A Review of the Current Management and Treatment Optionsfor Superficial Venous Insufficiency

Henry T. Zhan • Ruth L. Bush

� Societe Internationale de Chirurgie 2014

Abstract The recognition of lower extremity venous

disease as a significant cause of morbidity and lower

quality of life, afflicting up to 25 % of Western popula-

tions, has led to rapid and drastic improvements in treat-

ment options as well as an increasing awareness of the

disease. Superficial venous disease, a frequent medical

problem encountered in clinical practices, is now a com-

mon reason for referral to providers offering a spectrum of

interventions. Venous guidelines have been set forth by the

American Venous Forum and Society for Vascular Surgery

covering simple spider veins to chronic venous ulcerations.

(Gloviczki et al. J Vas Surg 53:2S–48S, 2011) This review

provides an overview of the modern management of vari-

cose veins and venous insufficiency.

Introduction

In the USA, lower extremity superficial venous disease and

varicose veins are common medical conditions, seen in

15 % of men and 30 % of women. Symptomatic lower

extremity varicose veins are associated with standing

vocations, leg injury and/or surgery, familial tendency, and

pregnancy in females [1–3]. The natural history of venous

disease is progression over time, with worsening symp-

tomatology and possible complications such as superficial

and deep thrombophlebitis, discomfort, disability, and

ulcer formation [4]. In a US national screening program

sponsored by the American Venous Forum, over 2,000

individuals were studied at various sites in 40 states. In this

study, 19 % of participants screened were found to have

more severe stages of venous disease (C3–C6; Table 1) [5].

In a population-based European study, a marked dis-

parity was shown to exist across participating countries,

particularly represented by the lower numbers of patients

with CEAP (clinical–etiologic–anatomic–pathophysio-

logic) clinical class 2 disease in the UK, Finland, and

Sweden compared with in the USA [6–8]. Various differ-

ences were also found in the prevalence of lower extremity

venous disease as well as in the predicted number of

indicated procedures with the actual numbers of interven-

tions being performed. Marked differences with the USA in

venous epidemiology and risk factors were also found in

this study. For example, in Finland, varicose veins have an

association with family history in both sexes, and tend to

be more strongly associated with arterial disease, not

hypertension as is seen in the USA [6, 7]. Economically,

venous disorders also cost medical systems a significant

amount, with an estimated cost in excess of $US 1 billion

per year in the USA [9].

The number of interventions performed for venous dis-

ease has recently increased due to several factors. Refined

diagnostic techniques and technological advances have

resulted in less invasive treatments being provided to

patients and with excellent outcomes. Diagnostically,

venous Duplex ultrasound mapping is an effective and

specific tool used for the identification of affected veins in

both the deep and the superficial systems (See Fig. 1). It is

important to know and remember that reflux may not only

be occurring at a superficial to deep junction, such as the

sapheno-femoral junction, but rather segmentally or via a

Presented at to the Finnish Vascular Society for International Surgical

Week 2013, Helsinki, Finland

H. T. Zhan � R. L. Bush (&)

Texas A&M Health Science Center, MS 1359, 8447 State

Highway 47, HPEB 3064, Bryan, TX 77807-3260, USA

e-mail: doctor66ruth@sbcglobal.net;

rbush@medicine.tamhsc.edu

123

World J Surg

DOI 10.1007/s00268-014-2621-0

perforating vein from the deep venous system. Further-

more, it has the ability to quantify the degree of venous

reflux and insufficiency via color flow methodology.

Additionally, the emergence of catheter-based procedures,

i.e. endovenous thermal ablation, as an alternative to tra-

ditional venous high ligation and stripping (LS) has

allowed for cross-specialty performance and a multidisci-

plinary approach. Even so, all of these factors have com-

bined with increased public awareness and demand from

the general patient population, resulting in an explosion in

the number of venous interventions, especially superficial

venous procedures. Finally, recognition of the medical

necessity and disability associated with venous insuffi-

ciency as well as increased reimbursement rates in the USA

by third-party payers have contributed to the increased

performance of venous interventions.

