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Superficial Venous Insufficiency: Varicose Veins and Venous Ulcers
Jonathan Fong, MBBS, BMedSci, PGDipSurgAnat; Iman Bayat, MBBS, MRCS, FRACS(Vasc); Jason Chuen, MBBS, PGDipSurgAnat, FRACS(Vasc), MPH | June 29, 2017
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Image courtesy of Rustempasic N, Cvorak A, Agincic A. Outcome of endovenous laser ablation of varicose veins. Acta Inform Med. 2014 Oct;22(5):329-32. [Open access.] PMID: 25568583, PMCID: PMC4272832.
Superficial Venous Insufficiency: Varicose Veins and Venous Ulcers
Jonathan Fong, MBBS, BMedSci, PGDipSurgAnat; Iman Bayat, MBBS, MRCS, FRACS(Vasc); Jason Chuen, MBBS, PGDipSurgAnat, FRACS(Vasc), MPH | June 29, 2017 | Contributor Information
Superficial venous disease broadly falls into two categories: venous insufficiency/reflux (eg, varicose veins [shown], chronic venous insufficiency) and veno-occlusive disease, including thrombosis (eg, superficial thrombophlebitis, deep venous thrombosis [DVT]). These conditions encompass a wide range of symptoms/signs and presentations. In more than 50% of the general population, superficial venous disease appears in the form of "spider" or reticular veins, but in approximately 20%-25% of the population, the disease can progress to visible varicosities at its extremes, such as ulceration or skin changes.[1,2]
This slideshow will focus primarily on venous insufficiency.
Image courtesy of OpenStax College. Blood flow, blood pressure, and resistance. OpenStax CNX. June 19, 2013. [Open source.] Available at: http://cnx.org/contents/03841c4c-9e9a-4822-95b2-12273c843a4e@3. Accessed June 20, 2017. Image courtesy of Jonathan Fong, MBBS, BMedSci, PGDipSurgAnat.
Superficial Venous Insufficiency: Varicose Veins and Venous Ulcers
Jonathan Fong, MBBS, BMedSci, PGDipSurgAnat; Iman Bayat, MBBS, MRCS, FRACS(Vasc); Jason Chuen, MBBS, PGDipSurgAnat, FRACS(Vasc), MPH | June 29, 2017 | Contributor Information
Calf-Pump System
The venous supply to the leg is via a deep and superficial low-pressure system. The flow of blood is from the peripheries toward the heart, maintained by the calf-pump system. Within the veins, a system of valves helps overcome the pull of gravity and maintains a unidirectional flow of blood (shown). When these valves become incompetent, retrograde flow of blood predominates and leads to venous hypertension, resulting in the changes seen with superficial venous disease.
Table courtesy of the authors.
Superficial Venous Insufficiency: Varicose Veins and Venous Ulcers
Jonathan Fong, MBBS, BMedSci, PGDipSurgAnat; Iman Bayat, MBBS, MRCS, FRACS(Vasc); Jason Chuen, MBBS, PGDipSurgAnat, FRACS(Vasc), MPH | June 29, 2017 | Contributor Information
Clinical Classification
The CEAP (clinical, etiologic, anatomic, pathophysiologic) criteria are used to aid classification of chronic venous disease, particularly in clinical studies and trials; thus, they help clinicians to stratify and communicate the severity of venous disease.[4] Typically, only the clinical portion (shown) of the CEAP classification system is fully utilized.[3]
Image courtesy of Wikimedia Commons/Lakeland1999.
Superficial Venous Insufficiency: Varicose Veins and Venous Ulcers
Jonathan Fong, MBBS, BMedSci, PGDipSurgAnat; Iman Bayat, MBBS, MRCS, FRACS(Vasc); Jason Chuen, MBBS, PGDipSurgAnat, FRACS(Vasc), MPH | June 29, 2017 | Contributor Information
Superficial Venous Insufficiency
Much about the etiology of varicose veins remains unknown. These manifestations are seen more commonly in developed countries and in women, and they are strongly associated with family history, increasing age, pregnancy, and DVT. Weak associations include obesity and some rare genetic abnormalities.[4]
Although few studies document the natural history of varicose veins (shown), superficial venous insufficiency is considered to be progressive over time, typically beginning as reticular veins or corona phlebectatica ("corona"), developing into isolated calf varicosities and, eventually, resulting in a tortuous and distended great saphenous vein.[5]
Reticular veins are typically small (1-3 mm), highly visible, and often pose a cosmetic problem for patients. Varicose veins are superficial and dilated; they are typically found in the calf but may also occur in the thigh, corresponding to the course of the long saphenous vein. Incompetence of the perforator and short saphenous veins can result in posterior calf varicosities.
