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18 Chronic Venous Disease andVaricose Veins
3. For patients with great saphenous vein incompetence requiring treatment, cya-
noacrylate adhesive closure should be considered when a non-thermal nontumescent technique is preferred.
4. For patients with great saphenous vein incompetence requiring treatment, mech-
anochemical ablation may be considered when a non-thermal non-tumescent
technique is preferred.
5. No difference in outcomes following mechanochemical ablation or cyanoacry-
late adhesive closure has been found. This suggests that the main determinant as
to which interventions to use would be surgeon and patient preference and the
cost-effectiveness of each technique.
6. For patients with saphenous trunk incompetence undergoing treatment, ultra-
sound guided foam sclerotherapy may be considered for treating saphenous
trunks with a diameter less than 6mm.
7. Endovenous ablation of supercial venous incompetence in combination with
compression improves leg ulcer healing when compared with compression alone.
8. Wearing compression stockings after endothermal ablation is advantageous in
the rst few days after treatment and is especially benecial for those having
concurrent phlebectomies.
References
1. De Maeseneer MG, Kakkos SK, Aherne T, et al. Editor's choice—European Society for
Vascular Surgery (ESVS) 2022 clinical practice guidelines on the management of chronic
venous disease of the lower limbs. Eur J Vasc Endovasc Surg. 2022;63:184–267.
2. Whing J, Nandhra S, Nesbitt C, Stansby G.Interventions for great saphenous vein incompetence. Cochrane Database Syst Rev. 2021;8(8):CD005624.
3. Cai PL, Hitchman LH, Mohamed AH, Smith GE, Chetter I, Carradice D.Endovenous ablation for venous leg ulcers. Cochrane Database Syst Rev. 2023;7(7):CD009494. https://doi.
org/10.1002/14651858.CD009494.
4. Farah MH, Nayfeh T, Urtecho M, Hasan B, Amin M, Sen I, Wang Z, Prokop LJ, Lawrence
PF, Gloviczki P, Murad MH.A systematic review supporting the Society for Vascular Surgery,
the American Venous Forum, and the American Vein and Lymphatic Society guidelines on the
management of varicose veins. J Vasc Surg Venous Lymphat Disord. 2022;10:1155–71.
5. Hamann SAS, Giang J, De Maeseneer MGR, Nijsten TEC, van den Bos RR.Editor's choice—
ve year results of great saphenous vein treatment: a meta-analysis. Eur J Vasc Endovasc Surg.
2017;54:760–70.
6. Aherne TM, Ryan ÉJ, Boland MR, McKevitt K, Hassanin A, Tubassam M, Tang TY, Walsh
S.Concomitant vs. staged treatment of varicose tributaries as an adjunct to endovenous ablation: a systematic review and meta-analysis. Eur J Vasc Endovasc Surg. 2020;60:430–42.
7. Turner BRH, Machin M, Jasionowska S, Salim S, Onida S, Shalhoub J, Davies AH.Systematic
review and meta-analysis of the additional benet of pharmacological thromboprophylaxis for
endovenous varicose vein interventions. Ann Surg. 2023;278:166–71.
8. Ma F, Xu H, Zhang J, Premaratne S, Gao H, Guo X, Yang T.Compression therapy following
endovenous thermal ablation of varicose veins: a systematic review and meta-analysis. Ann
Vasc Surg. 2022;80:302–12.
9. Hu H, Wang J, Wu Z, Liu Y, Ma Y, Zhao J.No benet of wearing compression stockings after
endovenous thermal ablation of varicose veins: a systematic review and meta-analysis. Eur J
Vasc Endovasc Surg. 2022;63:103–11.
References
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10. Shahzad N, Elsherif M, Obaidat I, Brar R.A systematic review and meta-analysis of randomised controlled trials comparing thermal versus non-thermal endovenous ablation in
supercial venous incompetence. Eur J Vasc endovasc Surg. 2023;66:687–95.
11. Lim AJM, Mohamed AH, Hitchman LH, Lathan R, Ravindhran B, Sidapra MM, Smith G,
Chetter IC, Carradice D.Clinical outcomes following mechanochemical ablation of supercial venous incompetence compared with endothermal ablation: meta-analysis. Br J Surg.
2023;110:562–7.
12. García-Carpintero E, Carmona M, Chalco-Orrego JP, González-Enríquez J, Imaz-Iglesia
I.Systematic review and meta-analysis of endovenous cyanoacrylate adhesive ablation for
incompetent saphenous veins. J Vasc Surg Venous Lymphat Disord. 2020;8:287–96.