Amidst this increased demand, it is important to set

realistic expectations and treatment goals with patients.

While treatments are effective and recovery is expeditious,

complications, as well as recurrences or new varicosities,

are common. The patient must be informed of the possible

complications and shortcomings of interventions. Further-

more, insurance companies often require an initial 6-week–

6-month trial of conservative therapy prior to authorization

of payment for a venous procedure. There exists much data

in the literature concerning technical aspects and efficacy

of various treatments for superficial venous disease, thus,

each practitioner should be familiar with the literature as

well as with published reporting standards set forth by the

American Venous Forum and Society for Vascular Surgery

[9].

Risk factors associated with venous disease

Due to the high prevalence of venous disease, many risk

factors have been extensively studied as to their implica-

tion in causation. Epidemiological and population-based

studies have often found female gender and advanced age

to be positive risk factors [2, 3, 10]. The strongest associ-

ation has been found in those with a positive family history

of venous disease. Other significant risk factors include

obesity (particularly in women), deep venous thrombosis

and post-phlebitic syndrome, non-Hispanic White race, and

occupations/vocations that require prolonged standing or

walking. Multiparity has also been found to slightly

increase the risk of varicose vein development in women,

as does a history of leg injury. Interestingly, in the San

Diego Population study, frequent exercise was found to be

protective for the development of superficial venous reflux

in men but not in women [2].

Specific treatments

The long-established first-line treatment is conservative

management consisting of leg elevation, weight loss, and

Table 1 Percent distribution of participants (n = 2,234) with the

highest CEAP classification for chronic venous disease

Classification Distribution (%)

C0 (no CVD) 29

C1 (telangiectasias) 29

C2 (varicose veins) 23

C3 (edema) 10

C4 (skin changes) 7

C5 (healed ulcer) 1.5

C6 (ulcer) 0.5

CEAP clinical–etiologic–anatomic–pathophysiologic, CVD chronic

venous disease

Reprinted from McLafferty et al. [5] with permission from Elsevier

Fig. 1 Patterns of superficial

venous reflux in the great

saphenous vein. Prevalence of

each pattern is indicated as a

percentage in the figure.

Reprinted from Engelhorn CA

et al. [57] with permission from

Elsevier

World J Surg

123

inexpensive over-the-counter analgesics [11]. Elastic

graduated compression stockings are commonly employed

for temporary symptomatic relief. These stockings reduce

the venous diameter, thus decreasing swelling and

increasing antegrade venous blood flow. The stockings

come in a variety of graduated strengths, lengths, and

fabric weights. For patients with active venous ulcers, a

multilayer compression dressing or ‘Unna boot’ can be

used. One layer of the compression commonly contains a

medication such as zinc oxide with or without calamine

lotion formulation, and the other layers provide compres-

sion and absorption. These treatments are effective, with up

to 73 % healing in patients who consistently comply with

the wraps [11]. However, studies have shown that com-

pliance among patients is low due to discomfort and

inconvenience [11–13]. More importantly, with conserva-

tive treatment alone, the underlying pathophysiology, such

as obstruction and/or reflux, has not been addressed [13].

Conventional surgical treatment

Traditionally, axial venous reflux disorders have been

surgically treated with great saphenous vein (GSV) ligation

with and without GSV stripping, GSV and tributary strip-

ping, stab avulsion phlebectomy, perforator surgery (Lin-

ton procedure), and equivalent small saphenous vein (SSV)

treatment. These treatments were generally reserved for

patients with the most severe symptoms due to the pre-

requisite 2- to 6-week recovery period. The complication

profile is broad, including bruising, hematoma, infection,

scarring, and nerve paresthesias [14]. Furthermore, up to

20 % of patients develop recurrent varicosities at 5 years,

and 24 % may require additional treatment for symptoms

[15]. Patients often report low post-operative quality of life

(QOL) due to prolonged recovery time, cosmetic issues,

and high recurrence rates [4, 16, 17].

