Brazilian guidelines on chronic venous disease of the Brazilian Society of Angiology and Vascular Surgery

Abstract

The Brazilian Society of Angiology and Vascular Surgery has set up a committee to provide new evidence-based recommendations for patient care associated with chronic venous insufficiency. Topics were divided in five groups: 1. Classification, 2. Diagnosis, 3. Conservative or non-invasive treatment, 4. Invasive treatment and 5. Treatment of small vessels. This last series is closely related to the activities of Brazilian angiologists and vascular surgeons, who are heavily involved in the treatment of small superficial veins. These guidelines are intended to assist in clinical decision-making for attending physicians and health managers. The decision to follow a guideline recommendation should be made by the responsible physician on a case-by-case basis taking into account the patient's specific condition, as well as local resources, regulations, laws, and clinical practice recommendations.

Keywords:
venous insufficiency; guideline; varicose veins; venous disease; treatment

Resumo

A Sociedade Brasileira de Angiologia e de Cirurgia Vascular organizou uma comissão para fornecer novas recomendações baseadas em evidências sobre questões críticas de atendimento ao paciente com insuficiência venosa crônica. São abordados aqui os temas de classificação, diagnóstico, tratamento conservador, tratamento invasivo e tratamento de pequenos vasos. Esta última série está muito relacionada à atividade de angiologistas e cirurgiões vasculares, que possuem forte atuação no tratamento de pequenas veias superficiais. Estas diretrizes destinam-se a auxiliar na tomada de decisões clínicas de médicos assistentes e gestores de saúde. A decisão de seguir uma recomendação de diretriz deve ser feita pelo médico responsável caso a caso, levando em consideração a condição específica do paciente, bem como recursos locais, regulamentos, leis e recomendações de prática clínica.

Palavras-chave:
insuficiência venosa; diretriz; varizes; doença venosa; tratamento

INTRODUCTION

Chronic venous disease is a condition affecting the venous system of the lower limbs and may present with various morphological and functional abnormalities.¹ Its clinical, etiological, anatomical, and physiopathological aspects are described in the CEAP classification.²,³ Stages C1 and C2 are the most frequent,⁴ and risk factors include female sex, advanced age, obesity, prolonged standing, positive family history, and parity.⁴ The progression of CVD may be more common in individuals who are overweight and have a history of deep vein thrombosis, and the presence of deep and superficial venous reflux may be associated with new varicose veins.⁵,⁶

In the most superficial segment, studies show the existence of venous valves in small-diameter veins, and that these valves may also be incompetent.⁷ The incompetence of these micro-valves may play a critical role in the progression of skin changes.⁸ The initial causes of these changes may be inflammatory phenomena⁹,¹⁰ which may have both ascending and descending progression.¹¹ The disease may also be caused by changes in perforator veins¹² or post-thrombotic syndromes, the latter with more severe complications.¹³ This communication and the anatomic complexity of the venous system may lead to skin changes, including severe hypoxia with the formation of venous ulcers.¹⁴,¹⁵

The clinical presentations of CVD are varied, and do not necessarily correspond to its clinical severity.¹⁶ The symptoms are also unspecific, and frequently mistaken for other diseases.¹⁷-¹⁹ CVD is a benign disorder, but which can be correlated with venous thrombosis or bleeding.²⁰,²¹

Scoring systems have been developed in an attempt to monitor treatment outcomes and assess the progression of the disease or other interventions, including the Venous Clinical Severity Score (VCSS), designed to assess changes in patient status after an intervention.²² The Villalta scale is used by both the patient and the physician to diagnose and assess the severity of post-thrombotic syndrome.²³,²⁴ Other tools used to assess CVD include the Aberdeen Varicose Veins Questionnaire (AVVQ),²⁵ the Chronic Venous Insufficiency Questionnaire (CIVIQ),²⁶ and the Venous Insufficiency Epidemiological and Economic Study - Quality of Life/Symptoms (VEINES-QOL/Sym).²⁷

Considering the high prevalence of the disease, with its many nuances in diagnosis and, consequently, in treatment, a national guideline is extremely important to guide practitioners and health system managers.

METHODS

Vascular surgeons specializing in venous disease and members of the Brazilian Society of Angiology and Vascular Surgery (SBACV) were invited to join the CVD Guidelines Project. All members disclosed their conflicts of interest related to the development of these guidelines. The project received no industry financing. Through biweekly online meetings starting on March 2022, all project members participated in decisions and choices regarding the development of the questions and the organization of this effort.

The group was split into subgroups to optimize the work, namely: 1) classification; 2) diagnosis; 3) conservative or non-invasive treatment; 4) invasive treatment; and 5) treatment of small vessels. Each project member participated in at least two subgroups.

Selection of recommendations

An initial brainstorming session with all group members was held to select what recommendations would be developed, with each topic then assigned to a subgroup. After this initial stage, the participants of each subgroup were responsible for selecting the most relevant subjects for this guideline.

Search terms were discussed within each subgroup and chosen for queries in the MEDLINE, LILACS, SciELO, and Central databases, in Portuguese, English, and Spanish. Originally, the search period was limited to the period between January 2013 and February 2022, but if search results were not quantitatively or qualitatively sufficient, new queries were performed without date limits.

If required, additional articles were handsearched as well. The article selection and classification process followed an article quality sequence, defined (in descending quality order): systematic reviews, randomized controlled trials, nonrandomized trials, retrospective studies, case series, and expert opinions. When possible, articles were classified for bias risk using Rob 2.0 and Rob cohort (Cochrane, Londres).

Recommendation criteria

The European Society of Cardiology system was used to grade recommendations according to evidence levels.²⁸ These criteria can be found in Tables 1 and 2.

Table 1
European Society of Cardiology (ESC) levels of evidence.

Level of evidence A	Data derived from multiple randomized clinical trials or meta-analyses.
Level of evidence B	Data derived from a single randomized clinical trial or large non-randomized studies.
Level of evidence C	Consensus of opinion of the experts and/or small studies, retrospective studies, and registries.

Table 2
European Society of Cardiology (ESC) classes of recommendations.

Class of recommendation	Definition
Class I	Evidence and/or general agreement that a given diagnostic procedure or treatment is beneficial, useful, and effective.
Class II	Conflicting evidence and/or a divergence of opinion about the usefulness or efficacy of the treatment or procedure.
Class IIa	Weight of evidence or opinion is in favor of usefulness or efficacy.
Class IIb	Usefulness or efficacy is less well established by evidence or opinion.
Class III	Evidence or general agreement that the treatment or procedure is not useful or effective and, in some cases, may be harmful.

CLASSIFICATION

Venous disease is much more common in women than in men. Advanced age and number of pregnancies are important factors for the development of the disease.²⁹,³⁰ The CEAP classification, originally established in 1994, was recently revised. Corona phlebectatica was added as C4c due its potential to progress to a venous ulcer.³¹,³²

Recommendation 1

• We recommend using the classification of clinical, etiological, anatomical, and physiopathological (CEAP) aspects for all chronic venous insufficiency patients for academic and legal purposes.

  • Level B

  • Class I

  • References:²⁹,³¹-³⁴

Subclass Esi was included to acknowledge intravenous causes, such as post-thrombotic changes and traumatic arteriovenous fistulas. No wall or valve injury was observed in the categorization of extravenous secondary etiologies. The triggers stem from conditions affecting venous hemodynamics.³¹

Clinical presentation is not always indicative of anatomic or hemodynamic severity. A cross-sectional study of 100 patients with varicose veins found no correlation between mean saphenous vein diameter and clinical classification. There was a correlation between advanced age and clinical severity (p = 0.04) and between obesity and greater diameter was measured using ultrasonography.³⁵

The primary advantage of CEAP classification is that it uses a single global language. It allows us to state that the physical and functional characteristics were compromised, especially in the more severe forms of CVD,³⁶ and that the prevalence of C2 disease is greater in Western Europe and lower in the Middle East and Africa,³⁴ and everyone in the scientific community understands what that means.

Recommendation 2

• We recommend using a severity classification score (Venous Clinical Severity Score [VCSS]) for all chronic venous insufficiency patients for academic and legal purposes.

  • Level B

  • Class I

  • References:³⁷-⁴¹

VCSS correlates well with the CEAP clinical classification and represents a reliable and reproducible tool to document symptom severity in patients with venous insufficiency in the lower limbs.³⁷ In an observational cross-sectional study, clinical severity was found to be related to pain, edema, sleep quality, depression, and quality of life for all patients.³⁸

VCSS and the Venous Disability Score (VDS) are strongly positively correlated with the Dermatology Quality Life Index (DLQI) and are important tools to assess the severity and impairment of chronic venous insufficiency. This once again stresses the need to develop a classification system for severity, since it is excluded from CEAP.³⁹,⁴²

VCSS was created for the purposes of staging and quantifying the natural progression of the disease over time. It enables cost effectiveness comparisons, as well as comparing technical, clinical, and quality of life responses. The suggested updates intend to increase the sensitivity of that assessment tool.⁴⁰

In Brazil, the lack of international consensus on classifications involving CVD has been singled out. An assessment of the scoring system for each revised VCSS criteria separately is provided in a format that could be adopted by the international community.⁴¹

We suggest using the CEAP classification alongside VCSS. Developing a consensus on an evolutionary assessment of disease progression is also required, as is monitoring treatment outcomes. CIVIQ and AVVQ have been developed specifically for patients with venous disease.