Image courtesy of Medscape.
Superficial Venous Insufficiency: Varicose Veins and Venous Ulcers
Jonathan Fong, MBBS, BMedSci, PGDipSurgAnat; Iman Bayat, MBBS, MRCS, FRACS(Vasc); Jason Chuen, MBBS, PGDipSurgAnat, FRACS(Vasc), MPH | June 29, 2017 | Contributor Information
Left untreated, superficial venous insufficiency can lead to the development of skin changes (shown) and, eventually, ulceration. The rate of progression and risk factors for developing chronic venous changes are still unknown.[6] Symptoms can include heaviness, swelling, aching, cramps, and itching.[7] Venous hypertension can subsequently develop due to excessive edema overwhelming the lymphatic system.
Venous eczema, hemosiderin staining, and lipodermatosclerosis are consequences of chronic venous stasis. Hemosiderin staining occurs from extravasation of red blood cells, causing a pigmented appearance to the limbs. Lipodermatosclerosis gives the affected limb a classic "inverted champagne bottle" appearance; this is thought to be caused by extravasation of fibrinogen or white blood cells into the dermal tissue due to capillary hypertension, thereby resulting in chronic inflammation and fibrosis of the subcutaneous tissue.[8]
Image courtesy of Jonathan Fong, MBBS, BMedSci, PGDipSurgAnat.
Superficial Venous Insufficiency: Varicose Veins and Venous Ulcers
Jonathan Fong, MBBS, BMedSci, PGDipSurgAnat; Iman Bayat, MBBS, MRCS, FRACS(Vasc); Jason Chuen, MBBS, PGDipSurgAnat, FRACS(Vasc), MPH | June 29, 2017 | Contributor Information
Venous insufficiency is the most common underlying etiology of chronic ulcers (shown) (range, 54%-75% in some observational studies).[9] Other conditions that should be considered in the differential diagnosis as a cause of such ulcers include arterial insufficiency, mixed venous and arterial disease, and vasculitic processes.
Venous ulcers take longer to heal, are often recurrent, and occur more frequently in older patients.[10] The Bonn Vein Study found a prevalence of 0.6% of healed and 0.1% of active venous ulcers in those younger than 79 years. These ulcers frequently affect the medial "gaiter" region but can also occur on the lateral aspect or the dorsum of the foot.[11] Venous ulcers rarely occur de novo but often manifest secondary to triggers such as cellulitis, injury, dermatitis, and rapid development of edema.[12]
Image courtesy of Jason Chuen, MBBS, PGDipSurgAnat, FRACS(Vasc).
Superficial Venous Insufficiency: Varicose Veins and Venous Ulcers
Jonathan Fong, MBBS, BMedSci, PGDipSurgAnat; Iman Bayat, MBBS, MRCS, FRACS(Vasc); Jason Chuen, MBBS, PGDipSurgAnat, FRACS(Vasc), MPH | June 29, 2017 | Contributor Information
Imaging Studies
Duplex ultrasonography remains the gold standard for investigation of venous disease. The duplex ultrasound image shown demonstrates reflux (reverse flow) within the femoral vein.
These studies should provide a map of the deep and superficial lower limb venous systems, including perforating veins and saphenofemoral and saphenopopliteal junctions, demonstrating patency, competency (absence of reflux), and (where treatment is considered) tortuosity and caliber.
Ovarian or pelvic vein reflux can be assessed noninvasively by ultrasound, computed tomography (CT), or magnetic resonance (MR) venography. Catheter-directed venography is reserved for treatment of pelvic vein reflux via embolization or, in cases of proximal venous obstruction (iliofemoral DVT, May-Thurner syndrome), venous recanalization and stenting. This procedure can be assisted by intravascular ultrasound (IVUS).[13]
Image courtesy of Jason Chuen, MBBS, PGDipSurgAnat, FRACS(Vasc).
