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BMJ Clin Evid. 2007; 2007: 0212.
Published online 2007 October 18.
PMCID: PMC2943819

Varicose veins

Paul Vincent Tisi, MS, FRCSEd(Gen.Surg), Consultant Vascular Surgeon

Key Points

Varicose veins are considered to be enlarged tortuous superficial veins of the leg.

  • Varicose veins are caused by poorly functioning valves in the veins, and decreased elasticity of the vein wall, allowing pooling of blood within the veins, and their subsequent enlargement.
  • Varicose veins affect up to 40% of adults and are more common in obese people, and in women who have had more than two pregnancies.

Compression stockings are often used as first-line treatment for varicose veins, but we don't know whether they reduce symptoms compared with no treatment.

Injection sclerotherapy may be more effective than compression stockings, but less effective than surgery, at improving symptoms and cosmetic appearance.

  • We don't know which sclerotherapy agent is the best to use.

Surgery (saphenofemoral ligation,stripping of the long saphenous vein, oravulsion) is likely to be beneficial in reducing recurrence, and improving cosmetic appearance, compared with sclerotherapy alone.

  • We don't know whether stripping the long saphenous vein after saphenofemoral ligation improves outcomes compared with avulsion alone after ligation, or what the best method is for vein stripping.
  • Powered phlebectomy may be as effective as avulsion, but may cause pain, bruising, and discolouration.
  • We don't know whether radiofrequency ablation or self help are effective in people with varicose veins.

About this condition

Definition

Although we found no consistent definition of varicose veins,it is commonly taken to mean enlarged tortuous subcutaneous veins. Any vein may become varicose, but the term "varicose veins" conventionally applies to the superficial veins of the leg, which may appear green, dark blue, or purple in colour. The condition is caused by poorly functioning (incompetent) valves within the veins and decreased elasticity of the vein walls, which allow de-oxygenated blood to be pumped back to the heart, and to flow backward and pool in the superficial veins, causing them to enlarge and become varicose. This often occurs in the saphenofemoral and saphenopopliteal junctions, and in the perforating veins that connect the deep and superficial venous systems along the length of the leg. The presence or absence of reflux caused by venous incompetence can be determined by clinical examination, handheld Doppler, or duplex ultrasound. Symptoms of varicose veins include pain, itching, limb heaviness, cramps, and distress about cosmetic appearance, although most lower limb symptoms may have a non-venous cause. This review focuses on uncomplicated, symptomatic varicose veins. We have excluded treatments for chronic venous ulceration and other complications. We have also excluded studies that solely examine treatments for small, dilated veins in the skin of the leg, known as thread veins, spider veins, or superficial telangiectasia.

Incidence/ Prevalence

One large US cohort study found the biannual incidence of varicose veins was 3% in women and 2% in men. The prevalence of varicose veins in Western populations was estimated in one study to be about 25-30% in women and 10-20% in men. However, a recent Scottish cohort study has found a higher prevalence of varices of the saphenous trunks and their main branches in men than in women (40% men v 32% women).Other epidemiological studies have shown prevalence rates ranging from 1% to 40% in men, and 1% to 73% in women.

Aetiology/ Risk factors

One cohort study found that parity with three or more births was an independent risk factor for development of varicose veins. A further large case control study found that women with two or more pregnancies were at increased risk of varicose veins, compared with women with one or no pregnancies (RR about 1.2-1.3 after adjustment for age, height, and weight). It found that obesity was also a risk factor, although only in women (RR about 1.3). One narrative systematic review found insufficient evidence on the effects of other suggested risk factors, including genetic predisposition, prolonged sitting or standing, tight undergarments, low fibre diet, constipation, deep vein thrombosis, and smoking.However, a large Danish population study found that prolonged standing or walking at work was an independent predictor of the need for varicose vein treatment.

Prognosis

We found no reliable data on prognosis, or on the frequency of complications, which include chronic inflammation of affected veins (phlebitis), venous ulceration, and bleeding rupture of varices.

Aims of intervention

To reduce symptoms, improve appearance, and prevent recurrence and complications, with minimal adverse effects.

Outcomes

Symptoms, including pain, ache, itching, heaviness, cramps, and cosmetic distress or cosmetic appearance (self or physician rated); quality of life; recurrence rates; complications of treatment, including haematoma formation; pigmentation; ulceration; superficial thrombophlebitis; and deep venous and pulmonary thromboembolism. Re-treatment rates were considered only if other outcomes were unavailable, and are described only in the comments sections.

Methods

BMJ Clinical Evidence search and appraisal May 2007. The following databases were used to identify studies for this systematic review: Medline 1966 to May 2007, Embase 1980 to May 2007, and The Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Clinical Trials 2007, Issue 2. Additional searches were carried out using these websites: NHS Centre for Reviews and Dissemination (CRD) — for Database of Abstracts of Reviews of Effects (DARE) and Health Technology Assessment (HTA), Turning Research into Practice (TRIP), and National Institute for Health and Clinical Excellence (NICE). We also searched for retractions of studies included in the review. Abstracts of the studies retrieved from the initial search were assessed by an information specialist. Selected studies were then sent to the author for additional assessment, using pre-determined criteria to identify relevant studies. Study design criteria for inclusion in this review were: published systematic reviews and RCTs in any language, at least single blinded, and containing more than 20 individuals of whom more than 80% were followed up. There was no minimum length of follow-up required to include studies. We excluded all studies described as "open", "open label", or not blinded unless blinding was impossible. In addition we use a regular surveillance protocol to capture harms alerts from organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA), which are added to the reviews as required.