Recommendation 3

• We suggest using a specific system for all patients with telangiectasias or reticular veins.

  • Level C

  • Class IIa

  • References:⁴³-⁴⁶

An open, controlled study attempted to explore the veins of individuals classified as C0S and compare them to C0A (asymptomatic) individuals. Doppler ultrasound identified two different flow patterns: unidirectional and bidirectional. Bidirectional flow was significantly higher (P = 0.05) for C0S compared to C0A patients. This suggests the presence of reflux in non axial veins.⁴⁷

The Bonn Vein Study studied a total of 1350 and 1722 women aged 18 to 79 years old. Leg symptoms (weight, tightness, swelling, pain on standing up or sitting down, pain when walking, muscle cramps, itching, and restless legs) were assessed using a standardized survey; 22.6 percent had varicose veins and 15.8 percent had chronic venous insufficiency (CVI).⁴⁶

Venous disease at several stages has also been found to be associated with cardiovascular death in a cohort study. However, despite different symptoms and clinical manifestations, there is no analysis of CEAP C1 patient scores.⁴⁸

The lesions of CEAP C1 patients clearly have different origins, and saphenous vein reflux is also associated in 40 to 50 percent of patients. This may impact therapeutic decision regarding how these lesions are treated, which would support the need for a separate classification within this clinical class.

CEAP C1-3 patients had less intense reflux scores in Doppler ultrasound than C4-6 patients.⁴⁹,⁵⁰ This shows the diagnostic utility of Doppler ultrasonography in venous reflux. A literature review including systematic reviews and guidelines concluded that Doppler ultrasonography is the method of choice for CVD diagnosis.⁵¹

DIAGNOSTIC TESTS

Vein mapping is essential for surgical planning and should be performed on an individual basis for each patient and treatment technique. Venous reflux is defined as reverse flow time greater than 1 second in the common femoral vein.⁵¹,⁵² Doppler ultrasonography enables a topographic and hemodynamic assessment of the deep and superficial systems.

A cohort study of 43 patients surveyed telangiectasias of the lateral thigh by ultrasound. Obese and overweight patients had a higher frequency of incompetent perforator veins and larger reticular veins compared to when compared to those with normal weight (P < 0.05).⁵³ The same process was applied to C1 patients to determine whether ultrasound mapping of the saphenous veins is justified. There was a statistically significant tendency that the increased presence of incompetent deep and/or superficial venous incompetence also increases the presence of telangiectasias.⁵⁴,⁵⁵

An analysis of saphenous vein escape points to reticular veins and small varicosities also found a positive correlation.⁵⁶,⁵⁷ This shows the importance of using this tool even for early-stage patients.

Recommendation 4

• We recommend using duplex scanning as an early diagnosis tool for all patients with suspected chronic venous insufficiency.

  • Level A

  • Class I

  • References:⁴⁹,⁵¹,⁵²,⁵⁸

Recommendation 5

• We recommend using duplex scanning as an early diagnosis tool for patients with a C1 clinical, etiological, anatomical, and pathophysiological (CEAP) classification.

  • Level B

  • Class IIa

  • References:⁵³-⁵⁵,⁵⁷

Recommendation 6

• We recommend using abdominal and pelvic venous duplex scanning as an early diagnosis tool for patients with suspected chronic venous insufficiency and suspected suprainguinal stenosis/occlusion.

  • Level B

  • Class IIa

  • References:⁵⁹-⁶²

A Brazilian studied attempted to determine the sonographic criteria for diagnosis of iliac venous outflow obstruction by assessing the correlation of this method with intravascular ultrasound (IVUS) in patients with CVI. The best criteria to detect venous outflow obstruction was a velocity ratio greater than 2.5.⁵⁹ Doppler ultrasound scanning had a positive predictive value of 95.5 percent in detecting more severe stenoses in this segment.⁶⁰

The use of Doppler ultrasonography for iliocaval venous disease has gained popularity in recent years primarily because it is noninvasive. In experienced hands, transabdominal Doppler ultrasonography can consistently show the ovarian veins as well as document their diameter and possible reflux.⁶⁰-⁶² This enables physicians to avoid more expensive forms of treatment and more time-consuming imaging techniques.

Recommendation 7

• We suggest using other imaging examinations (CT angiography, magnetic resonance angiography and/or venography) in the diagnosis of patients with chronic venous insufficiency and suspected suprainguinal stenosis/occlusion.

  • Level B

  • Class IIb

  • References:⁶³-⁶⁸

Recommendation 8

• We recommend using intravascular ultrasound (IVUS) as an additional investigation method for diagnosis and/or suspected suprainguinal stenosis/occlusion.

  • Level A

  • Class IIa

  • References:⁶⁶-⁷¹

Venography does not identify the presence of iliocaval injuries in 19 percent of limbs. The median maximum area stenosis was significantly greater with IVUS than with venography.⁶³ Paradoxically, a review found that anteroposterior venography can successfully guide the diagnosis of venous occlusion.⁷²

IVUS is consistently superior to venography in detect iliac stenosis.⁶⁴-⁶⁷,⁶⁹ Computed tomography (CT) scans can detect iliac vein compression of 50 percent or higher compared to IVUS with 94.09 percent sensitivity and 79.2 specificity. Therefore, though IVUS may be more reliable, CT scans are a possible alternative, especially in cases of stenosis.

Recommendation 9

• We suggest using photoplethysmography as a supplementary diagnosis and therapeutic guidance tool for chronic venous insufficiency patients.

  • Level C

  • Class IIa

  • References:⁷³,⁷⁴

Capillary blood pressure is the primary driving force behind the exchange of fluids between micro-vessels. Subclinical systemic venous congestion, before evident peripheral edema, may directly result in increased peripheral blood pressure. Photoplethysmography (PPG) can be a complementary diagnostic tool for venous insufficiency with functional repercussions.⁷³,⁷⁵,⁷⁶

Even after treatment, plethysmography found suspected reflux in 71 percent of patients, and precisely those patients had no improvements in quality of life scores. This happened because there was something else wrong: the presence of insufficient perforator veins or residual varicosities in their legs.⁷⁴,⁷⁷ Therefore, photoplethysmography can be used for both diagnosis and follow-up care.

CONSERVATIVE OR NON-INVASIVE TREATMENT

In pharmacological treatment, calcium dobesilate was found to be effective in reducing edema in C3-4 patients.⁷⁸,⁷⁹ For various symptoms, other medications were also efficient, such as red vine leaf extract,⁸⁰ rutosides,⁸¹ and sulodexide.⁸² All had few adverse effects.

Systematic reviews suggest venoactive drugs probably slightly reduce edema compared to placebos and probably reduce ankle circumference. Gastrointestinal disturbance were the most frequently reported adverse events. The medication of choice in reviews is usually diosmin and hesperidin in micronized fraction.⁸³-⁸⁵

Recommendation 10

• We recommend using venoactive drugs for the symptomatic treatment of chronic venous insufficiency.

  • Level A

  • Class IIa

  • References:⁷⁸,⁷⁹,⁸¹-⁸⁴,⁸⁶

Recommendation 11

• We recommend using compression therapy for the symptomatic treatment of chronic venous insufficiency.

  • Level B

  • Class I

  • References:⁸⁷-⁸⁹

For compression therapy, the use of various grades of compression stockings stands out. The reduction of pain or discomfort and their use in lowering recurrence rates for leg ulcers indicate its use may be positive.⁸⁷

Despite several positive demonstrations, treatment adherence remains a major hurdle, especially when using higher pressures.⁸⁸,⁸⁹

Physical exercise protocols have shown improvement in range of motion of the tibiotarsal joint and should be considered for treatment of CVI.⁹⁰ Increased muscle strength was found to impact the venous pump, improving its function and the range of motion of the ankle. In addition, pain decreased and quality of life improved after adopting the exercise program.⁹¹-⁹³ Studies show that physical activity is important to improve venous insufficiency, regardless of intensity.⁹⁴,⁹⁵

Recommendation 12

• We recommend physical exercise to treat chronic venous insufficiency at any stage.

  • Level B

  • Class I

  • References:⁹⁰-⁹⁷

Recommendation 13

• We recommend controlling body mass to treat and prevent chronic venous insufficiency at any stage.