Endovenous ablation techniques

Following its introduction in the early 2000s, endovenous

ablation using either radiofrequency (RFA) or laser energy

has now replaced stripping as the standard of care for the

treatment of axial venous reflux. Endovenous therapy

offers rapid recovery times and established high success

rates [9, 17–22]. Current endothermal venous ablation

treatment options all share the common goal of addressing

the underlying pathophysiology of venous reflux and/or

obstruction without disfigurement of the patient. The sur-

geon may then add various adjunctive procedures to this

modality as indicated by the individual patient, such as

phlebectomies or sclerotherapy, or even iliac stent

placement in those with deep venous narrowing or

obstruction [23, 24].

For axial vein obliteration, ultrasound-guided foam

sclerotherapy (UGFS) is increasingly being used and

becoming more and more popular [25–27]. This technique,

along with endovenous ablation, with the same expected

end result, has been well described in the literature [28]. A

recent, prospective, randomized trial compared endovenous

ablation with either RFA or laser (endovenous laser ther-

apy [EVLT]), UGFS, and surgical stripping [29]. In this

study, 500 patients were randomized to one of four treat-

ment groups. All vein ablation modalities were efficacious

in eliminating the refluxing vein segment, and patients had

similar satisfaction rates. However, more venous recanali-

zation and the need for repeat procedures were seen after

UGFS. Regardless of the modality chosen, to achieve the

best possible outcome, as with any interventional treat-

ment, one must use accurate diagnosis, form an appropriate

treatment plan, and set realistic expectations with the

patient.

In the performance of endovenous ablation, an ultra-

sound-guided catheter equipped with either RFA or a laser

energy source is used to obliterate the length of the

saphenous vein, effectively denaturing the collagen, initi-

ating venous thrombosis, and eventually venous closure

(Figs. 2, 3). In a prospective randomized study comparing

RFA versus LS of the GSV, patients who received RFA

had significantly shorter recovery times (1.15 vs.

3.89 days) [30]. Notably, of those who received RFA

performed with only local anesthesia (n = 30), 33 % were

able to return to normal physical activity on the same day

as the procedure. Functional outcomes were described

using the venous clinical severity score. These were fol-

lowed throughout the study visits and showed a drop in

severity score between the first week visit and third month

visit; this benefit persisted throughout the follow-up period.

Furthermore, QOL follow-up surveys showed significant

early advantages in favor of RFA over LS. In another study

performed by Proebstle et al. [22], a European multicenter

prospective trial showed RFA to be feasible, safe, and

beneficial, with a venous occlusion rate of 99.6 % at the

6-month follow-up visit. The follow-up visit at 36 months

revealed results of 92.6 % occlusion, 95.7 % reflux free,

and 95.7 % pain free. In the same year, the ClosureFast�

(Covidien Inc., VNUS Medical) 4-year data were presented

[31], which involved eight European and five American

centers. In this study, 201 patients or 262 limbs were

treated with RFA. At the 4-year follow-up, 93.2 % of the

patients were reflux free, and their CEAP classification had

decreased from their baseline level. Similar to Proebstle

et al. [22], this study had a low complication profile. The

relatively minor complications included ecchymosis

(5.3 %), paresthesia (4 %), skin pigmentation (3 %),

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erythema (2.3 %), and phlebitis (1.5 %), but only pares-

thesia and phlebitis occurred during 3- and 4-year follow-

up.

Many have studied various factors that may be associ-

ated with the infrequent but existent anatomical failure that

may follow endothermal ablation [22, 31, 32]. Technically,

EVLT has been associated with a lower venous closure rate

when lower laser fluence (joules/cm) rates are employed.

