73 original studies (45 were randomized controlled trials) and one systematic review from 12,915 candidate references. Moderate certainty of evidence supported the utility of duplex ultrasound (DU) as the gold standard test for diagnosing saphenous vein incompetence in patients with varicose veins and chronic venous insufficiency (CEAP class C2 - C6). High ligation and stripping (HL&S) was associated with higher anatomic closure rates at 30 days and five years when compared to radiofrequency ablation (RFA) and Ultrasound-guided foam sclerotherapy (UGFS) (moderate to high certainty), while no significant difference was seen when compared to endovenous laser ablation (EVLA) at five years. UGFS was associated with an increased risk of recurrence compared to HL&S. EVLA was associated with lower anatomic closure rates at 30 days than cyanoacrylate closure (CAC) and higher rates at one and five years when compared to UGFS. Compared to non-thermal interventions, thermal interventions were associated with lower generic quality of life (QoL) scores and an increased risk of adverse events compared to CAC or N-butyl cyanoacrylate (NBCA) (low certainty). Thermal interventions were associated with a lower risk of recurrent incompetence when compared to UGFS and an increased risk of recurrent incompetence than CAC. The evidence for great saphenous vein (GSV) ablation alone to manage perforator disease was inconclusive.\n\n\nCONCLUSION\nThe current systematic review summarizes the evidence to develop and support forthcoming updated SVS/AVF/AVLS clinical practice guideline recommendations. The evidence supports duplex scanning for evaluating patients with varicose veins and confirms that HL&S resulted in similar long-term saphenous vein closure rates as EVLA and in better rates than RFA and UGFS. Thermal interventions were associated with inferior generic quality of life scores than non-thermal interventions but had a lower risk of recurrent incompetence than UGFS. The recommendations in the guidelines should consider this information as well as other factors such as patients values and preferences, anatomical considerations of individual patients, and surgical expertise.