  • Level C

  • Class I

  • References:⁹⁸-¹⁰²

Physical exercise is effective at improving venous reflux, muscle strength, and range of motion of the ankle. Even unsupervised guided exercises can be beneficial.⁹⁶-⁹⁸

Obesity and reduced mobility, in turn, ran counter to venous return, and obesity contributed to the higher incidence of venous ulcers.⁹⁹,¹⁰³ Foot venous pressure is significantly higher in obese individuals in all positions. Venous disease is also more severe in obese patients compared to non-obese ones, possibly due to the increase in intra-abdominal pressure. After bariatric surgery in morbidly obese patients, reports of improvements in venous insufficiency are frequent.¹⁰⁰-¹⁰²,¹⁰⁴

INVASIVE TREATMENT

Treatment of saphenous veins

Venous disease is known to be highly prevalent, and its treatment, with the suppression of sites of reflux, has been found to be effective at improving symptoms.¹⁰⁵ The procedure is also followed by improved quality of life, lower morbidity, and reduced skin ulcers. The total cost for the health system is greater for surgical treatment compared to conservative treatment, but also offers greater health benefits for patients.¹⁰⁶-¹⁰⁸

Recommendation 14

• We recommend invasive treatment with suppression of sites of reflux for patients with symptoms and diagnosis of chronic venous insufficiency.

  • Level A

  • Class I

  • References:¹⁰⁵,¹⁰⁷,¹⁰⁸

Invasive treatment is recommended, depending on technical availability, for patients with symptomatic varicose disease. Endovenous laser treatment has been found to be highly effective, with a 92 percent success rate in treating great saphenous vein insufficiency. According to patients, longer wavelengths produce more satisfactory outcomes, and are less painful. Few adverse effects have been observed.¹⁰⁹-¹¹²

Other thermal ablation instruments have been studies, sch as electrocoagulation,¹¹³ but laser and radiofrequency, with tumescent anaesthesia and without ligation of the saphenofemoral junction (SFJ), have been found to have superior outcomes.¹¹⁴-¹¹⁷

Compared to stripping, for instance, thermal ablation has the same long-term success rates, but fewer and less frequent complications in the short term. After 1 year, there were no differences in occlusion rate, and the Aberdeen Varicose Vein Questionaire (AVVQ) 3 months after treatment was similar.¹¹⁸

Recommendation 15

• We recommend thermal ablation without SFJ ligation to treat greater saphenous vein (GSV) and small saphenous vein (SSV) insufficiency.

  • Level A

  • Class I

  • References:¹⁰⁸,¹¹⁴,¹¹⁶,¹¹⁸-¹²³

Recommendation 16

• We recommend stripping to treat GSV and SSV insufficiency.

  • Level A

  • Class IIa

  • References:¹⁰⁸,¹¹⁴,¹¹⁶,¹¹⁸,¹¹⁹,¹²¹-¹²⁴

In terms of the use of ultrasound guided foam, there are frequent reports of greater recanalization rates compared to other techniques.¹¹⁹ The most frequent outcome in systematic reviews and clinical trials is similar long term outcomes for thermal ablation and stripping and inferior outcomes for foam.¹²⁰-¹²⁴

Specifically for ultrasound guided foam, outcomes are better when tributary veins are treated compared to saphenous or perforator veins.¹²⁵-¹²⁷ For tributary veins, foam sclerotherapy has durable and impactful results in perceived improvements among patients, despite an expected retreatment rate of 20 percent of limbs within one year.¹²⁸

In the long run, quality scores worsened, requiring therapeutic reintervention, especially in patients with greater vein diameters and distal vein reflux.¹²⁹,¹³⁰ The primary advantage of using foam is that treatment is easier, does not require anesthesia, and can be repeated (including the possibility of treatment with active ulcers).¹³¹ Even so, when analyzing long term costs, thermal ablation with local anesthesia are found to have better cost-benefit ratios more frequently. Therefore, that mode of treatment is less effective for patients with large veins and baseline reflux. In a British review, endovenous laser ablation (EVLA) with local anesthesia was considered the most economic strategy overall.¹³²

In order to improve sclerotherapy outcomes, there are attempts at using long catheters for foam delivery or combining it with devices utilizing mechanical injury to the vein wall.¹³³-¹⁴¹

Though promising, mechanochemical ablation techniques have yet to be found to be at the same level as thermal ablation, with lower occlusion rates. This was observed at 12 to 36-month follow-up.¹³⁴-¹³⁶

Recommendation 17

• We recommend ultrasound-guided foam sclerotherapy to treat GSV and SSV insufficiency.

  • Level A

  • Class IIb

  • References:¹⁰⁸,¹¹⁶,¹¹⁹-¹²¹,¹²⁶,¹²⁹,¹³²

Recommendation 18

• We recommend mechanochemical ablation (MOCA) to treat GSV and SSV insufficiency.

  • Level B

  • Class IIb

  • References:¹³⁴-¹³⁶,¹³⁹,¹⁴¹

However, there are positive aspects to these techniques. They are simpler to perform than others, which require a learning curve. Reported complication rates are lower.¹³⁸,¹³⁹

There are two major schools of thought about the hemodynamics of the superficial venous system. The CHIVA (Cure conservatrice et Hemodynamique de l’Insuffisance Veineuse en Ambulatoire - Conservative Hemodynamic Correction of Venous Insufficiency) procedure is a surgical intervention to repair abnormal hemodynamic vessels. ASVAL (Ablation Sélective des Varices Sous Anesthésie Locale — Selective Varicose Vein Ablation under Local Anesthesia) proposes the multifocal ascending theory, and the pressure of the blood column, combined with the weakness of the vein wall, creates a varicose reservoir.¹⁴²-¹⁴⁸

Recommendation 19

• We suggest saphenous vein preservation surgery to treat chronic venous insufficiency.

  • Level C

  • Class IIb

  • References:¹⁴²,¹⁴³,¹⁴⁵

When comparing CHIVA, conventional surgery and EVLA, CHIVA and EVLA have better aesthetic outcomes and are less painful. Despite the benefits suggested by CHIVA, it requires a longer learning curve and greater surgeon expertise than venous hemodynamics.¹⁴²,¹⁴⁵

The CHIVA technique is based on the concept of hemodynamics, treating venous shunts with ligation of escape points and preservation of saphenous veins. The results also indicate reduced diameter, with an acceptable recurrence rate.¹⁴³-¹⁴⁵

Treatment of perforator veins

Foam sclerotherapy can be recommended as a first-line treatment for perforator veins since it is minimally painful and less expensive than other forms of treatment. Unlike outcomes for saphenous veins, even thermal ablation can have disappointing success rates.¹⁴⁹,¹⁵⁰

Recommendation 20

• We suggest the use of thermal ablation to treat perforator veins, when indicated.

  • Level C

  • Class IIa

  • References:¹⁵⁰,¹⁵¹

Recommendation 21

• We suggest the use of foam sclerotherapy to treat perforator veins, when indicated.

  • Level C

  • Class IIa

  • References:¹⁵²,¹⁵³, ²⁰⁶, ²⁰⁷

Occlusion rates for perforator veins range from 30 to 70 percent, with improvements when treatment is repeated.¹⁵¹,¹⁵⁴-¹⁵⁶ The need to treat perforator veins is still controversial. Laser or radiofrequency (RF) thermal ablation has a long learning curve, and technical skill can be an important hurdle. For many, however, foam is the first choice, because it is less invasive and more easily performed.²⁰⁷ Occlusion rates are slightly worse, but ease of reintervention makes it the most frequently used technique.¹⁵⁴-¹⁵⁶, ²⁰⁶, ²⁰⁷

Treatment of tributary veins

The outpatient phlebectomy procedure was first described many years ago and has changed little over time, with widely known results. However, other modes of treatment have garnered interest in the area, such as foam sclerotherapy or even endovenous laser.¹⁵⁷-¹⁷⁴

Recommendation 22

• We recommend phlebectomy to treat tributary veins.

  • Level B

  • Class I

  • References:¹⁵⁷,¹⁵⁸,¹⁶¹

Recommendation 23

• We suggest endovenous laser as an alternative to treat tributary veins.

  • Level C

  • Class IIb

  • References:¹⁶⁵,¹⁶⁷

Recommendation 24

• We recommend foam sclerotherapy to treat tributary veins.

  • Level B

  • Class IIa

  • References:¹⁵⁸,¹⁶³,¹⁷³

The outpatient phlebectomy procedure was first described many years ago and has changed little over time. It reigned for many years as the standard treatment technique for tributary veins. The procedure is performed safely and effectively in outpatient settings.¹⁵⁸,¹⁵⁹

Both 1-year and 2-year recurrence rates are small for phlebectomy, though there are complications inherent to the surgical procedure. These situations are not present in foam sclerotherapy treatment, for instance.¹⁵⁷,¹⁶¹

The use of sclerotherapy to treat tributary veins is well-known and has been used for many years in phlebology. It can use a wide range of concentrations, both in liquid and foam mode, and is effective.¹⁶⁸,¹⁷⁰,¹⁷¹ However, its most common adverse event, superficial thrombophlebitis, is extremely unpleasant, and increases the risk of pigmentation.

For larger extents and a greater number of tributary veins, foam volume may be an obstacle.¹⁷²,¹⁷³ Foam sclerotherapy and phlebectomy, when used for tributary veins combined with endothermal approaches for saphenous veins, has high rates of success, preferably performed as a single procedure.¹⁵⁷,¹⁶²,¹⁶³,¹⁶⁹,¹⁷⁰

There is little evidence of the benefits of using endovenous laser for tributary veins. The longer technique, higher costs, and rate of post-procedure hardening make it unpopular among experts. In addition, there are lingering questions about the power used and the proper indications for that mode of treatment.¹⁶⁴,¹⁶⁵,¹⁶⁷

Recommendation 25

• We suggest the use of intra-procedural Doppler ultrasound during invasive vein treatment.

