Skip to main content

Advertisement

SpringerLink
Log in

Current Therapeutic Interventions in Lower Extremity Venous Insufficiency: a Comprehensive Review

  • Other Pain (A. Kaye and N. Vadivelu, Section Editors)
  • Published:
Current Pain and Headache Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

Chronic venous disease (CVD), although affecting up to 40% of the US population, is often underdiagnosed by healthcare professionals due to an incomplete understanding of the presenting symptoms. CVD is a common cause of lower extremity pain and discomfort, including aching, cramping, tingling, burning, swelling, heaviness, restlessness, and fatigue, and may lead to significant morbidity if left untreated. The negative impact of CVD on quality of life is well established and the optimization of management strategies is an important area of evolving research.

Recent Findings

Management of CVD has rapidly evolved over the last two decades with the development of minimally invasive endovenous ablative techniques, now the mainstay of treatment. We discuss the data supporting various methods of CVD treatment with an emphasis on the impact on patient comfort and quality of life.

Summary

Both radiofrequency ablation (RFA) and endovenous laser therapy (EVLA) are excellent options for treatment of lower extremity venous disease, but RFA is associated with less post-procedure discomfort. Ultrasound-guided foam therapy is best reserved for the adjuvant setting or for patients ineligible for RFA or EVLA.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Eklof B, Rutherford RB, Bergan JJ, Carpentier PH, Gloviczki P, et al. Revision of the CEAP classification for chronic venous disorders: consensus statement. J Vasc Surg. 2004;40:1248–52.

    Article  Google Scholar 

  2. Widmer LK, Mall TH, Martin H. Epidemiology and social medical importance of diseases of the veins. Munch Med Wochenschr. 1974;116:1421–6.

    CAS  Google Scholar 

  3. Langer RD, Ho E, Denenberg JO, Fronek A, Allison M, al e. Relationships between symptoms and venous disease. Arch Intern Med. 2005;165(12):1420–4.

    Article  Google Scholar 

  4. Bradbury A, Evans C, Allan P, Lee A, Ruckley CV, et al. What are the symptoms of varicose veins? Edinborough Vein Study Cross Sectional Population Survey. BMJ. 1999;318:318–53.

    Article  Google Scholar 

  5. Brand FN, Dannenberg AL, Abbott RD, Kannel WB. The epidemiology of varicose veins: the Framingham study. Am J Prev Med. 1998;4(2):96–101.

    Article  Google Scholar 

  6. Vasquez MA, Rabe E, McLaffery RB, Shortell CK, al MWA e. Revision of the venous clinical severity score: venous outcomes consensus statement: special communication of the American venous forum ad hoc outcomes working group. J Vasc Surg. 2010;52(5):1387–96.

    Article  Google Scholar 

  7. •• Wrona M, Jockel K-H, Pannier F, Hoffman B, Rabe E. Association of venous disorders with leg symptoms: results from the Bonn vein study. Eur J Endovasc Surg. 2015;50:360–7 Large cross-sectional study establishing the association between symptoms of venous disease and CEAP stage.

    Article  CAS  Google Scholar 

  8. Garratt AM, MacDonald LM, Ruta DA, et al. Towards measures of outcome for patients with varicose veins. Qual Helath Care. 1993;2:5–10.

    Article  CAS  Google Scholar 

  9. Launois R, Le Moine JG, Lozano FS. Construction and international validation of CIVIQ-14 (a short form of CIVIQ-20), a new questionnaire with a stable factorial structure. Qual Life Res. 2012;21:1051–8.

    Article  CAS  Google Scholar 

  10. Kuet M, Lane T, Anwar MA, Davies A. Comparison of disease-specific quality of life tools in patients with chronic venous disease. Phlebology. 2014;29(10):648–53.

    Article  Google Scholar 

  11. Gloviczki P, Comerota AJ, Dalsing MC, Eklof BG, Gillespie DL, 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. 2011;53:2S.

    Article  Google Scholar 

  12. •• O'Flynn N, Vaughan M, Kelley K. Diagnosis and management of varicose veins in the legs: NICE guideline. Br J Gen Pract. 2014;64(623):314–5 Current Practice Guidelines for diagnosis and management of varicose veins.

    Article  Google Scholar 

  13. MacKenzie RK, Paisley A, Allan PL, Lee AJ, Ruckley CV, Bradbury AW. The effect of long saphenous vein stripping on quality of life. J Vasc Surg. 2002;35(6):1197–203.

    Article  CAS  Google Scholar 

  14. Baker DM, Turnbull NB, Pearson JC, Makin GS. How successful is varicose vein surgery? A patient outcome study following varicose vein surgery using the SF-36 health assessment questionnaire. Eur J Vasc Endovasc Surg. 1995;9(3):299–304.

