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[Guideline 'Diagnosis and treatment of varicose veins']
Cees H A Wittens1, Kees-Peter de Roos, Th A A Ted van den Broek
1HagaZiekenhuis, locatie Leyenburg, afd. Algemene Heelkunde, Den Haag, The Netherlands. tvdbroek@wlz.nl
Insights
The Dutch guideline simplifies varicose vein diagnosis by focusing on the CEAP clinical classification. Traditional tests are omitted for C2-C3 varicose veins, with duplex ultrasound recommended before invasive treatments.
Area of Science:
- Vascular Surgery
- Phlebology
- Medical Guidelines
Background:
- Current diagnostic and treatment protocols for varicose veins require optimization.
- The CEAP classification provides a standardized framework for assessing venous disease severity.
- Traditional diagnostic tests may lack utility in specific varicose vein classifications.
Purpose of the Study:
- To outline updated recommendations for the diagnosis and treatment of varicose veins based on the CEAP classification.
- To streamline diagnostic procedures by identifying and omitting superfluous tests.
- To establish evidence-based treatment standards for different stages of varicose vein disease.
Main Methods:
- Adoption of the CEAP clinical classification ('C') in patient records.
- Discontinuation of Trendelenburg and Perthes tests for C2 and C3 varicose veins.
- Utilization of handheld Doppler for initial reflux assessment in C1-C3 veins.
- Mandatory duplex investigation of superficial and deep venous systems before invasive treatment for C2-C3 varicose veins.
Main Results:
- Handheld Doppler is sufficient for reflux exclusion in primary C1-C3 varicose veins; duplex is indicated if reflux is found or in doubt.
- Functional investigations like plethysmography and intravenous pressure measurement are deemed unnecessary for C2-C3 varicose veins.
- Stripping with side branch interruption is the gold standard for insufficient greater saphenous veins (C2-C3).
- Endovenous techniques (radiofrequency ablation, laser) show comparable efficacy to stripping for C2-C3 varicose veins.
- Insufficient perforating veins in C2-C3 patients do not require specific treatment.
- Pre-operative duplex marking of the lesser saphenous vein's entry into the popliteal vein is crucial.
- Hook needle extraction is the preferred method for treating side branches.
Conclusions:
- The Dutch guideline emphasizes a streamlined approach to varicose vein diagnosis and treatment.
- Duplex ultrasound is essential for invasive treatment planning in C2-C3 varicose veins.
- Both traditional and endovenous techniques are effective, with specific indications for each.
- Management strategies are tailored to the CEAP classification, improving diagnostic accuracy and treatment efficiency.
Abstract:
The Dutch guideline on the diagnosis and treatment of varicose veins recommends that the 'C' from the North American Venous Forum classification CEAP ('C' = clinical, 'E' = aetiological, 'A' = anatomical, and 'P' = pathophysiological classification ) be recorded in the clinical case notes and that traditional tests as described by Trendelenburg and Perthes be omitted as they are of no use in patients with C2 and C3 varicose veins. In primary C1, C2 and C3 varicose veins that have not previously been treated, a handheld Doppler may be used to exclude reflux. If reflux is found or if in doubt, duplex investigation is necessary. Before any invasive treatment of C2 or C3 varicose veins is scheduled, duplex investigation of the superficial and deep systems is mandatory. In C2 and C3 varicose veins functional investigations such as plethysmography and intravenous pressure measurement are superfluous. With respect to treatment of an insufficient greater saphenous vein, stripping from knee to groin with side branch interruption in the groin is the gold standard in the treatment of C2 and C3 varicose veins. Endovenous techniques such as radio frequency ablation or laser are comparable with the classical stripping method in the treatment of C2 and C3 varicose veins. Insufficient perforating C2 or C3 veins in these patients need no specific treatment. Prior to surgery the entrance level of the lesser saphenous vein into the popliteal vein should be marked with the patient lying in supine position and with the aid of duplex. For patients with side-branches hook needle extraction through mini- incisions is the treatment of choice.
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