  • Level C

  • Class I

  • References: ^{176,consensus}

The chronic nature of the disease makes it difficult to assess efficacy, but follow-up of high patient-satisfaction cases make it an interesting alternative. With the development of new endovenous techniques, the need for real-time treatment monitoring has emerged. The benefits of ultrasound-guided puncture is clear, with an 82 percent decrease in failure rates.¹⁷⁴-¹⁷⁶ In fact, procedures are already described as ultrasound-guided, which makes them inherent to the performance of the procedure. In other words, the procedure would not be possible without ultrasonography.

TREATMENT OF SMALL VESSELS

Sclerotherapy has a wide range of applications in the treatment of cutaneous telangiectasia, superficial venous insufficiency, pelvic venous reflux, and venous malformations. Strokes, the most feared complication from sclerotherapy, are fortunately rare. Migraines and visual disturbances, however, are reported more frequently.¹⁷⁷

Recommendation 26

• We recommend liquid chemical sclerotherapy to treat chronic venous disease C1.

  • Level A

  • Class IIa

  • References:¹⁷⁸-¹⁸³

Recommendation 27

• We recommend the use of transcutaneous laser treatment for chronic venous disease C1, especially for telangiectasias.

  • Level B

  • Class IIa

  • References:¹⁸²-¹⁸⁴

Liquid sclerotherapy is recommended for smaller reticular veins, venulectasia, and telangiectasia. Setting realistic expectations for patients relieves anxiety and enables a positive treatment experience.¹⁷⁸ Few post-sclerotherapy or thrombophlebitis complications are observed in ulcers, while hyperpigmentation is the most frequent minor adverse event.¹⁷⁹,¹⁸⁵

Though there is no clear evidence of superiority among sclerosants, superior results tend to be observed with the use of a detergent (such as polidocanol) compared to the use of a hypertonic agent (such as 75% glucose) alone.¹⁸⁰,¹⁸¹

The use of transcutaneous laser treatment has grown, especially for telangiectasias. However, results vary widely, depending on parameter used, wavelength, and agent compared.¹⁸²-¹⁸⁴,¹⁸⁶-¹⁹⁰

The 1064 nm Nd:YAG long pulse laser is the most widely used to treat leg veins, but still requires further studies and assessment. One of the primary advantages of transcutaneous laser treatment is the possibility to treat lesions for which sclerotherapy is not a viable choice.¹⁸⁹

Recommendation 28

• We suggest radiofrequency transcutaneous treatment for C1 chronic venous disease, especially for telangiectasias.

  • Level C

  • Class IIa

  • References:¹⁹¹

Recommendation 29

• We suggest the use of laser associated with chemical sclerotherapy to treat chronic venous disease C1.

  • Level C

  • Class IIb

  • References:¹⁹²-¹⁹⁴

Radiofrequency treatment can also be used to treat small vessels. Outcomes for standalone treatment and in combination seem promising, but still require more robust studies before it can be indicated and become better known.¹⁸⁴,¹⁹⁰,¹⁹¹

The combination of laser and liquid or foam sclerotherapy has been widely used and was highly recommended until recently. However, studies of the associated procedures are limited to a few case series, and though most have very promising results, others have had disastrous complications.¹⁹²-¹⁹⁴

Recommendation 30

• We suggest compression therapy after treatment of small vessels with sclerotherapy, laser, or radiofrequency.

  • Level B

  • Class IIb

  • References:¹⁹⁵-¹⁹⁹

Recommendation 31

• We suggest against the routine use of topical medications after all modes of treatment for venous disease C1.

  • Level C

  • Class III

  • References:²⁰⁰-²⁰²

The use of compression therapy with compression stockings is controversial. Though previous studies have found the possibility of better outcomes, recent randomized studies did not corroborate those findings.¹⁹⁶-¹⁹⁹

Therefore, the use of compression therapy after treatment of small vessels is still debatable. Their actual benefit is hard to explain when we know the pressure required for vessel collapse is very high. Other authors state that costs are costs and benefits uncertain.¹⁹⁸,¹⁹⁹

Routine use of topical ointments and medications after treatment of small vessels is unsupported in the scientific literature. There is no evidence that the use of substances such as corticosteroids, arnica or bromelain provide any benefits. Some may actually be harmful.²⁰⁰-²⁰⁴ There are reports of the use of topical substances in the attempt to reverse some complications, such as matting, but still no significant evidences.²⁰³,²⁰⁴

After treatment, the recommendation is that patients use sunscreen and moisturizers, but, even so, there is no evidence of improved results or lower complications rates.²⁰⁵

FINAL CONSIDERATIONS

The goal of this project was to provide guidelines for professionals and for the population in general when faced with a wide varied of situations involving an extremely common illness. At no point did the recommendations provided here intend to become absolute rules for medical practice. Rather, their goal was to help attending physicians make the best decision for their patients.

The development of these recommendations followed an extensive review of scientific publications, combined with expert opinions when the evidence was scarce or conflicting.

There are still gaps in scientific knowledge, and further publications in this area are needed. Therefore, these recommendations should be reviewed and revised periodically in light of new evidence.

• How to cite: Kikuchi R, Nhuch C, Drummond DAB et al. Brazilian guidelines on chronic venous disease of the Brazilian Society of Angiology and Vascular Surgery. J Vasc Bras. 2023;22:e20230064. https://doi.org/10.1590/1677-5449.202300642
• Financial support: None.
• The study was carried out at Brazilian Society of Angiology and Vascular Surgery (SBACV), São Paulo, SP, Brazil.