Superficial Venous Insufficiency: Varicose Veins and Venous Ulcers
Jonathan Fong, MBBS, BMedSci, PGDipSurgAnat; Iman Bayat, MBBS, MRCS, FRACS(Vasc); Jason Chuen, MBBS, PGDipSurgAnat, FRACS(Vasc), MPH | June 29, 2017 | Contributor Information
Open Varicose Vein Surgery and Saphenous Vein Stripping
Since it was first described, in 1890, ligation of the great saphenous vein has been used to treat varicose veins to good effect. The procedure is typically done as a day surgery, under general or spinal anesthesia. The saphenofemoral junction, where the great saphenous vein enters the femoral vein through the cribriform fascia, is identified through a transverse incision (shown). The junction needs to be positively confirmed before ligation and disconnection.
Image courtesy of Jason Chuen, MBBS, PGDipSurgAnat, FRACS(Vasc).
Superficial Venous Insufficiency: Varicose Veins and Venous Ulcers
Jonathan Fong, MBBS, BMedSci, PGDipSurgAnat; Iman Bayat, MBBS, MRCS, FRACS(Vasc); Jason Chuen, MBBS, PGDipSurgAnat, FRACS(Vasc), MPH | June 29, 2017 | Contributor Information
Typically, once the saphenofemoral junction and the surrounding tributaries have been ligated, the great saphenous vein is then stripped to reduce the risk of recurrence (shown).[14] Depending on the surgeon's preference, the vein can be stripped to the knee or the ankle; however, the risk of injury to the saphenous nerve is higher with more distal stripping.[15] If saphenopopliteal junction incompetence is present, the short saphenous vein can also be ligated. Large varicosities are removed by stab avulsions (ambulatory phlebotomy).
The saphenous nerve in the calf, the sural nerve behind the knee, and the peroneal nerve at the fibular head are all at risk of injury during stripping, ligation, and avulsion; sensory loss occurs if these nerves are injured. Although recurrence rates vary between 5% and 25% at 5 years and up to 80% at 20 years, patients have reported a high satisfaction rate (92%) on review at 5 years.[16,17]
Image courtesy of Jason Chuen, MBBS, PGDipSurgAnat, FRACS(Vasc).
Superficial Venous Insufficiency: Varicose Veins and Venous Ulcers
Jonathan Fong, MBBS, BMedSci, PGDipSurgAnat; Iman Bayat, MBBS, MRCS, FRACS(Vasc); Jason Chuen, MBBS, PGDipSurgAnat, FRACS(Vasc), MPH | June 29, 2017 | Contributor Information
Postoperatively, the patient is encouraged to be mobile immediately. The leg is also compressed with bandages for 1-5 days to reduce bruising and hematoma (shown); once these compression bandages are removed, they are typically replaced by compression stockings for a brief period.[18]
Complications of open surgery include infection, bleeding, DVT, nerve injury, and recurrence. Bruising along the route of the vein strip is common, but bleeding that requires intervention is exceedingly rare. DVT is an uncommon (0.5%-5.3% in the literature) but concerning complication.
Image courtesy of Medscape/Steven E Zimmet, MD, FACPH.
Superficial Venous Insufficiency: Varicose Veins and Venous Ulcers
Jonathan Fong, MBBS, BMedSci, PGDipSurgAnat; Iman Bayat, MBBS, MRCS, FRACS(Vasc); Jason Chuen, MBBS, PGDipSurgAnat, FRACS(Vasc), MPH | June 29, 2017 | Contributor Information
Endovenous Thermal Ablation
An alternative to traditional surgery is the minimally invasive approach offered by endovenous thermal ablation—a term used to encompass techniques of endothelial injury delivered via a percutaneous intraluminal ablation catheter. Technologies in common use include endovenous laser ablation (EVLA) and radiofrequency ablation (RFA). Cryotherapy and steam ablation have also been described. Tumescent anesthetic is delivered outside the vein to prevent excess thermal injury, collapse the vein around the catheter, and reduce pain. Ideal veins are straight, broad (>3 mm), and deep (>1 cm from skin).
The ablation catheter is inserted under ultrasonographic guidance. Longitudinal duplex ultrasonogram of the saphenofemoral junction is shown during the positioning of the tip of a laser fiber for EVLA. The laser tip (arrow) is in the great saphenous vein (GSV) just beyond the superficial epigastric vein (SEV) termination. FV = femoral vein.