Glossary

Avulsion
(phlebectomy) Used to treat multiple varicosities after saphenofemoral or saphenopopliteal ligation or in people with perforator incompetence. Small incisions are made in the skin overlying each varicosity and the affected vein interrupted or excised using either a vein hook or forceps.
Cryostripping
(cryosurgery) Involves introducing a cryoprobe into the long saphenous vein following saphenofemoral ligation.The probe is cooled to –85 °C using NO2 or CO2. This causes the vein to freeze to the probe and this is then removed, stripping the vein.
Ecchymosis
This is a small, rounded or irregular blue or purple patch caused by a small haemorrhage in the skin or mucous membrane.
Foam sclerotherapy
A new technique in which a standard sclerosant is mixed with air to create a foam. This is then injected into the varicosities under ultrasound guidance.
Ligation
Involves tying off a vein close to the site of incompetence to prevent blood flowing from the deep to the superficial system.
Long saphenous vein
is also known as great saphenous vein.
Powered phlebectomy
Involves infiltrating subcutaneous tissues with a saline solution containing local anaesthetic (lidocaine) and dilute epinephrine (adrenaline). A mechanical device is then introduced. This has a blade that rotates at 800–1000 rpm, destroying the varicose vein. Vein fragments are removed by suction connected to the device.
Radiofrequency ablation
A new technique involving the introduction of a catheter into the greater or lesser saphenous vein under ultrasound guidance. This delivers radiofrequency energy which heats the saphenous vein, thereby sealing the lumen.
Sclerosant
An injected solution which displaces blood from the vein, causing inflammation of the vein wall and occlusion. Commonly used sclerosants include sodium tetradecyl sulphate (sotradecol) and polidocanol (also called aetoxysclerol, aethoxysclerol, aethoxyskerol, or hydroxypolyaethoxydodecan).
Short saphenous vein
is also know as lesser saphenous vein.
Stripping
A wire, plastic, or metal rod is passed through the lumen of the saphenous vein and is used to strip the entire vein out of the leg. This disconnects any superficial veins from the deep venous system. Inversion stripping is a newer technique where the vein is inverted upon itself after stripping.
Telangiectasia
Dilated superficial blood vessels in the skin. This is often synonymous with the term “thread veins” or “spider veins”.
Urticaria
(hives) is the presence of itchy, raised patches of skin (wheals), which may be due to certain foods or drugs, as well as other factors including stress. The condition may be acute or chronic.

Notes

Disclaimer

The information contained in this publication is intended for medical professionals. Categories presented in Clinical Evidence indicate a judgement about the strength of the evidence available to our contributors prior to publication and the relevant importance of benefit and harms. We rely on our contributors to confirm the accuracy of the information presented and to adhere to describe accepted practices. Readers should be aware that professionals in the field may have different opinions. Because of this and regular advances in medical research we strongly recommend that readers' independently verify specified treatments and drugs including manufacturers' guidance. Also, the categories do not indicate whether a particular treatment is generally appropriate or whether it is suitable for a particular individual. Ultimately it is the readers' responsibility to make their own professional judgements, so to appropriately advise and treat their patients.To the fullest extent permitted by law, BMJ Publishing Group Limited and its editors are not responsible for any losses, injury or damage caused to any person or property (including under contract, by negligence, products liability or otherwise) whether they be direct or indirect, special, incidental or consequential, resulting from the application of the information in this publication.

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2007; 2007: 0212.
Published online 2007 October 18.

Compression stockings

Summary

One crossover RCT found no significant difference in symptoms between compression stockings for 4 weeks and no treatment in people with varicose veins. However, the study might have lacked power to detect clinically important effects. One systematic review found that, in pregnant women with varicose veins, sodium tetradecyl sulphate sclerotherapy improved symptoms and cosmetic appearance of varicose veins compared with compression stockings after 6–24 months.

Benefits

Compression stockings versus no treatment:

We found one crossover RCT (72 people aged under 65 years with two or more of the following symptoms: pain, heaviness, itching, night cramps, swelling, or cosmetic distress). People with a history of deep vein thrombosis were excluded. The study did not specify the sites of venous incompetence. It compared four treatments: a pharmacological agent (O-[beta-hydroxyethyl]-rutoside, 1 g/day orally), placebo alone, stockings plus placebo, and stockings plus the drug. Stockings were fitted to apply a pressure of 30–40 mm Hg to each ankle. Each treatment was given for 4 weeks before crossover to another treatment. The trial found no significant difference between stockings plus placebo and placebo alone for any symptom scores after each treatment (analysis not by intention to treat; 6 people excluded from analysis; symptom scores measured on 100-point visual analogue scale [high score = more severe]; pain: mean score 35 with stockings v 38 with placebo; P = 0.06; heaviness: 34 with stockings v 36 with placebo; P = 0.39; itching: 32 with stockings v 31 with placebo; P = 0.56; swelling: 28 with stockings v 35 with placebo; P = 0.13; night cramps: 22 with stockings v 25 with placebo; P = 0.24; cosmetic distress: 43 with stockings v 41 with placebo; P = 0.43). The RCT might have lacked power to detect clinically important effects.

Compression stockings versus injection sclerotherapy:

See benefits of injection sclerotherapy.

Compression stockings versus surgery:

See benefits of surgery.

Harms

The RCT did not report on the harms of compression stockings.

Comment

Compression stockings versus no treatment:

The RCT did not report whether investigators were blinded to treatment allocation. Reliability of results may be reduced because previous treatments might have continued to have effects, even after crossover. The study did not report the duration of any washout period, which might have reduced such an effect between treatment periods.

Clinical guide:

Compression stockings are often used as first-line treatment for varicose veins in primary care. There is no good evidence that this is beneficial. Further RCTs are unlikely to be undertaken.

Substantive changes

No new evidence

2007; 2007: 0212.
Published online 2007 October 18.