References

• ¹
  Eklof B, Perrin M, Delis KT, et al. Updated terminology of chronic venous disorders: the VEIN-TERM transatlantic interdisciplinary consensus document. J Vasc Surg. 2009;49(2):498-501. http://dx.doi.org/10.1016/j.jvs.2008.09.014 PMid:19216970.
  » http://dx.doi.org/10.1016/j.jvs.2008.09.014
• ²
  Beebe HG, Bergan JJ, Bergqvist D, et al. Classification and grading of chronic venous disease in the lower limbs. A consensus statement. Eur J Vasc Endovasc Surg. 1996;12(4):487-91, discussion 491-2. http://dx.doi.org/10.1016/S1078-5884(96)80019-0 PMid:8980442.
  » http://dx.doi.org/10.1016/S1078-5884(96)80019-0
• ³
  Eklöf B, Rutherford RB, Bergan JJ, et al. Revision of the CEAP classification for chronic venous disorders: consensus statement. J Vasc Surg. 2004;40(6):1248-52. http://dx.doi.org/10.1016/j.jvs.2004.09.027 PMid:15622385.
  » http://dx.doi.org/10.1016/j.jvs.2004.09.027
• ⁴
  Salim S, Machin M, Patterson BO, Onida S, Davies AH. Global epidemiology of chronic venous disease: a systematic review with pooled prevalence analysis. Ann Surg. 2021;274(6):971-6. http://dx.doi.org/10.1097/SLA.0000000000004631 PMid:33214466.
  » http://dx.doi.org/10.1097/SLA.0000000000004631
• ⁵
  Evans CJ, Fowkes FG, Ruckley CV, Lee AJ. Prevalence of varicose veins and chronic venous insufficiency in men and women in the general population: Edinburgh Vein Study. J Epidemiol Community Health. 1999;53(3):149-53. http://dx.doi.org/10.1136/jech.53.3.149 PMid:10396491.
  » http://dx.doi.org/10.1136/jech.53.3.149
• ⁶
  Robertson LA, Evans CJ, Lee AJ, Allan PL, Ruckley CV, Fowkes FG. Incidence and risk factors for venous reflux in the general population: Edinburgh Vein Study. Eur J Vasc Endovasc Surg. 2014;48(2):208-14. http://dx.doi.org/10.1016/j.ejvs.2014.05.017 PMid:24951373.
  » http://dx.doi.org/10.1016/j.ejvs.2014.05.017
• ⁷
  Phillips MN, Jones GT, van Rij AM, Zhang M. Micro-venous valves in the superficial veins of the human lower limb. Clin Anat. 2004;17(1):55-60. http://dx.doi.org/10.1002/ca.10141 PMid:14695589.
  » http://dx.doi.org/10.1002/ca.10141
• ⁸
  Vincent JR, Jones GT, Hill GB, van Rij AM. Failure of microvenous valves in small superficial veins is a key to the skin changes of venous insufficiency. J Vasc Surg. 2011;54(6, Suppl):62S-9S, e1-3. http://dx.doi.org/10.1016/j.jvs.2011.06.085 PMid:21917406.
  » http://dx.doi.org/10.1016/j.jvs.2011.06.085
• ⁹
  Raffetto JD. Pathophysiology of chronic venous disease and venous ulcers. Surg Clin North Am. 2018;98(2):337-47. https://doi.org/10.1016/j.suc.2017.11.002
  » https://doi.org/10.1016/j.suc.2017.11.002
• ¹⁰
  Mansilha A, Sousa J. Pathophysiological mechanisms of chronic venous disease and implications for venoactive drug therapy. Int J Mol Sci. 2018;19(6):1669. http://dx.doi.org/10.3390/ijms19061669 PMid:29874834.
  » http://dx.doi.org/10.3390/ijms19061669
• ¹¹
  Labropoulos N, Giannoukas AD, Delis K, et al. Zhere does venous reflux start? J Vasc Surg. 1997;26(5):736-42. http://dx.doi.org/10.1016/S0741-5214(97)70084-3 PMid:9372809.
  » http://dx.doi.org/10.1016/S0741-5214(97)70084-3
• ¹²
  Lee BB, Nicolaides AN, Myers K, et al. Venous hemodynamic changes in lower limb venous disease: the UIP consensus according to scientific evidence. Int Angiol. 2016;35(3):236-352. PMid:27013029.
• ¹³
  Labropoulos N, Patel PJ, Tiongson JE, Pryor L, Leon LR Jr, Tassiopoulos AK. Patterns of venous reflux and obstruction in patients with skin damage due to chronic venous disease. Vasc Endovascular Surg. 2007;41(1):33-40. http://dx.doi.org/10.1177/1538574406296246 PMid:17277241.
  » http://dx.doi.org/10.1177/1538574406296246
• ¹⁴
  Bollinger A, Leu AJ, Hoffmann U, Franzeck UK. Microvascular changes in venous disease: an update. Angiology. 1997;48(1):27-32. http://dx.doi.org/10.1177/000331979704800105 PMid:8995340.
  » http://dx.doi.org/10.1177/000331979704800105
• ¹⁵
  Raju S, Knight A, Lamanilao L, Pace N, Jones T. Peripheral venous hypertension in chronic venous disease. J Vasc Surg Venous Lymphat Disord. 2019;7(5):706-14. http://dx.doi.org/10.1016/j.jvsv.2019.03.006 PMid:31196767.
  » http://dx.doi.org/10.1016/j.jvsv.2019.03.006
• ¹⁶
  Perrin M, Eklof B, Van Rij A, et al. Venous symptoms: the SYM Vein Consensus statement developed under the auspices of the European Venous Forum. Int Angiol. 2016;35(4):374-98. PMid:27081866.
• ¹⁷
  Van der Velden SK, Shadid NH, Nelemans PJ, Sommer A. How specific are venous symptoms for diagnosis of chronic venous disease? Phlebology. 2014;29(9):580-6. http://dx.doi.org/10.1177/0268355513515859 PMid:24390751.
  » http://dx.doi.org/10.1177/0268355513515859
• ¹⁸
  Wrona M, Jockel KH, Pannier F, Bock E, Hoffmann B, Rabe E. Association of venous disorders with leg symptoms: results from the Bonn Vein Study 1. Eur J Vasc Endovasc Surg. 2015;50(3):360-7. http://dx.doi.org/10.1016/j.ejvs.2015.05.013 PMid:26141786.
  » http://dx.doi.org/10.1016/j.ejvs.2015.05.013
• ¹⁹
  Vuylsteke ME, Thomis S, Guillaume G, Modliszewski ML, Weides N, Staelens I. Epidemiological study on chronic venous disease in Belgium and Luxembourg: prevalence, risk factors, and symptomatology. Eur J Vasc Endovasc Surg. 2015;49(4):432-9. http://dx.doi.org/10.1016/j.ejvs.2014.12.031 PMid:25701071.
  » http://dx.doi.org/10.1016/j.ejvs.2014.12.031
• ²⁰
  Serra R, Ielapi N, Bevacqua E, et al. Haemorrhage from varicose veins and varicose ulceration: a systematic review. Int Wound J. 2018;15(5):829-33. http://dx.doi.org/10.1111/iwj.12934 PMid:29808553.
  » http://dx.doi.org/10.1111/iwj.12934
• ²¹
  Vasquez M, Rabe E, McLafferty R, et al. 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. http://dx.doi.org/10.1016/j.jvs.2010.06.161 PMid:20875713.
  » http://dx.doi.org/10.1016/j.jvs.2010.06.161
• ²²
  Passman MA, McLafferty RB, Lentz MF, et al. Validation of Venous Clinical Severity Score (VCSS) with other venous severity assessment tools from the American Venous Forum, National Venous Screening Program. J Vasc Surg. 2011;54(6, Suppl):2S-9S. http://dx.doi.org/10.1016/j.jvs.2011.05.117 PMid:21962926.
  » http://dx.doi.org/10.1016/j.jvs.2011.05.117
• ²³
  Villalta SBP, Picolli A, Lensing A, Prins M, Prandoni P. Assessment of validity and reproducibility of a clinical scale for the post thrombotic syndrome. Haemostasis. 1994;24:157.
• ²⁴
  Kahn SR. Measurement properties of the Villalta scale to define and classify the severity of the post-thrombotic syndrome. J Thromb Haemost. 2009;7(5):884-8. http://dx.doi.org/10.1111/j.1538-7836.2009.03339.x PMID: 19320818.
  » http://dx.doi.org/10.1111/j.1538-7836.2009.03339.x
• ²⁵
  Garratt AM, Macdonald LM, Ruta DA, Russell IT, Buckingham JK, Krukowski ZH. Towards measurement of outcome for patients with varicose veins. Qual Health Care. 1993;2(1):5-10. http://dx.doi.org/10.1136/qshc.2.1.5 PMid:10132081.
  » http://dx.doi.org/10.1136/qshc.2.1.5
• ²⁶
  Launois R, Reboul-Marty J, Henry B. Construction and validation of a quality of life questionnaire in chronic lower limb venous insufficiency (CIVIQ). Qual Life Res. 1996;5(6):539-54. http://dx.doi.org/10.1007/BF00439228 PMid:8993100.
  » http://dx.doi.org/10.1007/BF00439228
• ²⁷
  Lamping DL, Schroter S, Kurz X, Kahn SR, Abenhaim L. Evaluation of outcomes in chronic venous disorders of the leg: development of a scientifically rigorous, patient-reported measure of symptoms and quality of life. J Vasc Surg. 2003;37(2):410-9. http://dx.doi.org/10.1067/mva.2003.152 PMid:12563215.
  » http://dx.doi.org/10.1067/mva.2003.152
• ²⁸
  Ponikowski P, Voors AA, Anker SD, et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J. 2016;37(27):2129-200. http://dx.doi.org/10.1093/eurheartj/ehw128 PMid:27206819.
  » http://dx.doi.org/10.1093/eurheartj/ehw128
• ²⁹