Proebstle et al. [33] performed a short-term study utilizing

higher laser energy rates and had a 100 % immediate

success rate and a low number of recanalizations at 1-year

follow-up. This technique must be balanced with a possible

increase in complications due to histologic microperfora-

tions that may be seen [34]. Interestingly, both Dietzek [31]

and Eidson et al. [32] found that body mass index, a GSV

with multiple tributaries and secondary varicosities, as well

as a longer treatment segment of GSV are associated with

anatomic failure. The major question still remains as to

whether or not anatomic failure, or recanalization, can be

used as a surrogate marker for clinical failure. Many

investigators have acknowledged a \5 % recanalization

rate at 6–12 months; however, the majority of the patients

did not have recurrent symptoms.

Similar to RFA, EVLT also offers high success rates in

treating venous disease. Min et al. [35] used 810 nm laser

to treat 499 GSVs in 423 subjects in a 3-year single-center

prospective study. In this review, 490 GSVs were suc-

cessfully occluded (98.2 %) without complications of

paresthesia, skin burns, or cases of deep vein thrombosis.

However, bruising occurred in 24 % of the patients and

phlebitis in 5 %. Interestingly, tumescent anesthesia, when

used effectively, was found to reduce heat-related com-

plications. In this study, the recurrence rate at 2 years was

\7 %. Limited research has been published on UGFS, but

recent closure rates at 6 months have been reported to be

88 % [36].

RFA, EVLT, and UGFS, which will not be discussed

further in this review, can all be performed in an outpatient

setting utilizing either tumescent or local anesthesia. Both

RFA and EVLT require a capital outlay for equipment and

disposables, which may be a barrier for their adoption.

RFA is performed in 7-cm segments in a short sheath with

no wire guidance. In contrast, EVLT requires a long sheath,

Fig. 2 Ultrasound guided access of great saphenous vein (courtesy of Dr. John Kaufman and Dr. Eric Hohenwalter)

Fig. 3 Peri-venous injection of tumescent solution as seen in

transverse ultrasound image (courtesy of Dr. John Kaufman and Dr.

Eric Hohenwalter). Arrow points to hyperechoic shadow of the

endovenous catheter. Tumescent anesthetic fluid surrounding cen-

trally located great saphenous vein and endovenous catheter

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a guide wire, and careful gauging of the speed and energy

delivered. Although no statistical difference has been seen

in multiple studies between EVLT and RFA in either

venous occlusion or complication rates, RFA has been

shown to be superior to laser in recovery time and QOL

measure in the short term [18, 37].

Complications of endothermal ablation

Reported complications of endovenous thermal ablation,

regardless of energy source, include bleeding with possible

hematoma formation, hyperpigmentation, scarring, super-

ficial thrombophlebitis, nerve injury or irritation, deep

venous thrombosis, infection, blistering, and skin necrosis

[34, 38–40]. With refinement in technique over the past

decade, more severe complications are rarely seen.

Bleeding and hematomas are typically not extensive, often

localized to the surgical site. The same is true for super-

ficial thrombophlebitis of remaining venous tributaries.

Anticoagulants that patients may be receiving for other

medical conditions may exacerbate bleeding, but post-

operation compression treatment continued for up to 72 h

is beneficial to minimize ecchymosis, hematoma forma-

tion, and superficial venous thrombophlebitis. Procedural

discomfort, while it can be treated pharmacologically with

anxiolytics and topical lidocaine, is alleviated by enhanc-

ing the patient’s peri-operative comfort with soft soothing

music and warm blankets. Both the setting of realistic

expectations with the patient and proceeding slowly during

the surgery while maintaining effective and clear channels

of communication will also reduce the patient’s anxiety.

This can easily be accomplished by performing a thorough

pre-operative assessment of the patient’s apprehension

level as well as their perceived level of tolerance for pain.

Thigh skin hyperpigmentation developing along the

course of the saphenous vein is another complication that

can be disconcerting for unsuspecting patients. This is

especially true for those seeking cosmetic improvement

from venous disease and/or varicose veins. For such

patients, it may be best to avoid endothermal ablation by

performing a high ligation of the GSV with phlebectomy of

the remaining vessels. Skin hyperpigmentation may be

treated with topical bleaching creams (e.g. hydroquinone

4 %) used over an extended period of time. Risks of heat-

related complications can be further reduced by infusion of

tumescent anesthesia with the addition of 50 mg of meth-

ylprednisolone per 500 ml [17].