The advantages of this procedure lie in reducing the use of general anesthesia and the rates of bruising, bleeding, and nerve injury. Endovenous ablation can therefore promote an earlier return to work for patients.[19] Complications include skin burns and endovenous heat-induced thrombosis, with an incidence below 1%.
Image courtesy of the authors.
Superficial Venous Insufficiency: Varicose Veins and Venous Ulcers
Jonathan Fong, MBBS, BMedSci, PGDipSurgAnat; Iman Bayat, MBBS, MRCS, FRACS(Vasc); Jason Chuen, MBBS, PGDipSurgAnat, FRACS(Vasc), MPH | June 29, 2017 | Contributor Information
Sclerotherapy and Pharmacomechanical Ablation
Instead of thermal ablation, chemical ablation can also be used to obliterate the varicose vein. Foam sclerotherapy, initially devised to treat small reticular veins, can now be used to sclerose incompetent great saphenous veins with only a slightly lower efficacy than traditional surgery, according to a meta-analysis.[20]
The procedure is performed on an outpatient basis under local anesthesia, or without anesthesia using a fine-bore needle. Multiple sessions are sometimes required to achieve a full result. A chemical agent such as polidocanol or sodium tetradecyl sulfate (STS) is selected and produced into a foam, which is then injected under ultrasonographic guidance into the varicose vein. The sclerosing agent induces thrombosis, leading to a lumpy coagulum as it takes effect; the site is usually compressed with bandaging or with a stocking.[21-23] Patients recover rapidly following the procedure; some may require aspiration of the coagulum but in most cases it dissipates over time.
Common complications include skin pigmentation and thrombophlebitis, but chemical ablation rarely causes DVT or pulmonary embolism (PE) (0.19%-0.7%).[21-23]
Chemical ablation can be combined with mechanical irritation to induce venous spasm and increase efficacy. More recently, cyanoacrylate glue has been used to create an adhesive obliteration of the venous lumen.[24]
Images courtesy of the authors.
Superficial Venous Insufficiency: Varicose Veins and Venous Ulcers
Jonathan Fong, MBBS, BMedSci, PGDipSurgAnat; Iman Bayat, MBBS, MRCS, FRACS(Vasc); Jason Chuen, MBBS, PGDipSurgAnat, FRACS(Vasc), MPH | June 29, 2017 | Contributor Information
Phlebectomy
Phlebectomy, also referred to as stab avulsions, is the removal of large varicosities by direct incision. It is often performed in conjunction with open surgery, but may also be done as part of a course of minimally invasive saphenous vein treatments such as endovenous thermal ablation or injection sclerotherapy. The procedure can be performed under local anesthesia and in some cases can be assisted by transillumination or powered phlebectomy devices.
Image courtesy of Wikimedia Commons/Frank C. Müller.
Superficial Venous Insufficiency: Varicose Veins and Venous Ulcers
Jonathan Fong, MBBS, BMedSci, PGDipSurgAnat; Iman Bayat, MBBS, MRCS, FRACS(Vasc); Jason Chuen, MBBS, PGDipSurgAnat, FRACS(Vasc), MPH | June 29, 2017 | Contributor Information
Compression Stockings
Compression stockings (shown) have long been the mainstay of nonoperative management for varicose veins. However, there is a lack of good evidence to show their efficacy, and patient compliance is a significant hurdle, as many find the stockings to be itchy, hot, and difficult to put on and take off.
Although a number of studies outline the potential of pharmacotherapy in reducing symptoms, particularly the use of horse chestnut extract, thus far, the benefit of such treatment has been shown to be limited.
Image courtesy of Jonathan Fong, MBBS, BMedSci, PGDipSurgAnat.
Superficial Venous Insufficiency: Varicose Veins and Venous Ulcers
Jonathan Fong, MBBS, BMedSci, PGDipSurgAnat; Iman Bayat, MBBS, MRCS, FRACS(Vasc); Jason Chuen, MBBS, PGDipSurgAnat, FRACS(Vasc), MPH | June 29, 2017 | Contributor Information
Considerations in Treatment Selection
When selecting the appropriate treatment for patients with superficial venous disease, many factors must be taken into account. These include the severity and extent of the venous disease, the anatomy of the varicosities, the presence of ulceration (shown) and/or comorbid conditions, any previous treatments, and the goal of treatment (cosmetic, ulcer healing, or symptom management).