  Carman TL, Al-Omari A. Evaluation and management of chronic venous disease using the foundation of CEAP. Curr Cardiol Rep. 21:114. https://doi.org/10.1007/s11886-019-1201-1
  » https://doi.org/10.1007/s11886-019-1201-1
• ³⁰
  Scuderi A, Raskin B, Al Assal F, et al. The incidence of venous disease in Brazil based on the CEAP classification. Int Angiol. 2002;21(4):316-21. PMid:12518109.
• ³¹
  Lurie F, Passman M, Meisner M, et al. The 2020 update of the CEAP classification system and reporting standards. J Vasc Surg Venous Lymphat Disord. 2020;8(3):342-52. http://dx.doi.org/10.1016/j.jvsv.2019.12.075 PMid:32113854.
  » http://dx.doi.org/10.1016/j.jvsv.2019.12.075
• ³²
  Hess CT. Venous ulcer assessment and management: using the updated CEAP Classification System. Adv Skin Wound Care. 2020;33(11):614-5. http://dx.doi.org/10.1097/01.ASW.0000719052.33284.73 PMid:33065684.
  » http://dx.doi.org/10.1097/01.ASW.0000719052.33284.73
• ³³
  Lurie F, De Maeseneer MGR. The 2020 Update of the CEAP Classification: what is new? Eur J Vasc Endovasc Surg. 2020;59(6):859-60. http://dx.doi.org/10.1016/j.ejvs.2020.04.020 PMid:32376218.
  » http://dx.doi.org/10.1016/j.ejvs.2020.04.020
• ³⁴
  Salim S, Machin M, Patterson BO, Onida S, Davies AH. Global epidemiology of chronic venous disease: a systematic review with pooled prevalence analysis. Ann Surg. 2021;274(6):971-6. http://dx.doi.org/10.1097/SLA.0000000000004631 PMid:33214466.
  » http://dx.doi.org/10.1097/SLA.0000000000004631
• ³⁵
  Naleini F, Hassani M, Bagherhosseini N, Sobhiyeh M. Ultrasonographic measurement of saphenous vein diameter compared to CEAP classification in patients with varicose veins. J Vasc Nurs. 2022;40(1):43-6. http://dx.doi.org/10.1016/j.jvn.2021.11.003 PMid:35287833.
  » http://dx.doi.org/10.1016/j.jvn.2021.11.003
• ³⁶
  Moura RM, Gonçalves GS, Navarro TP, Britto RR, Dias RC. Relationship between quality of life and the CEAP clinical classification in chronic venous disease. Rev Bras Fisioter. 2010;14(2):99-105. http://dx.doi.org/10.1590/S1413-35552010005000007 PMid:20464164.
  » http://dx.doi.org/10.1590/S1413-35552010005000007
• ³⁷
  Marston WA, Vasquez MA, Lurie F, et al. Multicenter assessment of the repeatability and reproducibility of the revised Venous Clinical Severity Score (rVCSS). J Vasc Surg Venous Lymphat Disord. 2013;1(3):219-24. http://dx.doi.org/10.1016/j.jvsv.2012.10.059 PMid:26992578.
  » http://dx.doi.org/10.1016/j.jvsv.2012.10.059
• ³⁸
  I Y, Karakelle SG, Aydın GT, R M, T O, Iu A. The relationship between clinical severity and outcome measures in patients with chronic venous insufficiency with or without leg ulcer. J Tissue Viability. 2021;30(3):310-6. http://dx.doi.org/10.1016/j.jtv.2021.06.002 PMid:34140210.
  » http://dx.doi.org/10.1016/j.jtv.2021.06.002
• ³⁹
  Mallick S, Sarkar T, Gayen T, Naskar B, Datta A, Sarkar S. Correlation of venous clinical severity score and venous disability score with dermatology life quality index in chronic venous insufficiency. Indian J Dermatol. 2020;65(6):489-94. http://dx.doi.org/10.4103/ijd.IJD_485_20 PMid:33487704.
  » http://dx.doi.org/10.4103/ijd.IJD_485_20
• ⁴⁰
  Vasquez MA, Munschauer CE. Revised venous clinical severity score: a facile measurement of outcomes in venous disease. Phlebology. 2012;27(Suppl 1):119-29. http://dx.doi.org/10.1258/phleb.2012.012s16 PMid:22312078.
  » http://dx.doi.org/10.1258/phleb.2012.012s16
• ⁴¹
  dos Santos VP, Queiroz AB. Venous disease classifications and generic and disease-specific quality of life questionnaires: which, why, and when to use? J Vasc Bras. 2019;18:e20190114. PMid:31807131.
• ⁴²
  Catarinella FS, Nieman FH, Wittens CH. An overview of the most commonly used venous quality of life and clinical outcome measurements. J Vasc Surg Venous Lymphat Disord. 2015;3(3):333-40. http://dx.doi.org/10.1016/j.jvsv.2014.09.003 PMid:26992316.
  » http://dx.doi.org/10.1016/j.jvsv.2014.09.003
• ⁴³
  Dong Z, Zhao Y, Zhao X, et al. Summary of diagnostic and characteristic parameters of C₀to C₂patients based on the CEAP2020 classification. J Vasc Surg Venous Lymphat Disord. 2022;10(6):1201-1207.e2. http://dx.doi.org/10.1016/j.jvsv.2022.05.007 PMID: 35810993.
  » http://dx.doi.org/10.1016/j.jvsv.2022.05.007
• ⁴⁴
  Bissacco D, Oberto S. C0a and C0s patients: potential benefits for an unclear population. Int Angiol. 2018;37(6):486. http://dx.doi.org/10.23736/S0392-9590.18.04029-4 PMid:30203641.
  » http://dx.doi.org/10.23736/S0392-9590.18.04029-4
• ⁴⁵
  Engelhorn CA, Engelhorn AL, Cassou MF, Salles-Cunha S. Patterns of saphenous venous reflux in women presenting with lower extremity telangiectasias. Dermatol Surg. 2007;33(3):282-8. PMid:17338684.
• ⁴⁶
  Benigni JP, Bihari I, Rabe E, et al. Venous symptoms in C0 and C1 patients: UIP consensus document. Int Angiol. 2013;32(3):261-5. PMid:23711678.
• ⁴⁷
  Lugli M, Maleti O, Iabichella ML, Perrin M. Investigation of non-saphenous veins in C0S patients. Int Angiol. 2018;37(2):169-75. http://dx.doi.org/10.23736/S0392-9590.18.03901-9 PMid:29376624.
  » http://dx.doi.org/10.23736/S0392-9590.18.03901-9
• ⁴⁸
  Prochaska JH, Arnold N, Falcke A, et al. Chronic venous insufficiency, cardiovascular disease, and mortality: a population study. Eur Heart J. 2021;42(40):4157-65. http://dx.doi.org/10.1093/eurheartj/ehab495 PMid:34387673.
  » http://dx.doi.org/10.1093/eurheartj/ehab495
• ⁴⁹
  Konoeda H, Yamaki T, Hamahata A, Ochi M, Sakurai H. Quantification of superficial venous reflux by duplex ultrasound-role of reflux velocity in the assessment the clinical stage of chronic venous insufficiency. Ann Vasc Dis. 2014;7(4):376-82. http://dx.doi.org/10.3400/avd.oa.14-00047 PMid:25593622.
  » http://dx.doi.org/10.3400/avd.oa.14-00047
• ⁵⁰
  Panpikoon T, Wedsart B, Treesit T, Chansanti O, Bua-Ngam C. Duplex ultrasound findings and clinical classification of lower extremity chronic venous insufficiency in a Thai population. J Vasc Surg Venous Lymphat Disord. 2019;7(3):349-55. http://dx.doi.org/10.1016/j.jvsv.2018.08.012 PMid:30477978.
  » http://dx.doi.org/10.1016/j.jvsv.2018.08.012
• ⁵¹
  Garcia R, Labropoulos N. Duplex ultrasound for the diagnosis of acute and chronic venous diseases. Surg Clin North Am. 2018;98(2):201-18. http://dx.doi.org/10.1016/j.suc.2017.11.007 PMid:29502767.
  » http://dx.doi.org/10.1016/j.suc.2017.11.007
• ⁵²
  Malgor RD, Labropoulos N. Diagnosis and follow-up of varicose veins with duplex ultrasound: how and why? Phlebology. 2012;27(Suppl 1):10-5. http://dx.doi.org/10.1258/phleb.2011.012s05 PMid:22312061.
  » http://dx.doi.org/10.1258/phleb.2011.012s05
• ⁵³
  Santiago FR, Piscoya M, Chi YW. A sonographic study of thigh telangiectasias. Phlebology. 2018;33(7):500-1. http://dx.doi.org/10.1177/0268355517717404 PMid:28683584.
  » http://dx.doi.org/10.1177/0268355517717404
• ⁵⁴
  Engelhorn CA, Engelhorn AL, Cassou MF, Salles-Cunha S. Patterns of saphenous venous reflux in women presenting with lower extremity telangiectasias. Dermatol Surg. 2007;33(3):282-8. PMid:17338684.
• ⁵⁵
  Ruckley CV, Allan PL, Evans CJ, Lee AJ, Fowkes FG. Telangiectasia and venous reflux in the Edinburgh Vein Study. Phlebology. 2012;27(6):297-302. http://dx.doi.org/10.1258/phleb.2011.011007 PMid:22106449.
  » http://dx.doi.org/10.1258/phleb.2011.011007
• ⁵⁶
  Yun S. Ultrasound-based topographic analysis of tributary vein connection with the saphenous vein during ambulatory conservative hemodynamic correction of chronic venous insufficiency. J Vasc Surg Venous Lymphat Disord. 2019;7(3):356-63. http://dx.doi.org/10.1016/j.jvsv.2018.09.011 PMid:30777672.
  » http://dx.doi.org/10.1016/j.jvsv.2018.09.011
• ⁵⁷
  Engelhorn CA, Manetti R, Baviera MM, et al. Progression of reflux patterns in saphenous veins of women with chronic venous valvular insufficiency. Phlebology. 2012;27(1):25-32. http://dx.doi.org/10.1258/phleb.2011.010077 PMid:21903684.