Injection sclerotherapy

Summary

One systematic review found no RCTs that compared injection sclerotherapy versus no treatment or conservative treatment. One subsequent RCT found that injection sclerotherapy reduced aching and cosmetic concerns, but not heaviness, itching, or swelling compared with conservative treatment after one year. One RCT identified by a systematic review found that, in pregnant women with varicose veins, sodium tetradecyl sulphate sclerotherapy improved symptoms and cosmetic appearance of varicose veins compared with compression stockings after 6–24 months. One RCT found no significant difference between sclerotherapy using polidocanol and using sodium tetradecyl sulphate for improving the appearance of varicose veins at 16 weeks. One RCT found that polidocanol plus sodium tetradecyl sulphate improved symptoms and reduced oedema compared with polidocanol or sodium tetradecyl sulphate alone. One RCT reported a similar incidence of new varicose veins at 5 or 10 years with standard-dose conventional sclerotherapy, high-dose conventional sclerotherapy, and foam sclerotherapy. One systematic review found that injection sclerotherapy alone was less effective than surgery (avulsion, stripping, ligation with or without sclerotherapy) in reducing varicose vein recurrence, and improving cosmetic appearance. One RCT found that saphenofemoral ligation plus foam sclerotherapy reduced time to return to normal activity, and improved quality of life compared with saphenofemoral ligation plus stripping plus avulsions.

Benefits

Injection sclerotherapy versus no treatment or conservative treatment:

We found one systematic review and one subsequent RCT. The systematic review (search date 2006) identified no RCTs . The subsequent RCT (34 participants with minor below knee varicose veins without reflux, but with symptoms of aching or cosmetic concerns) compared injection sclerotherapy with STD versus conservative treatment. The conservative treatment included advice on wearing support stockings, exercise, ideal weight, and effects of work and pregancy on varicose veins. The injection sclerotherapy was followed by compression using foam pads and a class II graduated compression stocking or bandage all the way up the leg from the foot. The RCT found that injection sclerotherapy significantly reduced the proportion of people reporting aching and cosmetic concerns compared with conservative treatment after one year (aching: 69% with sclerotherapy v 28% with conservative treatment; P less than 0.05 and cosmetic concerns: 84% with sclerotherapy v 14% with conservative treatment; P less than 0.05). The RCT found no significant difference between injection sclerotherapy and conservative treatment in reduction of heaviness, itching, or swelling at one year (heaviness: 84% with sclerotherapy v 43% with conservative treatment; itching: 84% with sclerotherapy v 50% with conservative treatment; swelling: 84% with sclerotherapy v 57% with conservative treatment; P values reported as not significant).

Injection sclerotherapy versus compression stockings:

One systematic review (search date 2002) found one RCT (101 pregnant women with primary or recurrent varicose veins), which compared sclerotherapy using sodium tetradecyl sulphate versus compression stockings. It found that sclerotherapy significantly improved symptoms and cosmetic appearance compared with compression stockings after 6–24 months (improved symptoms and cosmetic appearance: 43/44 [98%] with sclerotherapy v 17/28 [61%] with compression stockings; RR 1.61, 95% CI 1.19 to 2.18).

Injection sclerotherapy versus surgery:

We found one systematic review (search date 2004, 6 RCTs) and one subsequent RCT comparing sclerotherapy versus surgery. The review did not conduct a meta-analysis of the results of the RCTs because of heterogeneity of the data. The first RCT identified by the review (164 people with symptomatic primary varicose veins, aged 21–65 years) compared injection sclerotherapy (polidocanol 30 mg/mL; 0.5–0.75 mL injected into each varicosity, repeated after 1–2 weeks if required) versus surgery. Participants were allocated to treatments without regard to site of venous incompetence (53 legs with saphenofemoral or saphenopopliteal incompetence alone; 97 legs with saphenofemoral or saphenopopliteal incompetence combined with perforator incompetence; 17 legs with perforator incompetence only). Among people allocated to surgery, the surgical technique depended on the site of venous incompetence (see comment below). The RCT found that surgery increased the proportion of people who were free of varicose veins at 5 years compared with injection sclerotherapy (AR for freedom from varicose vein at 5 years: 3% with sclerotherapy v 55% with surgery; significance not reported; see comment below). The second RCT identified by the review (249 people with varicose veins, but no prior treatment, aged 15–64 years) compared injection sclerotherapy versus surgery. The study did not specify the proportions of people with saphenofemoral, saphenopopliteal, or perforator incompetence. The extent and type of surgery depended on the site of venous incompetence (see comment below). The trial did not report on symptoms, quality of life, or recurrence (see comment below). The third RCT identified by the review (82 people aged over 18 years) compared sclerotherapy (3% polidocanol; repeat treatments at 2 or 4 weeks, or both, as necessary) versus avulsion under local anaesthetic. People with saphenofemoral or deep venous incompetence were excluded. Sclerotherapy was significantly less effective in reducing recurrence at 1 and 2 years compared with avulsion (AR for recurrence at 1 year: 25% with sclerotherapy v 2% with avulsion; RR 12, 95% CI 1.62 to 88.7; AR for recurrence at 2 years: 38% with sclerotherapy v 2% with avulsion; RR 18, 95% CI 2.5 to 129.5). The fourth RCT identified by the review (887 people with long saphenous vein incompetence, with or without perforator incompetence; see above) compared six treatments: standard-dose conventional sclerotherapy (148 people); high-dose conventional sclerotherapy (136 people); foam sclerotherapy (150 people); ligation (155 people); stab avulsion (144 people); and combined ligation and high-dose conventional sclerotherapy (154 people). Avulsion or ligation with or without sclerotherapy reduced the incidence of new varicose veins at 5 and 10 years compared with sclerotherapy alone, although it was not clear whether differences were significant (AR for new varicose veins at 5 years: 48% with standard-dose sclerotherapy v 41% with high-dose sclerotherapy v 44% with foam sclerotherapy v 34% with ligation v 40% with stab avulsion v 37% with ligation plus sclerotherapy; AR for new varicose veins at 10 years: 56% standard-dose sclerotherapy v 49% high-dose sclerotherapy v 51% foam sclerotherapy v 38% ligation v 41% stab avulsion v 37% ligation plus sclerotherapy; significance not reported for any outcome). The fifth RCT identified by the review (516 people with primary varicose veins) compared three treatments: conventional long or short saphenous surgery under general anaesthetic (161 people); local anaesthetic ligation of the saphenofemoral or saphenopopliteal junctions followed by injection sclerotherapy (165 people); and injection sclerotherapy with 3% aethoxysklerol (137 people). It found that conventional surgery significantly improved objective outcomes (appearance of varicose veins, as judged by the surgeon) and subjective outcomes (appearance of varicose veins, as judged by the participant) compared with ligation plus sclerotherapy at 3 years (P less than 0.0005). It also found that ligation plus sclerotherapy significantly improved objective and subjective outcomes compared with sclerotherapy alone at 3 years (P less than 0.0005). The sixth RCT identified by the review (156 people with primary long saphenous vein incompetence, 181 limbs) compared ligation plus stripping of the long saphenous vein to the ankle (78 people, 89 limbs) versus ligation plus sclerotherapy using 1% aethoxysklerol (78 people, 92 limbs). It found that ligation plus stripping significantly improved both subjective cosmetic appearance (as judged by the participant) and objective cosmetic appearance (as judged by the surgeon) compared with ligation plus sclerotherapy at 3 years (subjective improvement: 72% with surgery v 54% with sclerotherapy; P less than 0.05; objective improvement: 61% with surgery v 39% with sclerotherapy; P less than 0.05).