The availability of therapeutic options and the expertise of the treating surgeon also have roles in the decision-making process. For example, EVLA and radiofrequency ablation (RFA) treatments are more financially costly than traditional surgery because they often require a heavier investment in instruments.
Patients should be made aware that surgery for varicose veins can result in bruising and short-term pain and, most importantly, recurrence is common. Moreover, although the bulk of the varicosities is removed, residual small veins often remain and may require further intervention.
Table courtesy of Jonathan Fong, MBBS, BMedSci, PGDipSurgAnat. Data from Nesbitt et al.[20]
Superficial Venous Insufficiency: Varicose Veins and Venous Ulcers
Jonathan Fong, MBBS, BMedSci, PGDipSurgAnat; Iman Bayat, MBBS, MRCS, FRACS(Vasc); Jason Chuen, MBBS, PGDipSurgAnat, FRACS(Vasc), MPH | June 29, 2017 | Contributor Information
A number of systematic reviews and meta-analyses have compared the three main procedures for the treatment of varicose veins (ie, open surgery, endovenous ablation, foam sclerotherapy). Note, however, that the results of these analyses must be considered against the heterogeneity in the methodology of the randomized controlled trials used in the analyses.
Although several recent guidelines have suggested that endovenous ablation should be considered first-line therapy for suitable patients,[25-27] open varicose vein surgery is still considered the gold standard to which other treatments are compared. A Cochrane review found little difference between treatments in terms of the risk of early clinical recurrence (shown) or recanalization of the great saphenous vein on the basis of early duplex sonograms.[20] EVLA and RFA typically cost more, but they have the benefit of reduced rates of wound infections and hematoma, as well as an earlier return to work.[28] Although the Cochrane review showed equal effectiveness with sclerotherapy,[20] other studies have reported that, at 5-year follow-up, those who underwent surgery were more likely to remain recurrence free.[29]
Image courtesy of the authors.
Superficial Venous Insufficiency: Varicose Veins and Venous Ulcers
Jonathan Fong, MBBS, BMedSci, PGDipSurgAnat; Iman Bayat, MBBS, MRCS, FRACS(Vasc); Jason Chuen, MBBS, PGDipSurgAnat, FRACS(Vasc), MPH | June 29, 2017 | Contributor Information
Ulcers
Venous leg ulceration is a common yet difficult condition to treat, particularly in the elderly. Management of these ulcers is costly, and without definitive early and ongoing long-term management, recurrence rates are high.
Multi-modality treatment of ulceration must include debridement of necrotic tissue and control of infection and microbial colonization. Arterial supply should be assessed and a suitable wound-healing environment supported. Pressure care, analgesia, nutrition, and smoking cessation should be addressed, along with medical comorbidities such as diabetes and cardiac failure. The presence of venous reflux or outflow insufficiency should be determined.
If present, venous disease should be treated with surgery or intervention—ideally after healing of the ulcer, which may be assisted with compression therapy and, if necessary, bed rest and elevation. Skin grafts or local flaps may be necessary to cover the defects (shown).
Image of chronic medial leg ulceration associated with long-standing venous insufficiency courtesy of Medscape.
Superficial Venous Insufficiency: Varicose Veins and Venous Ulcers
Jonathan Fong, MBBS, BMedSci, PGDipSurgAnat; Iman Bayat, MBBS, MRCS, FRACS(Vasc); Jason Chuen, MBBS, PGDipSurgAnat, FRACS(Vasc), MPH | June 29, 2017 | Contributor Information
Compression therapy has also been the mainstay of preventing recurrence of venous ulcers. However, there is evidence that in patients with incompetence of the great or small saphenous vein, surgical intervention is associated with improved rates of healing as well as lower recurrence rates than with compression therapy alone.[30] Outcomes with surgical intervention do not appear to differ on the basis of the type of surgery performed (ie, open, endovenous, and sclerotherapy).
