Editing Varicose veins (section)

== Treatment options ==

* No treatment
* Conservative (compression)
** Generally done as a trial first step for patients in CEAP2-4 (20-30mm Hg) or CEAP6 (30-40mm Hg)
** ESCHAR trial - compression is comparable to compression plus ligation + stripping of the GSV in CEAP6 disease, but ulcer recurrence is much lower with surgery
* Surgery
** Rationale and treatment approach:
*** Goal is to close refluxing superficial veins
*** Treat most proximal point of reflux first - ''most'' (50-70% of patients) have SFJ incompetence, and one study found 85% with VV have GSV reflux and 20% SSV
*** Remove diseased segments but leave normal functioning veins behind - not necessary to treat normal or atretic sections of GSV
*** Use the least invasive technique possible - start with RFA and step up if necessary
*** Need to remove as many superficial varicosities as possible - if left behind, even after GSV ligation +/- stripping, they can drain by alternate pathways and persist.
*** GSV disease: RCTs have shown benefit to surgery over conservative management. Early post-operative advantage in pain for endovenous ablation, but no long-term difference.
**** Indications for GSV surgery as opposed to EVA:
***** Superficial saphenous tributary (risks skin burns unless 1cm between vein and skin)
***** GSV dilation or aneurysmal venous segments >2.5cm (the probe won't ablate properly because it won't contact the vein walls)
***** Chronic thrombophlebitis (prevents advancement of catheter)
***** Excessive tortuosity (can't advance)
***** Acute superficial thrombophlebitis (EVA contraindicated in any vein with acute thrombus)
*** SSV disease: EVA is probably effective, but concern persists over potential for thermal injury to popliteal neurovascular structures.
*** Reticular veins/telangiectasias: sclerotherapy - controversial whether this treatment should happen simultaneously with primary VV treatment
** Endovenous
***
*** RFA:
**** Segmental ablation - catheter contacts vein wall and delivers radiofrequency energy, resulting in destruction of endothelium, contraction of vein wall collagen, and thrombus formation. Eventually fibrosis occurs, resulting in a durable ablation.
**** Contraindications:
***** SVT
***** DVT
***** Venous aneurysm
***** ABI < 0.9
***** Pacemaker - needs assessment by cardiologist prior
**** Results
***** 74% had improved CEAP at 36 months
***** 93% had continued occlusion of treated truncal veins at 3 years
*** Sclerotherapy
**** Introduction of a chemical into a vein to induce endothelial damage that results in thrombosis and eventually fibrosis.
**** Indications
***** Most often used to treat smaller vessels such as reticular veins and telangiectasias
**** Relative contraindications
***** Asthma
***** Late complications of diabetes
***** Hypercoagulable state
***** Leg oedema
***** Advanced PAD
***** Bad CKD
**** Absolute contraindications
***** Known allergy
***** Acute cellulitis
***** Acute respiratory or skin disease
***** Severe systemic disease
***** Phlebitis migrans
***** Acute superficial thrombophlebitis
***** Pregnancy
***** Hyperthyroidism
***** Bedridden status
** Surgical



[[Category:Vascular]]