Injection sclerotherapy plus saphaphemoral ligation versus saphenofemoral ligation plus stripping plus avulsion:

We found one RCT comparing local anaesthetic saphenofemoral ligation combined with ultrasound guided foam sclerotherapy versus saphenofemoral ligation plus stripping plus avulsion. It found that ligation plus foam sclerotherapy significantly reduced time to return to normal activity compared with ligation plus stripping plus avulsions (60 people with primary long saphenous varicose veins; median time to return to normal activity: 2 days with ligation plus sclerotherapy v 8 days with ligation plus stripping plus avulsions; P less than 0.001). At 3 months ligation plus foam sclerotherapy significantly improved quality of life compared with ligation plus stripping plus avulsions (assessed using the Aberdeen Varicose Vein Questionnaire [higher score = worse quality of life]; decrease in median score: 46% with ligation plus sclerotherapy v 40% with ligation plus stripping plus avulsions; P less than 0.001).

Different types of sclerosant:

See glossary. One systematic review (search date 2002) found no RCTs reporting clinical outcomes in people with varicose veins. We found two subsequent RCTs. The first subsequent RCT (87 people with a total of 109 varicose veins; 55 veins 1–3 mm diameter; 54 veins 3–6 mm diameter) excluded people with saphenofemoral or saphenopopliteal incompetence. Each vein, rather than each person, was randomly allocated to injection sclerotherapy with either polidocanol or sodium tetradecyl sulphate. The strength of solution depended on the size of the vein being treated (veins 1–3 mm diameter: polidocanol 1% or sodium tetradecyl sulphate 0.5%; veins 3–6 mm diameter: polidocanol 3% or sodium tetradecyl sulphate 2%). The RCT found no significant difference between polidocanol and sodium tetradecyl sulphate in change in photographic appearance of either size group of veins 16 weeks after treatment (scale of 1–5 [1 = worse than pretreatment photograph; 5 = complete disappearance]; mean score for veins 1–3 mm diameter: 4.6 with sodium tetradecyl sulphate v 4.4 with polidocanol; P = 0.83; mean score for veins 3–6  mm diameter: 4.5 with sodium tetradecyl sulphate v 4.7 with polidocanol; P = 0.58). The second subsequent RCT (1622 people) compared three treatments: polidocanol, sodium tetradecyl sulphate, and polidocanol plus sodium tetradecyl sulphate. It found that more people taking polidocanol plus sodium tetradecyl sulphate had improved symptoms (night cramps, pains, fatigue, and heaviness) and that fewer people had oedema compared with polidocanol or sodium tetradecyl sulphate alone, at 5 years (symptoms: 211/306 [69%] with polidocanol v 277/380 [73%] with sodium tetradecyl sulphate v 180/228 [79%] with polidocanol plus sodium tetradecyl sulphate; significance not reported; oedema: 185/304 [61%] with polidocanol v 123/152 [64%] with sodium tetradecyl sulphate v 27/36 [74%] with polidocanol plus sodium tetradecyl sulphate; significance not reported).

Foam sclerotherapy versus conventional sclerotherapy:

We found two RCTs. The first RCT (887 people with uncomplicated varicose veins and long saphenous vein incompetence, with or without perforator incompetence) compared six treatment arms: standard-dose conventional sclerotherapy (1–2 mL 2% or 3% sodium tetradecyl sulphate according to vein calibre, with 2–3 weeks' compression after sclerotherapy); high-dose conventional sclerotherapy (3–6 mL 3% sodium tetradecyl sulphate, with 1–2 weeks' compression); foam sclerotherapy (foaming agent plus 3% sodium tetradecyl sulphate); ligation; stab avulsion; and ligation plus sclerotherapy. The RCT found that the incidence of new varicose veins was similar with foam sclerotherapy, standard-dose conventional sclerotherapy, and high-dose conventional sclerotherapy at 5 and 10 years (AR for new veins at 5 years: 48% with standard-dose sclerotherapy v 41% with high-dose sclerotherapy v 44% with foam sclerotherapy; AR for new veins at 10 years: 56% with standard-dose sclerotherapy v 49% with high-dose sclerotherapy v 51% with foam sclerotherapy; significance not reported). The second RCT (88 people with long saphenous vein incompetence) compared sclerotherapy with 3% polidocanol foam versus 3% polidocanol liquid. The RCT did not report on clinical outcomes other than harms (see harms below).