13. Kolluri R, Chung J, Kim S, Nath N, Bhalla BB, Jain T, Zygmunt J, Davies A.Network metaanalysis to compare VenaSeal with other supercial venous therapies for chronic venous insufciency. J Vasc Surg Venous Lymphat Disord. 2020;8:472–81.
14. Guo J, Zhang F, Guo J, Guo L, Gu Y, Huang Y.A systematic review and meta-analysis comparing the efcacy of cyanoacrylate ablation over endovenous thermal ablation for treating
incompetent saphenous veins. Phlebology. 2021;36:597–608.
15. Hassanin A, Aherne TM, Greene G, Boyle E, Egan B, Tierney S, Walsh SR, McHugh S, Aly
S.A systematic review and meta-analysis of comparative studies comparing nonthermal versus thermal endovenous ablation in supercial venous incompetence. J Vasc Surg Venous
Lymphat Disord. 2019;7:902–13.
16. Schaink A, etal. Ontario Health (Quality) Nonthermal Endovenous Procedures for varicose
veins: a health technology assessment. Ont Health Technol Assess Ser. 2021;21:1–188.
17. Nyamekye IK, Pullen BJ, Kelly N, Hayes W.Six year extension study of patients from a randomised clinical trial comparing venet, radiofrequency induced thermal therapy, and endovenous radiofrequency ablation for treatment of incompetent great saphenous veins. Eur J Vasc
Endovasc Surg. 2023;66:94–101.
18. Bootun R, Belramman A, Bolton-Saghdaoui L, Lane TRA, Riga C, Davies AH.Randomized
controlled trial of compression after endovenous thermal ablation of varicose veins (COMETA
trial). Ann Surg. 2021;273:232–9.
19. Brittenden J, Cooper D, Dimitrova M, etal. Five-year outcomes of a randomized trial of treatments for varicose veins. N Engl J Med. 2019;381(10):912–22.
20. Lawson JA, Gauw SA, van Vlijmen CJ, Pronk P, Gaastra MTW, Tangelder MJ, Mooij
MC.Prospective comparative cohort study evaluating incompetent great saphenous vein closure using radiofrequency-powered segmental ablation or 1470-nm endovenous laser ablation
with radial-tip bers (Varico 2 study). J Vasc Surg Venous Lymphat Disord. 2018;6:31–40.
21. Holewijn S, van Eekeren RRJP, Vahl A, de Vries JPPM, Reijnen MMPJ, MARADONA study
group. Two-year results of a multicenter randomized controlled trial comparing mechanochemical endovenous ablation to RADiOfrequeNcy ablation in the treatment of primary great
saphenous vein incompetence (MARADONA trial). J Vasc Surg Venous Lymphat Disord.
2019;7:364–74.
22. Belramman A, Bootun R, Tang TY, Lane TRA, Davies AH.Pain outcomes following mechanochemical ablation vs cyanoacrylate adhesive for the treatment of primary truncal saphenous
vein incompetence: the MOCCA randomized clinical trial. JAMA Surg. 2022;157:395–404.
23. Scheerders ERY, van der Velden SK, Goossens LMA, Hamann SAS, de Maeseneer MGR,
Malskat WSJ, de Mik L, Nijsten TEC, van den Bos RR, members of the SAPTAP group. A
randomized clinical trial of isolated ambulatory phlebectomy versus saphenous thermal ablation with concomitant phlebectomy (SAPTAP trial). Br J Surg. 2023;110:333–42.
24. Lurie F, Passman M, Meisner M, etal. The 2020 update of the CEAP classication system and
reporting standards. J Vasc Surg Venous Lymphat Disord. 2020;8:342–52. Erratum in: J Vasc
Surg Venous Lymphat Disord. 2021;9(1):288
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Chapter 19
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Deep Vein Thrombosis oftheLower Limb
andPost-Thrombotic Syndrome
19.1 Guidelines
19.1.1 European Society ofCardiology
The “European Society of Cardiology working groups of aorta and peripheral vascular diseases and pulmonary circulation and right ventricular function” have published a joint consensus document on diagnosis and management of acute deep vein
thrombosis [1].
19.1.1.1 Consensus Statement: Diagnosis
• Clinical prediction rule (two-level modied Wells score, Table19.1) is recom-
mended to stratify patients with suspected lower limb deep vein thrombosis (DVT).
• ELISA D-dimer measurement is recommended in ‘unlikely’ clinical probability
patients to exclude DVT.
• Venous US is recommended as rst line imaging method for DVT diagnosis.
• Venous CT scan should be reserved to selected patients only.
• Venous US should be proposed also in case of conrmed pulmonary embolism
(PE), for initial reference venous imaging, useful in case of DVT recurrence
suspicion or further stratication in selected patients.
