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ACP guidelines

ACP publishes superficial venous disease guidelines

The guidelines incorporate the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to evaluate the efficacy of treatments

The American College of Phlebology (ACP) has released revised guidelines for the treatment of superficial venous disease of the lower leg. Combining the comprehensive 2011 review by Peter Gloviczki et al with current studies, the ACP’s consensus of experts prepared a guidelines document, which reflects evidenced-based recommendations and standards of care.

The guidelines incorporate the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to evaluate the efficacy of treatments. CEAP and VCSS are also employed to introduce the concept of “medically significant venous insufficiency,” in order to eliminate confusion around “cosmetic” or “not medically necessary” treatments.

According to the ACP, the ‘Summary of Guidelines for Treatment of Venous Disease Indications for Treatment Compression’ therapy is an effective method for the management of symptoms related to superficial disease but it does not correct the source of reflux. When patients have a correctable source of reflux definitive treatment should also be offered unless it is contraindicated or unwanted. GRADE 1A).

They recommend against compression therapy as a pre-requisite therapy for symptomatic venous reflux disease when other definitive treatments such as endovenous ablation are appropriate (GRADE 1A).

After interventional treatment, they recommend the use of a compression garment in the postoperative period.  There is extra benefit to the patient in the form of reduced pain after use of compression.  The compression dosage and duration is at the discretion and clinical judgment of the treating physician (GRADE 2B).

They also recommend that patients with this disease be counselled to wear a compression garment even after definite treatment has been provided. The compression dosage is at the discretion and clinical judgment of the treating physician (GRADE  2C).

The recommendations suggest the treatment of some CEAP C2 patients with isolated varices, by medical compression hose alone may be an acceptable form of treatment.  A short 1-2 week trial of compression hose may be appropriate where an alternative aetiology of symptoms is considered, eg. musculoskeletal pain or neuropathy eg. spinal stenosis, sciatica, hip or knee arthritis, diabetic neuropathy etc (GRADE 2C).

Indications for treatment include pain or other discomfort (ie, aching, heaviness, fatigue, soreness, burning), enema, varix haemorrhage, recurrent superficial phlebitis, stasis dermatitis or ulceration.

They recommend patients should be evaluated using the CEAP classification and the Venous Clinical Severity Score (VCSS) and define medically necessary as a CEAP classification of C2 or higher (GRADE 1A)

In addition, the paper recommends all patients being considered for treatment must have a duplex ultrasound of the superficial venous system and, at a minimum, evaluation of the common femoral vein and popliteal vein for patency and competence. The exam should ideally be done in the standing position (GRADE 1A).

They also suggest all non-invasive vascular diagnostic studies be per formed by a qualified physician or by a qualified technologist under the general supervision of a qualified physician (GRADE 1C).

The recommendations states that named veins (Great Saphenous Vein (GSV),  Small Saphenous Vein (SSV),  Anterior Accessory of the Great Saphenous Vein (AAGSV), Posterior Accessory of the Great Saphenous Vein (PAGSV ), Intersaphenous Vein (Vein of Giacomini)) must have a reflux time > 500 msec, regardless of the reported vein diameter (GRADE 1A).

When treating named saphenous veins, the guidelines recommend that endovenous thermal ablation (laser and radiofrequency) is the preferred treatment for saphenous and accessory saphenous (GSV, SSV, AAGSV, PAGSV) vein incompetence (GRADE 1B).

The guidelines suggest mechanical/chemical ablation (Clarivein Device) may also be used to treat truncal venous reflux (GRADE 2B).

Open surgery

Open surgery is appropriate in veins not amenable to endovenous procedures but otherwise is not recommended because of increased pain, convalescent time, and morbidity (GRADE 1B). When open surgery of the great saphenous vein is performed it should include high ligation and invagination stripping to the level of the knee (GRADE 2B). For open surgery of the small saphenous vein is performed it include high ligation and selective invagination of the proximal portion (GRADE 1B).

Treatment of Circumflex Veins and Other Non-Truncal Veins The treatment of other non-truncal, tributary varicose vein reflux (circumflex veins anterior and posterior thigh) is more complex. The medical record should reflect that these veins are incompetent and note their size, presence or absence of tortuosity, and depth relationship to the skin, i.e. accessible or not accessible by phlebectomy.

They recommend varicose (visible) symptomatic tributary veins can be treated by stab phlebectomy, liquid sclerotherapy or foam chemical ablation (GRADE 1B).

For (non-visible) symptomatic tributary veins, treatment by ultrasound-guided liquid sclerotherapy or foam chemical ablation (GRADE 1B).

When treating incompetent perforating veins located beneath a healed or open venous ulcer, the guidelines recommend outward flow of 500ms, with a diameter of 3.5mm (GRADE 2B).

In patients with perforator reflux as the primary or only source of disease, treatment of the perforator with endovenous thermal ablation, ligation or ultrasound guided sclerotherapy is recommended. Subsequent or simultaneous treatment of symptomatic varicosities arising from the incompetent perforator is also considered best practice (GRADE 2B).

To access the guidelines, please click here