    Article  CAS  Google Scholar 

  15. Ratcliffe J, Brazier JE, Campbell WB, Palfreyman S, MacIntyre JB, Michaels JA. Cost-effectiveness analysis of surgery versus conservative treatment for uncomplicated varicose veins in a randomized clinical trial. Br J Surg. 2006;93(2):182–6.

    Article  CAS  Google Scholar 

  16. Critchley G, Handa A, Maw A, Harvey MR, Corbett CR. Complications of varicose vein surgery. Ann R Coll Engl. 1997;79(2):105–10.

    CAS  Google Scholar 

  17. Fischer R, Chandler JG, De Maeseneer MG, Frings N, Lefebvre-Vilarbedo, et al. The unresolved problem of recurrent Saphenofemoral reflux. J Am Coll Surg. 2002;195(1):80–94.

    Article  Google Scholar 

  18. Tessari L, Cavezzi A, Frullini A. Preliminary experience with a new sclerosing foam in the treatment of varicose veins. Dermatol Surg. 2001;27(1):58–60.

    CAS  PubMed  Google Scholar 

  19. Cabrera J, Cabrera JJ, Garcia-Olmedo MA. Treatment of varicose long saphenous veins with sclerosant in microfoam form: long-term outcomes. Phlebology. 2000;15:19–23.

    Article  Google Scholar 

  20. Wright D, Gobin JP, Bradbury A, Coleridge-Smith P, Spoelstra H, Berridge D, et al. Varisolve polidocanol microfoam compared with surgery or sclerotherapy in the management of varicose veins in the presence of trunk vein incompetence: European randomised controlled trial. Phlebology. 2006;21:180–90.

    Article  Google Scholar 

  21. Shadid N, Ceulen R, Nelemans P, Dirksen C, Veraart J, Schurink GW, et al. Randomized clinical trial of ultrasound-guided foam sclerotherapy versus surgery for the incompetent great saphenous vein. Br J Surg. 2012;99:1062–70.

    Article  CAS  Google Scholar 

  22. •• Rasmussen LH, Lawaetz M, Bjoern L, Vennits B, Blemings A, Eklof B. Randomized clinical trial comparing endovenous laser ablation, radiofrequency ablation, foam sclerotherapy and surgical stripping for great saphenous varicose veins. Br J Surg. 2011;98(8):1079–87 Trial comparing all the modalities of varicose vein treatment.

    Article  CAS  Google Scholar 

  23. Vähäaho S, Halmesmäki K, Albäck A, Saarinen E, Venermo M. Five-year follow-up of a randomized clinical trial comparing open surgery, foam sclerotherapy and endovenous laser ablation for great saphenous varicose veins. BJS. 2018;105:686–91.

    Article  Google Scholar 

  24. •• Lawaetz M, Serup J, Lawaetz B, Bjoern L, Blemings A, Ecklof E, et al. Comparison of endovenous ablation techniques, foam sclerotherapy and surgical stripping for great saphenous varicose veins. Extended 5-year follow-up of a RCT. Int Angiol. 2017;36(3):281–8 5-Year Follow Up of RCT Comparing EndoVenous Ablation vs. Surgery vs. Foam and Demonstrating a Quality of life Benefit with Endovenous Ablation Relative to Surgery.

    PubMed  Google Scholar 

  25. Lurie F, Creton D, Eklof B, Kabnick LS, Kistner RL, Pichot O, et al. Prospective randomised study of endovenous radiofrequency obliteration (closure) versus ligation and vein stripping (EVOLVeS): two-year follow-up. Eur J Vasc Endovasc Surg. 2005;29(1):67–73.

    Article  CAS  Google Scholar 

  26. Helmy ElKaffas K, ElKashef O, ElBaz W. Great saphenous vein radiofrequency ablation versus standard stripping in the management of primary varicose veins-a randomized clinical trial. Angiology. 2011;62(1):49–54.

    Article  Google Scholar 

  27. Subramonia S, Lees T. Randomized clinical trial of radiofrequency ablation or conventional high ligation and stripping for great saphenous varicose veins. Br J Surg. 2010;7(3):328–36.

    Article  Google Scholar 

  28. Min RJ, Khilnani N, Zimmet S. Endovenous laser treatment of saphenous vein reflux: long-term results. J Vasc Interv Radiol. 2003;14:991–6.

    Article  Google Scholar 

  29. Rass K, Frings N, Glowacki P, Hamsch C, Graber S, Vogt T, et al. Comparable effectiveness of endovenous laser ablation and high ligation with stripping of the great saphenous vein: two-year results of a randomized clinical trial (RELACS study). Arch Dermatol. 2012;148:49–58.