• Venous US may be considered for further stratication in selected patients with
concomitant suspected PE.
Switzerland AG 2023
E. S. Debus, R. T. Grundmann, Evidence-based Therapy in Vascular Surgery,
https://doi.org/10.1007/978-3-031-47397-5_19
405© The Author(s), under exclusive license to Springer Nature
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Table 19.1 The Wells score for clinical assessment of deep-vein thrombosis [1, 26]
Clinical variable Points
Active cancer (treatment ongoing or within previous 6months or palliative) +1
Paralysis, paresis or recent plaster immobilization of the lower extremities +1
Recently bedridden for 3days or more, or major surgery within the previous 12weeks
requiring general or regional anesthesia
Localized tenderness along the distribution of the deep venous system +1
Entire leg swelling +1
Calf swelling at least 3cm larger than that on the asymptomatic leg (measured 10cm
below the tibial tuberosity)
Pitting edema conned to the symptomatic leg +1
Collateral supercial veins (non varicose) +1
Previously documented DVT +1
Alternative diagnosis at least as likely as DVT -2
Three-level Wells score
– Low <1
– Intermediate 1–2
– High >2
Two-level Wells score:
– DVT unlikely: Score≤1
– DVT likely: Score≥2
19 Deep Vein Thrombosis oftheLower Limb andPost-Thrombotic Syndrome
+1
+1
19.1.1.2 Consensus Statement: Initial andLong-Term Management
• Patients with proximal DVT should be anticoagulated for at least 3-months.
• Patients with isolated distal DVT at high-risk of recurrence should be anticoagu-
lated, as for proximal DVT; for those at low risk of recurrence shorter treatment
(4–6weeks), even at lower anticoagulant doses, or ultrasound surveillance may
be considered.
• In the absence of contraindications, DOACs should be preferred as rst-line anti-
coagulant therapy in non-cancer patients with proximal DVT.
• Adjuvant catheter-directed thrombolysis (CDT) may be considered in selected
patients with ilio-common femoral DVT, symptoms <14 days, and life expectancy >1year if performed in experienced centres.
• Primary acute DVT stenting or mechanical thrombus removal alone are not
recommended.
• Vena cava lters may be considered if anticoagulation is contraindicated, their
use in addition to anticoagulation is not recommended.
• Compression therapy associated with early mobilization and walking exercise
should be considered to relieve acute venous symptoms.
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19.1.1.3 Consensus Statement: Extended Management
• Decision to discontinue or not anticoagulation should be individually tailored,
balancing risk of recurrence against bleeding risk, taking into account patients’
preferences and compliance.
• In the absence of contraindications, DOACs should be preferred as rst line anti-
coagulant therapy in non-cancer patients. Currently low-dose apixaban and rivaroxaban have shown their benet in this setting.
• When VKAs are proposed, they should be administered at conventional intensity
regimen (INR 2–3).
• Aspirin may be considered for extended treatment if anticoagulation is
contraindicated.
• Endovascular recanalization may be considered in patients with chronic venous
occlusion class CEAP 4–6.
• Regular (at least yearly) assessment of compliance and benet/risk balance
should be performed in patients on extended treatment.
• At anticoagulation discontinuation, venous US should be performed to establish
a baseline comparative exam in case of recurrence.
19.1.1.4 Consensus Statement: DVT Management inSpecial Situations
• In case of upper extremities DVT (UEDVT) suspicion, venous US is the rst
choice imaging test.
• Treatment of UEDVT is similar to that of lower limb DVT with regard to
anticoagulation.
• LMWH are recommended for acute treatment of cerebral vein thrombosis.
• LMWH are recommended for acute treatment of splanchnic vein thrombosis.
• LMWH are recommended for initial and long-term treatment in cancer patients.
• In cancer patients, after 6months, decision of continuation and, if so, the mode
of anticoagulation should be based on individual evaluation of the benet-risk
ratio, tolerability, patients’ preference, and cancer activity.
• During pregnancy, venous US is recommended as rst line DVT imaging test.
• During pregnancy, LMWH is recommended for initial and long-term treatment.
• Anticoagulant treatment should be continued for at least 6weeks after delivery
with a total of 3-months treatment.
19.1.1.5 Venous Occlusion Recanalization
The following comments are made in this guideline:
• Endovascular techniques are available for selected patients with post-thrombotic
syndrome (PTS). Case series and prospective cohort trials suggest that at least
some subgroups of PTS patients (CEAP classes 4–6) may benet from addition
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of endovascular therapy into overall management strategy. In patients with
moderate- to-severe PTS and iliac vein obstruction, endovascular stent placement
may be used to restore vein patency.