Peripheral arterial disease (PAD) caused by atherosclerosis affects approximately 8.5 million Americans aged 40 years or older. Learn more about the significant morbidity and mortality associated with this common condition.Slideshows, June 2017
Varicose veins and telangiectasia (spider veins) are the visible surface manifestations of an underlying problem with reverse venous flow, which is also termed venous insufficiency syndrome. Mild forms of venous insufficiency are merely uncomfortable, annoying, or cosmetically disfiguring, but severe venous disease can produce serious systemic consequences and can lead to loss of life or limb.Diseases/Conditions, September 2016
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Contributor Information
Authors
Jonathan Fong, MBBS, BMedSci, PGDipSurgAnat
Surgical Registrar
Austin Health
Melbourne, Victoria
Australia
Disclosure: Jonathan Fong, MBBS, BMedSci, PGDipSurgAnat, has disclosed no relevant financial relationships.
Iman Bayat, MBBS, MRCS, FRACS(Vasc)
Vascular Surgery Fellow
Austin Health
Melbourne, Victoria
Australia
Disclosure: Iman Bayat, MBBS, MRCS, FRACS(Vasc), has disclosed no relevant financial relationships.
Jason Chuen, MBBS, PGDipSurgAnat, FRACS(Vasc)
Vascular and Endovascular Surgeon
Elgar Hill Medical Suites;
Director of Vascular Surgery
Austin Health;
Clinical Senior Lecturer
Faculty of Medicine, Dentistry, and Health Sciences
The University of Melbourne
Melbourne, Victoria
Australia
Disclosure: Jason Chuen, MBBS, PGDipSurgAnat, FRACS(Vasc), has received speaking and teaching consulting fees from Medtronic and Cook Medical.
Editors
Olivia Wong, DO
Section Editor
Medscape Drugs & Diseases
New York, New York
Disclosure: Olivia Wong, DO, has disclosed no relevant financial relationships.
John Heinegg, RN
Section Editor
Medscape Drugs & Diseases
New York, New York
Disclosure: John Heinegg, RN, has disclosed no relevant financial relationships.
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References
Callam MJ. Epidemiology of varicose veins. Br J Surg. 1994 Feb;81(2):167-73. PMID: 8156326
Evans CJ, Allan PL, Lee AJ, Bradbury AW, Ruckley CV, Fowkes FG. Prevalence of venous reflux in the general population on duplex scanning: the Edinburgh vein study. J Vasc Surg. 1998 Nov;28(5):767-76. PMID: 9808843
Rabe E, Pannier F. Clinical, aetiological, anatomical and pathological classification (CEAP): gold standard and limits. Phlebology. 2012 Mar;27 suppl 1:114-8. PMID: 22312077
Wright N, Fitridge R. Varicose veins - natural history, assessment and management. Aust Fam Physician. 2013 Jun;42(6):380-4. PMID: 23781544
Tran NT, Meissner MH. The epidemiology, pathophysiology, and natural history of chronic venous disease. Semin Vasc Surg. 2002 Mar;15(1):5-12. PMID: 11840420
Bradbury A, Evans CJ, Allan P, Lee AJ, Ruckley CV, Fowkes FG. The relationship between lower limb symptoms and superficial and deep venous reflux on duplex ultrasonography: The Edinburgh Vein Study. J Vasc Surg. 2000 Nov;32(5):921-31. PMID: 11054224
Gross EA, Wood CR, Lazarus GS, Margolis DJ. Venous leg ulcers: an analysis of underlying venous disease. Br J Dermatol. 1993 Sep;129(3):270-4. PMID: 8286223
Körber A, Schadendorf D, Dissemond J. [Causes of leg ulcers. Analysis of the data from a dermatologic wound care center] [German]. Hautarzt. 2009 Jun;60(6):483-8. PMID: 19305956
Nelzén O, Bergqvist D, Lindhagen A. Venous and non-venous leg ulcers: clinical history and appearance in a population study. Br J Surg. 1994 Feb;81(2):182-7. PMID: 8156328
Pannier F, Rabe E. Differential diagnosis of leg ulcers. Phlebology. 2013 Mar;28 suppl 1:55-60. PMID: 23482536
Shai A, Halevy S. Direct triggers for ulceration in patients with venous insufficiency. Int J Dermatol. 2005 Dec;44(12):1006-9. PMID: 16409265