    Article  Google Scholar 

  30. Darwood RJ, Theivacumar N, Dellagrammaticas D, Mavor AI, Gough MJ. Randomized clinical trial comparing endovenous laser ablation with surgery for the treatment of primary great saphenous varicose veins. Br J Surg. 2008;95(3):294–301. https://doi.org/10.1002/bjs.6101.

    Article  CAS  PubMed  Google Scholar 

  31. Almeida JI, Javier JJ, Mackay E, Proebstle TM. First human use of cyanoacrylate adhesive for treatment of saphenous vein incompetence. J Vasc Surg Venous Lymphat Disord. 2013;1(2):174–80.

    Article  Google Scholar 

  32. •• Gibson K, Ferris B. Cyanoacrylate closure of incompetent great, small and accessory saphenous veins without the use of post-procedure compression: initial outcomes of a post-market evaluation of the VenaSeal System (the WAVES Study). Vascular. 2017;25(2):149–56 Outcomes for the VenaSeal procedure; a newly FDA approved adhesive treatment for saphenous ablation.

    Article  Google Scholar 

  33. Morrison N, Gibson K, McEnroe S, Goldman M, King T, Weiss R, et al. Randomized trial comparing cryanoacrylate embolization and radiofrequency ablation for incompetent great saphenous veins (VeClose). J Vasc Surg. 2015;61(4):985–94.

    Article  Google Scholar 

  34. Venermo M, Saarinen E, Eskelinen E, Vähäaho S. Saarinen et. al. randomized clinical trial comparing surgery, endovenous laser ablation and ultrasound-guided foam sclerotherapy for the treatment of great saphenous varicose veins. Br J Surg. 2016;103(11):1438–44.

    Article  CAS  Google Scholar 

  35. •• Brittenden J, Cotton SC, Elders A, et al. A randomized trial comparing treatments for varicose veins. N Engl J Med. 2014;1218:371 Large randomized control trial comparing various treatments for varicose veins.

    Google Scholar 

  36. •• Gale SS, Lee JN, Walsh ME, et al. A randomized, controlled trial of endovenous thermal ablation using the 810-nm wavelength laser and the ClosurePLUS radiofrequency ablation methods for superficial venous insufficiency of the great saphenous vein. Vasc Surg. 2010;53(3):645–50 Randomized control trial comparing RFA to Endovenous laser treatment and demonstrating comparable efficacy.

    Article  Google Scholar 

  37. Almeida JI, Kaufman J, Göckeritz O, Chopra P, Evans MT, et al. Radiofrequency endovenous ClosureFAST versus laser ablation for the treatment of great saphenous reflux: a multicenter, single-blinded, randomized study (RECOVERY study). J Vasc Interv Radiol. 2009;20(6):752–9.

    Article  Google Scholar 

  38. Goode SD, Chowdhury A, Crockett M, Beech A, Simpson R, Richards T, et al. Laser and radiofrequency ablation study (LARA study): a randomized study comparing radiofrequency ablation and endovenous laser ablation (810nm). Eur J Endovasc Surg. 2010;40(2):246–53.

    Article  CAS  Google Scholar 

  39. • Rasmussen L, Lawaetz M, Serup J, et al. Randomized clinical trial comparing endovenous laser ablation, radiofrequency ablation, foam sclerotherapy and surgical stripping for great saphenous varicose veins and 3-year follow-up. J Vasc Surg Venous Lymphat Disord. 2013;1(4):349–56 3-year results of the same trial demonstrating a significant QOL benefit.

    Article  Google Scholar 

  40. Van der Velden SK, Biemans AA, De Maeseneer MG, Kockaert MA, Cuypers PW, et al. A five-year results of a randomized clinical trial of conventional surgery, endovenous laser ablation and ultrasound-guided foam sclerotherapy in patients with great saphenous varicose veins. Br J Surg. 2015;102(10):1184–94.

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Vein Institute and Pain Centers of America, New York, NY, USA

    Caroline J. Novak, Namrata Khimani & R. Jason Yong

  2. Department of Anesthesiology, Louisiana State University Health Sciences Center, New Orleans, LA, USA

    Alan D. Kaye

  3. Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA

    Richard D. Urman

Authors
  1. Caroline J. Novak
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Namrata Khimani
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Alan D. Kaye
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. R. Jason Yong
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Richard D. Urman
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Namrata Khimani.

Ethics declarations

Conflict of Interest

Caroline J. Novak, Namrata Khimani, Alan D. Kaye, R. Jason Yong, and Richard D. Urman declare no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This article is part of the Topical Collection on Other Pain

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Novak, C.J., Khimani, N., Kaye, A.D. et al. Current Therapeutic Interventions in Lower Extremity Venous Insufficiency: a Comprehensive Review. Curr Pain Headache Rep 23, 16 (2019). https://doi.org/10.1007/s11916-019-0759-z

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/s11916-019-0759-z

Keywords

Search

Navigation