• In selected infrequent cases, surgical vein bypass may be an option to relieve
venous hypertension.
19 Deep Vein Thrombosis oftheLower Limb andPost-Thrombotic Syndrome
19.1.2 The Postthrombotic Syndrome—A Scientic Statement
fromtheAmerican Heart Association [2]
19.1.2.1 Recommendations forThrombolysis andEndovascular
Approaches toAcute DVT forthePrevention ofPostthrombotic
Syndrome (PTS)
• Catheter-directed thrombolysis (CDT) and pharmacomechanical catheter-
directed thrombolysis (PCDT), in experienced centers, may be considered in
select patients with acute (≤14days) symptomatic, extensive proximal DVT who
have good functional capacity, ≥1-year life expectancy, and low expected bleeding risk (Class IIb; Level of Evidence B).
• Systemic anticoagulation should be provided before, during, and after CDT and
PCDT (Class I, Level of Evidence C).
• Balloon angioplasty with or without stenting of underlying anatomic venous
lesions may be considered after CDT and PCDT as a means to prevent rethrombosis and subsequent PTS (Class IIb; Level of Evidence B).
• When a patient is not a candidate for percutaneous CDT or PCDT, surgical
thrombectomy, in experienced centers, might be considered in select patients
with acute (≤14days) symptomatic, extensive proximal DVT who have good
functional capacity and≥1-year life expectancy (Class IIb; Level of Evidence B).
• Systemic thrombolysis is not recommended for the treatment of DVT (Class III;
Level of Evidence A).
19.1.2.2 Recommendations fortheUse ofGraduated Elastic Compression
Stockings (ECS) andIntermittent Compression toTreat PTS
• A trial of ECS may be considered in patients with PTS who have no contraindi-
cations (e.g., arterial insufciency) (Class IIb; Level of Evidence C).
• For patients with moderate or severe PTS and signicant edema, a trial of an
intermittent compression device is reasonable (Class IIb; Level of Evidence C).
19.1 Guidelines
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19.1.2.3 Recommendations forExercise Training toTreat PTS
• In patients with PTS, a supervised exercise training program consisting of leg
strength training and aerobic activity for at least 6 months is reasonable for
patients who are able to tolerate it (Class IIa; Level of Evidence B).
19.1.2.4 Recommendations forVenous Ulcer Management
• Compression should be used to treat venous ulcers in preference to primary
dressing alone, noncompression bandage, or no compression (Class I; Level of
Evidence A).
• Multicomponent compression systems are more effective than single-component
systems (Class I; Level of Evidence B).
• Pentoxifylline can be useful for treating venous ulcers on its own or with com-
pression (Class IIa; Level of Evidence A).
• Neovalve reconstruction may be considered in patients with refractory post-
thrombotic venous ulcers (Class IIb; Level of Evidence C).
19.1.2.5 Recommendations forEndovascular andSurgical
Treatment ofPTS
• For the severely symptomatic patient with iliac vein or vena cava occlusion, sur-
gery (e.g., femoro-femoral or femoro-caval bypass) (Class IIb; Level of Evidence
C) or percutaneous endovenous recanalization (e.g., stent, balloon angioplasty)
(Class IIb; Level of Evidence B) may be considered.
• For severely symptomatic patients with postthrombotic occlusion of their com-
mon femoral vein, iliac vein, and vena cava, combined operative and endovenous
disobliteration may be considered (Class IIb; Level of Evidence C).
• For severely symptomatic patients with PTS, segmental vein valve transfer or
venous transposition may be considered (Class IIb; Level of Evidence C).
The endovascular, surgical and hybrid approaches to the treatment of PTS as recommended in this guideline are summarized in Table19.2. It is emphasized that experience with these procedures is limited and only the most severely affected patients
are considered for treatment. Outcomes of these procedures are highly dependent on
operator (surgical) expertise, and if not available locally, referral to a center with
expertise is recommended.