Endothermal heat-induced thrombus (EHIT) is a more

serious heat-related complication that requires immediate

attention, especially when it propagates into the common

femoral vein (Table 2; Fig. 4) [41–44]. The thrombus

typically regresses within 7–10 days, during which serial

ultrasound scanning should be carried out to assess for clot

propagation. To prevent EHIT, intraoperative low-mole-

cular-weight-heparin or other heparinoid of 2,500 or 5,000

units may be administered. There are no data to support

prophylactic use of anticoagulation in decreasing the

incidence of EHIT [44]. A recent study found on multi-

variate analysis that male gender and an increased Caprini

thrombosis risk factor assessment score were the only

factors predictive for EHIT following endothermal ablation

[44]. If the post-procedure ultrasound scan detects throm-

bus protrusion into the common femoral vein, the patient

should be placed on subcutaneous heparinoid with follow-

up scans at 1–2 weeks. Again, a thorough patient history,

along with proper patient education and documentation

will assist in reducing complications.

Venous ulcerations

For patients with advanced chronic venous insufficiency

(CVI) with skin ulcerations, the overall goal, in addition to

addressing venous reflux, is to treat venous incompetency,

thus reducing venous hypertension [45]. In order to ensure

that a patient’s skin ulcers on the lower extremities are due

to venous disease, the pulse and the ankle-brachial index

(ABI) are key determinants for a venous disease workup

after a complete history and physical plus wound assess-

ment and vascular exam (Fig. 5). The absence of a palpable

pedal pulse, in conjunction with an ABI \ 0.9 indicates an

arterial problem. However, if the ABI is[0.9 with palpable

pulses, other clinical signs of venous disease should be

present to differentiate venous disease from other etiolo-

gies. If the patient presents with chronic typical venous

symptoms of limb swelling, varicosity, cramping, aches,

heaviness, etc., venous duplex mapping should then be

performed to evaluate both the deep and the superficial

venous system to isolate the incompetent vein for

treatment.

CVI can be treated with compression alone or with LS

surgery. Lurie et al. [30, 46] found in the prospective,

randomized, multicenter study EVOLVeS that, despite the

Table 2 Classification system for endovenous heat-induced

thrombosis

Class Thrombus extension (from superficial vein)

1 Venous thrombosis in close proximity to superficial-deep

venous junction

2 Non-occlusive venous thrombosis with extension beyond

junction with cross-sectional diameter of \50 %

3 Non-occlusive venous thrombosis with extension beyond

junction with cross-sectional diameter of [50 %

4 Occlusive deep venous thrombosis

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equal healing rates of 65 %, the recurrence rate at

12 months for the surgery group was 50 % lower. These

results persisted at 4 years (31 vs. 55 % compared with

compression alone) [11, 30, 45, 46].

Incompetent perforator veins

Subfascial endoscopic perforator surgery (SEPS) was the first

step in the evolution of modern management of incompetent

perforating veins. This technique was introduced in the late

1980s by Hauer et al. [47] SEPS employs laparoscopic

equipment, similar to that used by general surgeons, and uses

the posterior stocking seam approach to access distal sites.

Early results demonstrated distinct advantages over the tra-

ditional open surgical ligation of perforators (Linton proce-

dure [48]), particularly a reduction in post-operative

complications and length of hospital stay. However, there are

many technical disadvantages of SPES, specifically, as one

moves distally, the subfascial space becomes increasingly

limited, correspondingly limiting the necessary dissection. In

addition, wound infection, notwithstanding the patient popu-

lation, is a notable complication of SEPS.