Harms

Injection sclerotherapy versus no treatment or conservative treatment:

The subsequent RCT found that more people receiving scleropathy than conservative treatment had phlebitis (2/13 [15%] with sclerotherapy v 1/15 [7%] with conservative treatment; P value not reported). The RCT also reported staining in 6/13 [46%] of the sclerotherapy group. One person [8%] receiving injection scleropathy reported blistering at the injection site.

Injection sclerotherapy versus compression stockings:

The systematic review gave no information on adverse effects.

Injection sclerotherapy versus surgery:

The first RCT identified by the review reported postoperative wound infection in 6% and symptoms of sural or saphenous nerve injury in 10% of surgically treated participants (rates not reported in the sclerotherapy group). Five people (proportion not reported) in the sclerotherapy group had migratory thrombophlebitis and 28% developed haematoma (rates not reported for surgical group). Duration of sick leave was greater with surgery than with sclerotherapy (mean duration 20 days with surgery v 1 day with sclerotherapy; significance not reported). One person in the surgical arm had a symptomatic pulmonary embolism that resolved without complications. No thromboembolic events occurred in the sclerotherapy group. The second RCT reported that one person in the surgically treated group had severe bronchospasm under anaesthetic. The 5-year follow-up to this study reported that during surgery one person had a myocardial infarction and one person had a pulmonary embolus. The third RCT found no significant difference in phlebitis between avulsion and sclerotherapy at 2 weeks (12% with avulsion v 27% with sclerotherapy; P = 0.07). Sclerotherapy reduced telangiectasia (thread veins) at 2 years compared with avulsion (6% with avulsion v 0% with sclerotherapy; P = 0.039). The fourth RCT did not discuss harms. The fifth RCT reported one pulmonary embolus with conventional surgery (significance not reported). There was no significant difference between treatments in minor complication rates (details of complications not reported; stated as not significant; P value not reported). The sixth RCT found saphenous nerve injury in 27 limbs (33%) with surgery compared with 0% with sclerotherapy (significance not reported). The subsequent RCT found no difference in early complication rates between ligation plus foam sclerotherapy and ligation plus stripping and avulsions (7/30 [23%] in both groups; difference reported as not significant). At 3 months, five people in the ligation plus foam sclerotherapy group (17%) had resolving skin pigmentation, whereas three (10%) had had an episode of thrombophlebitis. Three people (9%) in the ligation plus stripping plus avulsions group had evidence of saphenous nerve injury, and one person (3%) had a skin ulcer (statistical assessments for complications at 3 months not performed).

Different types of sclerosant:

The first subsequent RCT only reported local reactions. It found that both treatments were associated with similar rates of ecchymosis (70% of veins treated with sodium tetradecyl sulphate v 58% with polidocanol), hyperpigmentation (64% with sodium tetradecyl sulphate v 53% with polidocanol), and thrombosis (46% with sodium tetradecyl sulphate v 42% with polidocanol; significance not reported for any comparison). Polidocanol reduced local urticaria and skin necrosis compared with sodium tetradecyl sulphate (skin necrosis 7% with sodium tetradecyl sulphate v 0% with polidocanol; urticaria 36% with sodium tetradecyl sulphate v 23% with polidocanol; significance not reported). The second subsequent RCT found that sodium tetradecyl sulphate caused more local necrosis, hyperpigmentation and telangiectasia compared with polidocanol or polidocanol plus sodium tetradecyl sulphate combination treatment (absolute figures and significance data for the between group comparison not reported).

Foam sclerotherapy versus conventional sclerotherapy:

The first RCT did not discuss harms. The second RCT found similar rates of skin inflammation with polidocanol foam and with polidocanol liquid (2/45 [4%] with foam v 3/43 [7%] with liquid; P value not reported).

Comment

Injection sclerotherapy versus no treatment or conservative treatment:

The conservative treatment group in the subsequent RCT included advising participants to consider wearing grade I to III support stockings. It is not clear how many participants did this.

Injection sclerotherapy versus surgery:

The effects of surgery versus injection sclerotherapy or other treatments may vary according to the sites of venous incompetence. Some RCTs included in the systematic review failed to report the relative effects with regard to sites of venous incompetence. Only two out of nine RCTs included in the systematic review were judged by the review to be of sufficient quality. In the surgical groups of the first two RCTs, varicose veins from saphenofemoral or saphenopopliteal incompetence were treated by ligation and stripping, whereas incompetent perforator veins were treated by avulsion. The first RCT did not report whether the investigators were blinded to treatment allocation. It was also not clear whether analysis was by intention to treat. The subsequent RCT found that four people (13%) in the ligation plus foam sclerotherapy group needed a repeat treatment to deal with residual varicose veins.

Different types of sclerosant:

The first subsequent RCT also included a further 42 people with telangiectasia (veins less than 1 mm diameter). These were excluded from the results.

Clinical guide:

There is little evidence for the use of (liquid) injection sclerotherapy in treatment of symptomatic varicose veins with demonstrated reflux. Most clinicians would consider using this as an adjunctive treatment to other procedures, for example for residual varicose veins following surgery. RCTs of foam sclerotherapy versus surgery are feasible and should be undertaken.

Substantive changes

Injection sclerotherapy One RCT added, which found that injection sclerotherapy reduced aching and cosmetic concerns, but not heaviness, itching or swelling compared with conservative treatment after one year.Categorisation unchanged (Unknown effectiveness).

2007; 2007: 0212.
Published online 2007 October 18.