Raju S, McAllister S, Neglen P. Recanalization of totally occluded iliac and adjacent venous segments. J Vasc Surg. 2002 Nov;36(5):903-11. PMID: 12422099
Winterborn RJ, Foy C, Earnshaw JJ. Causes of varicose vein recurrence: late results of a randomized controlled trial of stripping the long saphenous vein. J Vasc Surg. 2004 Oct;40(4):634-9. PMID: 15472588
Cheatle T. The long saphenous vein: to strip or not to strip? Semin Vasc Surg. 2005 Mar;18(1):10-4. PMID: 15791547
Allegra C1, Antignani PL, Carlizza A. Recurrent varicose veins following surgical treatment: our experience with five years follow-up. Eur J Vasc Endovasc Surg. 2007 Jun;33(6):751-6. PMID: 17276095
Friedell ML, Samson RH, Cohen MJ, et al. High ligation of the greater saphenous vein for treatment of lower extremity varicosities: the fate of the vein and therapeutic results. Ann Vasc Surg. 1992 Jan;6(1):5-8. PMID: 1547077
Rastel D, Perrin M, Guidicelli H. [Compressive therapy after varicose vein surgery: results of a French national inquiry] [French]. J Mal Vasc. 2004 Feb;29(1):27-34. PMID: 15094663
Zan S, Contessa L, Varetto G, et al. Radiofrequency minimally invasive endovascular treatment of lower limbs varicose veins: clinical experience and literature review. Minerva Cardioangiol. 2007 Aug;55(4):443-58. PMID: 17653021
Nesbitt C, Bedenis R, Bhattacharya V, Stansby G. Endovenous ablation (radiofrequency and laser) and foam sclerotherapy versus open surgery for great saphenous vein varices. Cochrane Database Syst Rev. 2014 Jul 30;7:CD005624. PMID: 25075589
Kakkos SK, Bountouroglou DG, Azzam M, Kalodiki E, Daskalopoulos M, Geroulakos G. Effectiveness and safety of ultrasound-guided foam sclerotherapy for recurrent varicose veins: immediate results. J Endovasc Ther. 2006 Jun;13(3):357-64. PMID: 16784324
Rabe E, Breu FX, Cavezzi A, et al, for the Guideline Group. European guidelines for sclerotherapy in chronic venous disorders. Phlebology. 2014 Jul;29(6):338-54. PMID: 23559590
Brittenden J, Cotton SC, Elders A, et al. A randomized trial comparing treatments for varicose veins. N Engl J Med. 2014 Sep 25;371(13):1218-27. PMID: 25251616
Almeida JI, Javier JJ, Mackay E, Bautista C, Proebstle TM. First human use of cyanoacrylate adhesive for treatment of saphenous vein incompetence. Journal of Vascular Surgery: Venous and Lymphatic Disorders. 2013;1(2):174-80. PMID: 26992340
Gloviczki P, Comerota AJ, Dalsing MC, Eklof BG, Gillespie DL, Gloviczki ML, et al. The care of patients with varicose veins and associated chronic venous diseases: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg. [Practice Guideline]. 2011 May;53(5 Suppl):2S-48S. PMID: 21536172
Wittens C, Davies AH, Baekgaard N, Broholm R, Cavezzi A, Chastanet S, et al. Editor's Choice - Management of Chronic Venous Disease: Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg. [Practice Guideline Review]. 2015 Jun;49(6):678-737. PMID:25920631
National Institute for Health and Care Excellence. Varicose veins: Diagnosis and management. Manchester: NICE, 2013. Available at www.nice.org.uk/guidance/cg168
Siribumrungwong B, Noorit P, Wilasrusmee C, Attia J, Thakkinstian A. A systematic review and meta-analysis of randomised controlled trials comparing endovenous ablation and surgical intervention in patients with varicose vein. Eur J Vasc EndovascSurg. 2012 Aug;44(2):214-23. PMID: 22705163
Leopardi D, Hoggan BL, Fitridge RA, Woodruff PW, Maddern GJ. Systematic review of treatments for varicose veins. Ann Vasc Surg. 2009 Mar;23(2):264-76. PMID: 19059756
Mauck KF, Asi N, Undavalli C, et al. Systematic review and meta-analysis of surgical interventions versus conservative therapy for venous ulcers. J Vasc Surg. 2014 Aug;60(2 suppl):60S-70S.e1-2. PMID: 24835693
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