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Table 19.2 Endovascular, surgical and hybrid approaches to the treatment of post-thrombotic
syndrome (PTS) (according to [2])
Indication Approach
Iliocaval/iliofemoral
obstruction
Correction of
supercial reux
Infrainguinal venous
obstruction
Iliofemoral obstruction – Femoro-femoral bypass
Correction of reux – Segmental vein valve transfer via axillofemoral/popliteal transplant
Femoral and iliac vein
reconstruction
19 Deep Vein Thrombosis oftheLower Limb andPost-Thrombotic Syndrome
Endovascular approaches
Venoplasty and stenting
Endovenous thermal ablation
Surgical approaches
– Saphenopopliteal bypass
– Saphenotibial bypass
– Femoroiliac bypass
– Iliocaval bypass
– Femoro-caval bypass
or venous transposition
– Ligation of femoral vein
Hybrid approaches
– Surgical endophlebectomy of common femoral vein with patch
angioplasty and endoluminal balloon venoplasty and stenting of iliac
veins and vena cava
– Adjunctive arteriovenous stula to maintain patency
– Surgical disobliteration of common femoral vein to more
effectively drain infrainguinal venous system and provide inow to
recanalized iliac veins
19.1.3 CHEST Guideline forAntithrombotic Management
ofVenous Thromboembolism [3]
The guidelines recommend among others:
• In patients with supercial venous thrombosis (SVT) of the lower limb at
increased risk of clot progression to DVT or PE, we suggest the use of anticoagulation for 45days over no anticoagulation (weak recommendation, moderate certainty evidence).
• In patients with SVT who are treated with anticoagulation, we suggest
fondaparinux 2.5mg daily over other anticoagulant treatment regimens such as
(prophylactic- or therapeutic-dose) LMWH (weak recommendation, lowcertainty evidence).
• In patients with acute DVT of the leg we suggest anticoagulant therapy alone
over interventional (thrombolytic, mechanical, or pharmacomechanical) therapy
(weak recommendation, moderate-certainty evidence).
• In patients with VTE (DVT of the leg or PE) we recommend apixaban, dabiga-
tran, edoxaban, or rivaroxaban over VKA as treatment-phase (rst 3months)
anticoagulant therapy (strong recommendation, moderate-certainty evidence).
19.1 Guidelines
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• In patients with acute DVT of the leg, we suggest against using compression
stockings routinely to prevent PTS (weak recommendation, low-certainty
evidence).
• In patients with acute DVT of the leg, we recommend against the use of an infe-
rior vena cava (IVC) lter in addition to anticoagulants (strong recommendation,
moderate-certainty evidence).
• In patients with acute proximal DVT of the leg and a contraindication to antico-
agulation, we recommend the use of an IVC lter (strong recommendation,
moderate- certainty evidence).
• In patients with acute VTE who do not have a contraindication we recommend a
3-month treatment phase of anticoagulation (strong recommendation, moderatecertainty evidence).
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19.1.4 Clinical Practice Guidelines oftheEuropean Society
forVascular Surgery (ESVS) ontheManagement
ofChronic Venous Diseases oftheLower Limbs [4].
They Recommend
19.1.4.1 Recommendation 58
For patients with iliac vein outow obstruction and severe symptoms/signs, endovascular treatment should be considered, as the rst choice treatment.
(Recommendation class IIa/Level of evidence B).
19.1.4.2 Recommendation 59
For patients with iliac vein outow obstruction undergoing endovascular treatment,
the use of intravascular ultrasound should be considered to guide treatment.
(Recommendation class IIa/ Level of evidence C).
19.1.4.3 Recommendation 60
For patients with iliac vein outow obstruction suffering from a recalcitrant venous
ulcer, severe post-thrombotic syndrome, or disabling venous claudication, surgical
or hybrid deep venous reconstruction may be considered when endovascular options
alone are not appropriate. (Recommendation class IIb/ Level of evidence C).
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19.1.4.4 Recommendation 61
For patients with iliac vein outow obstruction, without severe symptoms, neither
endovascular nor surgical interventions are recommended. (Recommendation class
III/ Level of evidence C).
19.1.4.5 Recommendation 62
For patients undergoing either endovascular or surgical reconstruction of iliac vein
outow obstruction, duplex ultrasound surveillance is recommended 1 day and
2weeks after the intervention, and at regular intervals thereafter. (Recommendation
class I/Level of evidence C).
19.1.4.6 Recommendation 63
For patients with iliac vein outow obstruction, management by a multidisciplinary
team is recommended. (Recommendation class I/Level of evidence C).
19.1.4.7 Recommendation 64
19 Deep Vein Thrombosis oftheLower Limb andPost-Thrombotic Syndrome
For patients with extensive axial deep venous incompetence and severe persistent
symptoms and signs, where previous management has failed, surgical repair of valvular incompetence may be considered in specialised centres. (Recommendation
class IIb/ Level of evidence B).
19.1.5 European Society forVascular Surgery (ESVS) Clinical
Practice Guidelines ontheManagement
ofVenous Thrombosis
This guideline notes on thrombus removal strategies [5]:
19.1.5.1 Recommendation 34
In selected patients with symptomatic iliofemoral deep vein thrombosis, early
thrombus removal strategies should be considered. (Recommendation class IIa;
Level of evidence A).
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