Surgery (avulsion)

Summary

We found no RCTs comparing avulsion versus no treatment or compression stockings. There is consensus that avulsion is likely to be beneficial for the treatment of varicose veins. One systematic review found that surgery (avulsion, stripping, saphafemoral ligation with or without sclerotherapy) reduced varicose vein recurrence, and improved cosmetic appearance compared with injection sclerotherapy alone. One subsequent RCT found that saphenofemoral ligation plus foam sclerotherapy reduced time to return to normal activity, and improved quality of life compared with saphenofemoral ligation plus stripping plus avulsion. We found inconclusive results from two RCTs that compared avulsion plus stripping of the long saphenous vein to the knee versus avulsion alone, following ligation. The first RCT found that avulsion of the long saphenous vein to the knee increased clinical recurrence, and decreased participant satisfaction compared with avulsion plus stripping. The second RCT found no significant difference between avulsion and avulsion plus stripping in recurrence or participant satisfaction at 5 years. A further RCT found that avulsion alone decreased pain and bruising compared with stripping alone after 1 week. However, it found no significant difference between treatments in daily activity scores at 1 week. One RCT found no significant difference between avulsion and powered phlebectomy in pain at 8 days, or in participant satisfaction or cosmetic appearance at 6 weeks. It also found no significant difference between treatments in nerve injury or severe bruising after 2 weeks.

Benefits

Avulsion versus no treatment:

We found no RCTs that compared surgery versus no treatment.

Avulsion versus compression stockings:

We found no RCTs that compared surgery versus compression stockings.

Avulsion versus injection sclerotherapy:

See benefits of injection sclerotherapy.

Avulsion plus stripping versus avulsion alone:

We found two RCTs that compared avulsion plus stripping of the long saphenous vein to the knee following saphenofemoral ligation versus avulsion of the long saphenous vein alone following ligation. The first RCT (69 people, 89 legs randomised, followed up for a median of 21 months) found that avulsion plus stripping to the knee significantly decreased clinical recurrence and significantly increased participant satisfaction compared with avulsion alone (clinical recurrence: 28/43 [65%] with avulsion plus stripping v 8/46 [17%] with avulsion; P less than 0.001; proportion of legs rated as “successfully treated”: 28/43 [65%] with avulsion plus stripping v 17/46 [37%] with avulsion; P less than 0.05). The second RCT (100 people randomised, 133 legs treated) found no significant difference between treatments in recurrence or participant satisfaction at 5 years (legs free of recurrence: 32/52 [61%] with avulsion plus stripping v 28/58 [48%] with avulsion; RR 1.28, 95% CI 0.91 to 1.82; participants “satisfied”: 35/39 [90%] with avulsion plus stripping v 30/39 [77%] with avulsion; RR 1.17, 95% CI 0.95 to 1.42).. The second RCT had later results published in a subsequent paper although the follow-up of 51% falls below our inclusion limit. The extension of the second RCT found no significant difference between avulsion plus stripping and avulsion alone in recurrence of varicose veins after 11 years (absolute numbers not reported; P value reported as not significant.)

Avulsion versus powered phlebectomy:

See benefits of powered phlebectomy.

Harms

Surgery versus no treatment:

We found no RCTs.

Surgery versus compression stockings:

We found no RCTs.

Surgery versus injection sclerotherapy:

See harms of injection sclerotherapy.

Avulsion plus stripping versus avulsion:

The RCTs did not report on harms.

Stripping versus sequential avulsion:

See harms of stripping.

Avulsion versus powered phlebectomy:

See harms of powered phlebectomy.

Comment

Avulsion versus injection sclerotherapy:

See comment under injection sclerotherapy.

Clinical guide:

Most clinicians believe that, following saphenofemoral ligation, stripping to the knee plus avulsion is the first-line treatment for primary long saphenous varicose veins. Newer treatments for varicose veins such as foam sclerotherapy, radiofrequency ablation, or endovenous laser should be compared with surgery in well designed RCTs. There is no evidence for any benefit for powered phlebectomy over avulsions of varicose veins.

Substantive changes

No new evidence

2007; 2007: 0212.
Published online 2007 October 18.

Surgery (stripping)

Summary

We found no RCTs comparing stripping (partial or total, with or without avulsion) versus no treatment or compression stockings (see comment below). There is consensus that stripping is likely to be beneficial for the treatment of varicose veins. One systematic review found that surgery (avulsion, stripping, ligation with or without sclerotherapy) reduced varicose vein recurrence and improved cosmetic appearance compared with injection sclerotherapy alone. One RCT found that saphenofemoral ligation plus foam sclerotherapy reduced time to return to normal activity and improved quality of life compared with saphenofemoral ligation plus stripping plus avulsion. We found inconclusive results from two RCTs that compared stripping plus avulsion of the long saphenous vein to the knee versus avulsion alone. The first RCT found that stripping plus avulsion of the long saphenous vein decreased clinical recurrence, and increased participant satisfaction compared with avulsion alone. The second RCT found no significant difference between stripping plus avulsion and avulsion in recurrence or participant satisfaction at 5 years. A further RCT found that stripping alone increased pain and bruising compared with avulsion alone after 1 week. However, it found no significant difference between treatments in daily activity scores at 1 week. One RCT found similar improvements in clinician assessed clinical outcome with both partial stripping of the long saphenous vein to the knee and total stripping to the ankle. However, it found that partial stripping to the knee reduced the incidence of saphenous nerve damage, compared with total stripping to the ankle. One RCT found that inversion stripping reduced pain scores compared with conventional stripping at 1 week. The RCT found no significant difference between treatments in bruising after 1 week. One RCT found no significant difference between cryostripping (cryosurgery) compared with conventional stripping in pain during the day, night cramps, oedema, and visibility of varicose veins after 28 days. One RCT found that local anaesthetic flush of the long saphenous vein channel after stripping reduced postoperative pain over 6 weeks, analgesic intake over 1 week and haematoma formation.

Benefits

Stripping versus no treatment:

We found no RCTs that compared stripping versus no treatment (see comment below).

Stripping versus compression stockings:

We found no RCTs that compared stripping versus compression stockings.

Stripping versus injection sclerotherapy:

See benefits of injection sclerotherapy.

Adding stripping to avulsion versus avulsion alone:

See benefits of avulsion.