Despite the advancement of SEPS to using less invasive

endoscopic equipment, perforator vein ablation remains a

controversial treatment option for CVI, as results may be

confounded by concomitant GSV treatment [49–52]. While

the role of perforator veins in CVI is still not fully understood,

Fig. 4 Endovenous heat-

induced thrombosis class 1.

Note thrombosis extension from

great saphenous vein through

sapheno-femoral junction

(courtesy of Dr. Ruth L. Bush).

GSV great saphenous vein

Complete History and Physical Include Wound Assessment & Vascular Exam

Pulses Present and ABI > 0.9

No Signs of Venous Disease

Non-Arterial or Non-Venous Ulcer:

Search for Wound Etiology

Pulses Palpable and ABI > 0.9

Signs of Venous Disease

Venous Duplex Mapping

Diagnose for Incompetent GSV, SSV & IPV

Endovenous ablation of all vessels above found to be

incompetent: GSV, SSV & IPVs

Pulses Absent or non-palbable or ABI < 0.9

Initiate Normal Arterial Workup

as Priority

Fig. 5 Treatment algorithm for

patients with venous disease.

ABI ankle brachial index, GSV

great saphenous vein, IPV

incompetent perforator vein,

SSV small saphenous vein

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it is generally agreed to be important in advanced CVI as the

pattern of reflux is important in determining the perforator

vein contribution.

Marrocco et al. [20] found that RFA therapy, including that

of the perforating veins, produced outstanding ulcer healing

rates and satisfactory recurrent ulcer rates, but the treatment of

perforating veins in addition to GSV ablation did not yield

results differing from GSV ablation alone. More recently,

Harlander-Locke et al. [45, 53] found that healing time for

venous ulcers decreased, with 76 % of ulcers healed at

6 months post-operation, and that the recurrence rates for

ulcers decreased to 0 % at 6 months and 4.8 % at 12 months

compared with 67 % with compression therapy only. More-

over, Rueda et al. [54] concluded that perforator ablation is

beneficial irrespective of whether or not concomitant proce-

dures are performed. Retrospectively, positive prognostic

indicators of ulcers healing include smaller size, longer

duration, decreased use of walking aids, and presence of reflux

in deep veins and the popliteal vein.

Ambulatory phlebectomy

The modern method of ambulatory microphlebectomy is

largely due to the influence of Robert Muller, who designed

the first phlebectomy hooks [55]. The contemporary hooks

minimize incision size to a few millimeters. Often,

ambulatory phlebectomy may be performed at the same

time as endovenous ablation in the outpatient setting under

local anesthesia. Complications include hyperpigmenta-

tion, neovascularization, and tattooing.

Alternative phlebectomy techniques include combined

transillumination and tumescent anesthesia (TriVex, LeMai-

tre Vascular Inc., Burlington, MA, USA) [24, 56]. The veins

are visualized beneath the skin with a light source providing

subcutaneous illumination, and a second handle contains a

resector that mechanically extracts the veins. Use of this

instrumentation, which is a vein-extraction device, requires

deep sedation, spinal, or general anesthesia for maximal

patient comfort. Early complications with this technique were

mostly related to hematoma formation and fat necrosis at the

resection site. Modification of techniques since its introduc-

tion in 2000 has decreased the complications from transillu-

minated powered phlebectomy. The various technical

alterations include lower oscillation frequency, secondary

tumescence with the addition of dermal punch (1.5 mm)

drainage holes, and a subdermal tumescence stage.

Conclusions

Clearly, awareness and diagnosis of venous disease has

increased over the past several years. It is now regarded as

a major source of morbidity in affected patients. Treat-

ments have rapidly evolved and improved, thus offering

providers and patients effective options with excellent

outcomes. Working within a multidisciplinary team

involving wound care specialists, early referrals to vein

centers, and relocation of procedures into the outpatient

clinic setting have all positively impacted patient care.

Providers with successful phlebology practices are astute at

diagnostic techniques, familiar with patterns of venous

disease, and offer a wide variety of treatment options.

Disclosures Dr. Bush is a consultant and proctor for Covidien, Inc.

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