  » http://dx.doi.org/10.1258/phleb.2011.010077
• ⁵⁸
  García Carriazo M, Gómez de las Heras C, Mármol Vázquez P, Ramos Solís MF. Doppler ultrasound study and venous mapping in chronic venous insufficiency. Radiologia (Madr). 2016;58(1):7-15. http://dx.doi.org/10.1016/j.rxeng.2015.10.001 PMid:26655801.
  » http://dx.doi.org/10.1016/j.rxeng.2015.10.001
• ⁵⁹
  Metzger PB, Rossi FH, Kambara AM, et al. Criteria for detecting significant chronic iliac venous obstructions with duplex ultrasound. J Vasc Surg Venous Lymphat Disord. 2016;4(1):18-27. http://dx.doi.org/10.1016/j.jvsv.2015.07.002 PMid:26946891.
  » http://dx.doi.org/10.1016/j.jvsv.2015.07.002
• ⁶⁰
  Villalba L, Larkin TA. Transabdominal duplex ultrasound and intravascular ultrasound planimetry measures of common iliac vein stenosis are significantly correlated in a symptomatic population. J Vasc Surg Venous Lymphat Disord. 2021;9(5):1273-81. http://dx.doi.org/10.1016/j.jvsv.2021.01.015 PMid:33548556.
  » http://dx.doi.org/10.1016/j.jvsv.2021.01.015
• ⁶¹
  Labropoulos N, Jasinski PT, Adrahtas D, Gasparis AP, Meissner MH. A standardized ultrasound approach to pelvic congestion syndrome. Phlebology. 2017;32(9):608-19. http://dx.doi.org/10.1177/0268355516677135 PMid:27799418.
  » http://dx.doi.org/10.1177/0268355516677135
• ⁶²
  Sloves J, Almeida JI. Venous duplex ultrasound protocol for iliocaval disease. J Vasc Surg Venous Lymphat Disord. 2018;6(6):748-57. http://dx.doi.org/10.1016/j.jvsv.2018.06.005 PMid:30336903.
  » http://dx.doi.org/10.1016/j.jvsv.2018.06.005
• ⁶³
  Coelho A, O’Sullivan G. Usefulness of direct computed tomography venography in predicting inflow for venous reconstruction in chronic post-thrombotic syndrome. Cardiovasc Intervent Radiol. 2019;42(5):677-84. http://dx.doi.org/10.1007/s00270-019-02161-5 PMid:30627773.
  » http://dx.doi.org/10.1007/s00270-019-02161-5
• ⁶⁴
  Gagne PJ, Tahara RW, Fastabend CP, et al. Venography versus intravascular ultrasound for diagnosing and treating iliofemoral vein obstruction. J Vasc Surg Venous Lymphat Disord. 2017;5(5):678-87. http://dx.doi.org/10.1016/j.jvsv.2017.04.007 PMid:28818221.
  » http://dx.doi.org/10.1016/j.jvsv.2017.04.007
• ⁶⁵
  Montminy ML, Thomasson JD, Tanaka GJ, Lamanilao LM, Crim W, Raju S. A comparison between intravascular ultrasound and venography in identifying key parameters essential for iliac vein stenting. J Vasc Surg Venous Lymphat Disord. 2019;7(6):801-7. http://dx.doi.org/10.1016/j.jvsv.2019.03.015 PMid:31196766.
  » http://dx.doi.org/10.1016/j.jvsv.2019.03.015
• ⁶⁶
  Raju S, Walker W, Noel C, Kuykendall R, Powell T, Jayaraj A. Dimensional disparity between duplex and intravascular ultrasound in the assessment of iliac vein stenosis. Vasc Med. 2021;26(5):549-55. http://dx.doi.org/10.1177/1358863X211003663 PMid:33840321.
  » http://dx.doi.org/10.1177/1358863X211003663
• ⁶⁷
  Toh MR, Damodharan K, Lim HHMN, Tang TY. Computed tomography venography versus intravascular ultrasound in the diagnosis of iliofemoral vein stenosis. Vasa. 2021;50(1):38-44. http://dx.doi.org/10.1024/0301-1526/a000920 PMid:33153399.
  » http://dx.doi.org/10.1024/0301-1526/a000920
• ⁶⁸
  Montminy ML, Thomasson JD, Tanaka GJ, Lamanilao LM, Crim W, Raju S. A comparison between intravascular ultrasound and venography in identifying key parameters essential for iliac vein stenting. J Vasc Surg Venous Lymphat Disord. 2019;7(6):801-7. http://dx.doi.org/10.1016/j.jvsv.2019.03.015 PMid:31196766.
  » http://dx.doi.org/10.1016/j.jvsv.2019.03.015
• ⁶⁹
  Lau I, Png CYM, Eswarappa M, et al. Defining the utility of anteroposterior venography in the diagnosis of venous iliofemoral obstruction. J Vasc Surg Venous Lymphat Disord. 2019;7(4):514-521.e4. http://dx.doi.org/10.1016/j.jvsv.2018.11.012 PMid:30926244.
  » http://dx.doi.org/10.1016/j.jvsv.2018.11.012
• ⁷⁰
  Lorenção de Almeida B, Rossi FH, Guerra de Moraes Rego Sousa A, et al. Correlation between venous pressure gradients and intravascular ultrasound in the diagnosis of iliac vein compression syndrome. J Vasc Surg Venous Lymphat Disord. 2018;6(4):492-9. http://dx.doi.org/10.1016/j.jvsv.2017.11.015 PMid:29526687.
  » http://dx.doi.org/10.1016/j.jvsv.2017.11.015
• ⁷¹
  Rossi FH, Kambara AM, Rodrigues TO, et al. Comparison of computed tomography venography and intravascular ultrasound in screening and classification of iliac vein obstruction in patients with chronic venous disease. J Vasc Surg Venous Lymphat Disord. 2020;8(3):413-22. http://dx.doi.org/10.1016/j.jvsv.2019.09.015 PMid:32197952.
  » http://dx.doi.org/10.1016/j.jvsv.2019.09.015
• ⁷²
  Uhl JF. Three-dimensional modelling of the venous system by direct multislice helical computed tomography venography: technique, indications and results. Phlebology. 2012;27(6):270-88. http://dx.doi.org/10.1258/phleb.2012.012J07 PMid:23155152.
  » http://dx.doi.org/10.1258/phleb.2012.012J07
• ⁷³
  Łastowiecka-Moras E. How posture influences venous blood flow in the lower limbs: results of a study using photoplethysmography. Int J Occup Saf Ergon. 2017;23(2):147-51. http://dx.doi.org/10.1080/10803548.2016.1256938 PMid:27813456.
  » http://dx.doi.org/10.1080/10803548.2016.1256938
• ⁷⁴
  Neto FC, de Oliveira RG, Thomazinho F, Weinhardt Batista AP, Moraes Kessler I. Impact of great saphenous vein foam sclerotherapy on quality of life and photoplethysmography findings in chronic venous insufficiency: one-year follow-up. Dermatol Surg. 2020;46(3):369-75. http://dx.doi.org/10.1097/DSS.0000000000002063 PMid:31397782.
  » http://dx.doi.org/10.1097/DSS.0000000000002063
• ⁷⁵
  Liu J, Yan B, Chen SC, Zhang YT, Sodini C, Zhao N. Non-invasive capillary blood pressure measurement enabling early detection and classification of venous congestion. IEEE J Biomed Health Inform. 2021;25(8):2877-86. http://dx.doi.org/10.1109/JBHI.2021.3055760 PMid:33513121.
  » http://dx.doi.org/10.1109/JBHI.2021.3055760
• ⁷⁶
  Nelzén POE, Skoog J, Öster M, Zachrisson H. Impact on venous haemodynamics after treatment of great saphenous vein incompetence using plethysmography and duplex ultrasound. Phlebology. 2020;35(7):495-504. http://dx.doi.org/10.1177/0268355519898952 PMid:31959059.
  » http://dx.doi.org/10.1177/0268355519898952
• ⁷⁷
  Nelzén PO, Skoog J, Lassvik C, Länne T, Zachrisson H. Prediction of post-interventional outcome in great saphenous vein incompetence: the role of venous plethysmography with selective superficial vein occlusion. Eur J Vasc Endovasc Surg. 2016;52(3):377-84. http://dx.doi.org/10.1016/j.ejvs.2016.05.032 PMid:27405879.
  » http://dx.doi.org/10.1016/j.ejvs.2016.05.032
• ⁷⁸
  Rabe E, Ballarini S, Lehr L. A randomized, double-blind, placebo-controlled, clinical study on the efficacy and safety of calcium dobesilate in the treatment of chronic venous insufficiency. Phlebology. 2016;31(4):264-74. http://dx.doi.org/10.1177/0268355515586097 PMid:25991692.
  » http://dx.doi.org/10.1177/0268355515586097
• ⁷⁹
  Pittler MH, Ernst E. Horse chestnut seed extract for chronic venous insufficiency. Cochrane Database Syst Rev. 2012;11(11):CD003230. http://dx.doi.org/10.1002/14651858.CD003230.pub4 PMid:23152216.
  » http://dx.doi.org/10.1002/14651858.CD003230.pub4
• ⁸⁰
  Azhdari M, Zilaee M, Karandish M, et al. Red vine leaf extract (AS 195) can improve some signs and symptoms of chronic venous insufficiency, a systematic review. Phytother Res. 2020;34(10):2577-85. http://dx.doi.org/10.1002/ptr.6705 PMid:32314844.
  » http://dx.doi.org/10.1002/ptr.6705
• ⁸¹
  Aziz Z, Tang WL, Chong NJ, Tho LY. A systematic review of the efficacy and tolerability of hydroxyethylrutosides for improvement of the signs and symptoms of chronic venous insufficiency. J Clin Pharm Ther. 2015;40(2):177-85. http://dx.doi.org/10.1111/jcpt.12247 PMid:25630350.