Stripping versus sequential avulsion:

We found one RCT (80 people with primary saphenofemoral varicose veins) comparing stripping of the long saphenous vein to the knee plus avulsion after saphenofemoral ligation versus avulsion of the long saphenous vein after ligation.There was a technical procedure failure in five people in the stripping group and two people in the sequential avulsion group. It found that avulsion plus stripping significantly increased pain (assessed using a linear analogue pain scale from 0–10) compared with avulsion after 1 week (results presented graphically; P less than 0.001). It found no significant difference between treatments in daily activity scores (score range 0–7) at 1 week (results presented graphically; stated as not significant; P value not reported).

Partial stripping versus total stripping:

We found one RCT (163 people), which compared partial stripping of the long saphenous vein to the knee following saphenofemoral ligation versus total stripping to the ankle following ligation. It found similar improvements in clinical outcome with both treatments (clinician assessed using the Haegers classification system, where excellent = no symptoms and no residual varices, good = no symptoms but residual varices, fair = persisting symptoms and varices, poor = no improvement in symptoms and large persistent varices; treatment rated as excellent or good: 97% with partial stripping v 94% with total stripping; P value not reported).

Inversion stripping versus conventional stripping:

We found one RCT (30 people with primary long saphenous varicose veins), which compared inversion stripping of the long saphenous vein following saphenofemoral ligation versus conventional stripping following ligation. It found that inversion stripping significantly reduced pain scores (assessed on a visual analogue scale, where 0 = no pain and 5 = severe pain) compared with conventional stripping at 1 week (mean visual analogue scale score: 9.5 with conventional stripping v 5.5 with inversion stripping; P = 0.02).

Cryostripping versus conventional stripping:

We found one RCT (40 people with primary long saphenous varicose veins) which compared cryostripping (cryosurgery) versus conventional stripping. The RCT found no significant difference between cryostripping (cryosurgery) and conventional stripping in pain during the day, night cramps, oedema and visibility of varicose veins after 28 days (absolute figures not given, P value reported as not significant.)

Local anaesthetic flush after conventional stripping versus conventional stripping alone:

We found one RCT (100 people with primary varicose veins secondary to long saphenous vein incompetence), which compared using 20 ml of 0.25% bupivacaine to flush the long saphenous vein tunnel after conventional stripping versus using 20 ml of normal saline. The RCT looked at postoperative pain over 6 weeks, using a visual analogue score of 0–10, analgesic intake measured in number of times taken in the first week postoperatively, and proportion of people with haematoma formation. It found that local anaesthetic flush of the long saphenous vein tunnel after stripping significantly reduced postoperative pain over 6 weeks (median visual analogue score 6.8 with local anaesthetic v 26 with saline; P less than 0.001), analgesic intake over 1 week (median 6.5 with local anaesthetic v median 18 with saline; P less than 0.001) and haematoma formation (3/50 [6%] with local anaesthetic v 12/50 [24%] with saline; P = 0.007).

Harms

Stripping versus no treatment:

We found no RCTs that compared stripping versus no treatment.

Avulsion versus compression stockings:

We found no RCTs that compared stripping versus compression stockings.

Stripping versus sequential avulsion:

The RCT found that three people experienced minor sensory loss in the saphenous nerve distribution after treatment (2/40 [5%] with stripping v 1/40 [3%] with sequential avulsion; significance not reported). It also found that stripping significantly increased bruising compared with sequential avulsion (median area of bruising: 160 cm2 with stripping v 56 cm2 with sequential avulsion; P less than 0.01).

Surgery versus injection sclerotherapy:

See harms of injection sclerotherapy.

Adding stripping to avulsion versus avulsion alone:

See harms of avulsion.

Partial stripping versus total stripping:

The RCT found that partial stripping to the knee significantly reduced the incidence of saphenous nerve damage compared with total stripping to the ankle (5/77 [7%] with partial stripping v 31/80 [39%] with total stripping; P less than 0.001).

Inversion stripping versus conventional stripping:

The RCT found no significant difference between treatments in bruising after 1 week (median area: 137.5 cm2 with inversion stripping v 195.5 cm2 with conventional stripping; P = 0.08).

Cryostripping versus conventional stripping:

The RCT found that cryostripping significantly increased postoperative pain scores (numerical rating scale), compared with conventional stripping after five days (1.7 with cryostripping v 3.3 with conventional stripping; P = 0.04). However, it found no significant difference between cryostripping and conventional stripping in postoperative pain scores on the other postoperative days (up to 28 days). Haematoma percentage of the upper leg (calculated from measurement of upper leg length, knee circumference, and thigh circumference), was calculated using image processing. The RCT found no significant difference between cryosurgery and conventional stripping in haematoma percentage (51% with cryotherapy v 43% with conventional stripping; P value reported as not significant). Two people in the cryosurgery group and one person in the conventional stripping group had both thrombophlebitis and a wound infection (P value reported as not significant).

Local anaesthetic flush after conventional stripping versus conventional stripping alone:

The RCT reported that no adverse effects were found in people given the local anaesthetic flush.

Comment

Avulsion versus injection sclerotherapy:

See comment under injection sclerotherapy.

Clinical guide:

Most clinicians believe that, following saphenofemoral ligation, stripping to the knee plus avulsion is the first-line treatment for primary long saphenous varicose veins. Newer treatments for varicose veins such as foam sclerotherapy, radiofrequency ablation, or endovenous laser should be compared with surgery in well designed RCTs. There is no evidence for any benefit for powered phlebectomy over avulsions of varicose veins.

Substantive changes

Surgery (stripping) Two RCTs added; categorisation unchanged (Likely to be beneficial).

2007; 2007: 0212.
Published online 2007 October 18.

Surgery (powered phlebectomy)

Summary

We found no RCTs comparing powered phlebectomy versus no treatment or compression stockings. One RCT found no significant difference between powered phlebectomy and avulsion in pain at 8 days, or in participant satisfaction or cosmetic appearance at 6 weeks. It also found no significant difference between treatments in nerve injury or severe bruising after 2 weeks. A further RCT found that powered phlebectomy increased pain, bruising, and discolouration compared with avulsion.

Benefits

We found two RCTs comparing powered phlebectomy versus avulsion (conventional hook phlebectomy) following ligation. The first RCT found no significant difference between treatments in pain at 8 days (141 people, 188 legs randomised; pain assessed using a visual analogue scale, where 0 = no pain, and 10 = most severe pain; results presented graphically; stated as not significant; P value not reported). It found no significant difference between treatments in participant satisfaction or cosmetic appearance at 6 weeks (both measured on a visual analogue scale, where 0 = “very dissatisfied” and 10 = “very satisfied”; proportion of people “satisfied”: 87% with powered phlebectomy v 91% with avulsion; P = 0.88; mean cosmetic score: 7.44 with powered phlebectomy v 8.27 with avulsion; results presented graphically; P value not reported). The second RCT found that avulsion improved pain more than powered phlebectomy at 6 weeks (66 people with unilateral saphenofemoral incompetence; pain measured using a 10 cm Burford pain thermometer, scale ranging from 0 = no pain, to 100 = most severe pain imaginable; median change in Burford pain scale from baseline: –20 with avulsion v –2 with powered phlebectomy; P = 0.019.

Harms

Powered phlebectomy versus conventional phlebectomy:

The first RCT found no significant difference between treatments in the incidence of cellulitis, cutaneous nerve injury, or severe bruising after 2 weeks (cellulitis: 2/88 [2%] with powered phlebectomy v 3/100 [3%] with conventional phlebectomy; P = 0.33; cutaneous nerve injury: 16/88 [18%] with powered phlebectomy v 25/100 [25%] with conventional phlebectomy; P = 0.33; severe bruising: 8/88 [9%] with powered phlebectomy v 7/100 [7%] with conventional phlebectomy; P = 0.77). The second RCT found that powered phlebectomy increased bruising and discolouration compared with avulsion at 1 week (AR: 39% with powered phlebectomy v 25% with avulsion; P less than 0.001) and 6 weeks (AR: 7% with powered phlebectomy v 0% with avulsion; P less than 0.001). There was no difference between the groups in terms of cutaneous nerve injury (AR for saphenous neuropathy; at 1 week: 14% with powered phlebectomy v 3% with avulsion; P = 0.09; at 6 weeks: 7% with powered phlebectomy v 3% with avulsion; P = 0.07).

Comment

Powered phlebectomy versus avulsion:

Both RCTs comparing powered phlebectomy versus conventional phlebectomy found that powered phlebectomy significantly reduced the number of incisions, but this made no difference to participant satisfaction.

Clinical guide:

There is no evidence for any benefit for powered phlebectomy over avulsions of varicose veins.

Substantive changes

No new evidence

2007; 2007: 0212.
Published online 2007 October 18.

Radiofrequency ablation

Summary

One RCT found no significant difference between radiofrequency ablation and stripping in clinical detection of recurrence of varicose veins, and patient satisfaction with cosmetic result.

Benefits

Radiofrequency ablation versus stripping:

We found no systematic review (see comment below). We found one RCT comparing radiofrequency ablation versus stripping . The RCT (33 people with primary varicose veins) found no significant difference between radiofrequency ablation and stripping in clinical detection of recurrence of varicose veins (33% with radiofrequency ablation v 15% with stripping; P = 0.4) and patient satisfaction with cosmetic result (14/15 with radiofrequency abalation v 12/13 with stripping; P value not reported; significance not reported). The study did not appear to perform an intention to treat analysis.

Harms

Radiofrequency ablation versus stripping:

We found no systematic review (see comment below). In the RCT one person who had received radiofrequency ablation reported a period of superficial thrombophlebitis. One person who received radiofrequency ablation [7%] and five people who received stripping [38%] reported symptoms of saphenous nerve injury. No significance testing was reported for these adverse effects.

Comment

Radiofrequency ablation versus stripping:

We found one systematic review (search date 2004), which identified two RCTs comparing radiofrequency ablation versus stripping of the long saphenous vein following saphenofemoral ligation in people with complicated varicose veins. The review did not meet inclusion criteria for this topic because of population definition. The review did not perform a meta-analysis and the RCTs were considered to be of poor quality: assessors were not blind to treatment, methods of randomisation were unclear, and analyses were not by intention to treat. Both RCTs found that radiofrequency ablation significantly reduced postoperative pain compared with stripping, but found inconclusive evidence about the effects of radiofrequency ablation on quality of life outcomes. Subsequent data from one of these RCTs showed improved quality of life in the radiofrequency ablation group at 1 and 2 years.

Substantive changes

Radiofrequency ablation One RCT added; categorisation unchanged (Unknown effectiveness)

2007; 2007: 0212.
Published online 2007 October 18.

Endovenous laser

Summary

We found no systematic review or RCTs comparing endovenous laser versus no treatment (watchful waiting) or versus our other treatments of interest in people with varicose veins.

Benefits

We found no systematic review or RCTs.

Harms

We found no RCTs.

Comment

None.

Substantive changes

Endovenous laser for varicose veins New option added; no RCTs identified; categorised as Unknown effectiveness.

2007; 2007: 0212.
Published online 2007 October 18.

Self help (exercise, diet, elevation of legs, avoidance of tight clothing, advice)

Summary

We found no systematic review or RCTs comparing self help versus no treatment (watchful waiting) or versus our other treatments of interest in people with varicose veins.

Benefits

We found no systematic review or RCTs.

Harms

We found no RCTs.

Comment

Clinical guide:

We found no RCT evidence for self help measures fo treating varicose veins. Most clinicians would advise on weight loss (if overweight), regular exercise, avoidance of prolonged standing, and elevation of the legs to alleviate symptoms of varicose veins.

Substantive changes

Self help for varicose veins New option added; no RCTs identified; categorised as Unknown effectiveness


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