  » http://dx.doi.org/10.1111/jcpt.12247
• ⁸²
  Kakkos SK, Allaert FA. Efficacy of Ruscus extract, HMC and vitamin C, constituents of Cyclo 3 fort®, on improving individual venous symptoms and edema: a systematic review and meta-analysis of randomized double-blind placebo-controlled trials. Int Angiol. 2017;36(2):93-106. http://dx.doi.org/10.23736/S0392-9590.17.03815-9 PMid:28225220.
  » http://dx.doi.org/10.23736/S0392-9590.17.03815-9
• ⁸³
  Bignamini AA, Matuška J. Sulodexide for the symptoms and signs of chronic venous disease: a systematic review and meta-analysis. Adv Ther. 2020;37(3):1013-33. http://dx.doi.org/10.1007/s12325-020-01232-1 PMid:31989486.
  » http://dx.doi.org/10.1007/s12325-020-01232-1
• ⁸⁴
  Martinez-Zapata MJ, Vernooij RW, Simancas-Racines D, et al. Phlebotonics for venous insufficiency. Cochrane Database Syst Rev. 2020;11(11):CD003229. PMid:33141449.
• ⁸⁵
  de Lima DC. Varicose veins and occupational health: symptoms, treatment and prevention. Rev Bras Med Trab. 2019;17(4):589-93. http://dx.doi.org/10.5327/Z1679443520190460 PMid:32685759.
  » http://dx.doi.org/10.5327/Z1679443520190460
• ⁸⁶
  Kakkos SK, Nicolaides AN. Efficacy of micronized purified flavonoid fraction (Daflon®) on improving individual symptoms, signs and quality of life in patients with chronic venous disease: a systematic review and meta-analysis of randomized double-blind placebo-controlled trials. Int Angiol. 2018;37(2):143-54. http://dx.doi.org/10.23736/S0392-9590.18.03975-5 PMid:29385792.
  » http://dx.doi.org/10.23736/S0392-9590.18.03975-5
• ⁸⁷
  Kakkos SK, Timpilis M, Patrinos P, et al. Acute effects of graduated elastic compression stockings in patients with symptomatic varicose veins: a randomised double-blind placebo controlled trial. Eur J Vasc Endovasc Surg. 2018;55(1):118-25. http://dx.doi.org/10.1016/j.ejvs.2017.10.004 PMid:29129457.
  » http://dx.doi.org/10.1016/j.ejvs.2017.10.004
• ⁸⁸
  Dahm KT, Myrhaug HT, Strømme H, Fure B, Brurberg KG. Effects of preventive use of compression stockings for elderly with chronic venous insufficiency and swollen legs: a systematic review and meta-analysis. BMC Geriatr. 2019;19(1):76. http://dx.doi.org/10.1186/s12877-019-1087-1 PMid:30845919.
  » http://dx.doi.org/10.1186/s12877-019-1087-1
• ⁸⁹
  Knight Nee Shingler SL, Robertson L, Stewart M. Graduated compression stockings for the initial treatment of varicose veins in people without venous ulceration. Cochrane Database Syst Rev. 2021;7(7):CD008819. PMid:34271595.
• ⁹⁰
  Schmidt AC, Gomes LPOZ, Marinelli CM, Gomes RZ. Effects of strengthening the surae triceps muscle on venous pump function in chronic venous insufficiency. J Vasc Bras. 2021;20:e20200197. http://dx.doi.org/10.1590/1677-5449.200197 PMid:34456985.
  » http://dx.doi.org/10.1590/1677-5449.200197
• ⁹¹
  Aydin G, Yeldan I, Akgul A, Ipek G. Effects of inspiratory muscle training versus calf muscle training on quality of life, pain, venous function and activity in patients with chronic venous insufficiency. J Vasc Surg Venous Lymphat Disord. 2022;10(5):1137-46. http://dx.doi.org/10.1016/j.jvsv.2022.04.012 PMID: 35710091.
  » http://dx.doi.org/10.1016/j.jvsv.2022.04.012
• ⁹²
  Ercan S, Çetin C, Yavuz T, Demir HM, Atalay YB. Effects of isokinetic calf muscle exercise program on muscle strength and venous function in patients with chronic venous insufficiency. Phlebology. 2018;33(4):261-6. http://dx.doi.org/10.1177/0268355517695401 PMid:28954574.
  » http://dx.doi.org/10.1177/0268355517695401
• ⁹³
  Erdal ES, Demirgüç A, Kabalcı M, Demirtaş H. Evaluation of physical activity level and exercise capacity in patients with varicose veins and chronic venous insufficiency. Phlebology. 2021;36(8):636-43. http://dx.doi.org/10.1177/02683555211002339 PMid:33745365.
  » http://dx.doi.org/10.1177/02683555211002339
• ⁹⁴
  Keser İ, Özdemir K, Erer D, Onurlu İ, Bezgin S. Differences in pain, fatigue, and quality of life in patients with chronic venous insufficiency based on physical activity level. Turk Gogus Kalp Damar Cerrahisi Derg. 2020;28(1):76-83. http://dx.doi.org/10.5606/tgkdc.dergisi.2020.18068 PMid:32175146.
  » http://dx.doi.org/10.5606/tgkdc.dergisi.2020.18068
• ⁹⁵
  Mutlak O, Aslam M, Standfield N. The influence of exercise on ulcer healing in patients with chronic venous insufficiency. Int Angiol. 2018;37(2):160-8. http://dx.doi.org/10.23736/S0392-9590.18.03950-0 PMid:29368880.
  » http://dx.doi.org/10.23736/S0392-9590.18.03950-0
• ⁹⁶
  Silva KLS, Figueiredo EAB, Lopes CP, et al. The impact of exercise training on calf pump function, muscle strength, ankle range of motion, and health-related quality of life in patients with chronic venous insufficiency at different stages of severity: a systematic review. J Vasc Bras. 2021;20:e20200125. http://dx.doi.org/10.1590/1677-5449.200125 PMid:34093685.
  » http://dx.doi.org/10.1590/1677-5449.200125
• ⁹⁷
  Kiloatar H, Aras O, Korkmaz M, Vural AH. An evaluation of quality of life, physical activity level and symptoms in patients with early stages of chronic venous disease. J Vasc Nurs. 2021;39(4):108-13. http://dx.doi.org/10.1016/j.jvn.2021.07.007 PMid:34865720.
  » http://dx.doi.org/10.1016/j.jvn.2021.07.007
• ⁹⁸
  Davies HO, Popplewell M, Singhal R, Smith N, Bradbury AW. Obesity and lower limb venous disease - the epidemic of phlebesity. Phlebology. 2017;32(4):227-33. http://dx.doi.org/10.1177/0268355516649333 PMID: 27178403.
  » http://dx.doi.org/10.1177/0268355516649333
• ⁹⁹
  Parkyn WR, Chan CY, Van Rij AM. Skin problems in the lower legs of morbidly obese patients and possible role of bariatric surgery. J Obes Weight Loss Ther. 2014;4(4):230. http://dx.doi.org/10.4172/2165-7904.1000230
  » http://dx.doi.org/10.4172/2165-7904.1000230
• ¹⁰⁰
  van Rij AM, De Alwis CS, Jiang P, et al. Obesity and impaired venous function. Eur J Vasc Endovasc Surg. 2008;35(6):739-44. http://dx.doi.org/10.1016/j.ejvs.2008.01.006 PMID: 18313335.
  » http://dx.doi.org/10.1016/j.ejvs.2008.01.006
• ¹⁰¹
  Deol ZK, Lakhanpal S, Franzon G, Pappas PJ. Effect of obesity on chronic venous insufficiency treatment outcomes. J Vasc Surg Venous Lymphat Disord. 2020;8(4):617-28.e1. https://doi.org/10.1016/j.jvsv.2020.04.006
  » https://doi.org/10.1016/j.jvsv.2020.04.006
• ¹⁰²
  Shaalan W, El Emam A, Lotfy H, Naga A. Clinical and hemodynamic outcome of morbidly obese patients with severe chronic venous insufficiency with and without bariatric surgery. J Vasc Surg Venous Lymphat Disord. 2021;9(5):1248-1256.e2. http://dx.doi.org/10.1016/j.jvsv.2021.01.005 PMid:33540136.
  » http://dx.doi.org/10.1016/j.jvsv.2021.01.005
• ¹⁰³
  Meulendijks AM, Franssen WMA, Schoonhoven L, Neumann HAM. A scoping review on chronic venous disease and the development of a venous leg ulcer: the role of obesity and mobility. J Tissue Viability. 2020;29(3):190-6. http://dx.doi.org/10.1016/j.jtv.2019.10.002 PMID: 31668667.
  » http://dx.doi.org/10.1016/j.jtv.2019.10.002
• ¹⁰⁴
  Wiewiora M, Piecuch J, Glück M, Slowinska-Lozynska L, Sosada K. Impact of weight loss due to sleeve gastrectomy on shear stress of the femoral vein in morbid obesity. Obes Surg. 2014;24(5):806-12. http://dx.doi.org/10.1007/s11695-013-1175-9 PMid:24421156.
  » http://dx.doi.org/10.1007/s11695-013-1175-9
• ¹⁰⁵
  Michaels JA, Brazier JE, Campbell WB, MacIntyre JB, Palfreyman SJ, Ratcliffe J. Randomized clinical trial comparing surgery with conservative treatment for uncomplicated varicose veins. Br J Surg. 2006;93(2):175-81. http://dx.doi.org/10.1002/bjs.5264 PMid:16432825.
  » http://dx.doi.org/10.1002/bjs.5264
• ¹⁰⁶
  Carradice D, Wallace T, Gohil R, Chetter I. A comparison of the effectiveness of treating those with and without the complications of superficial venous insufficiency. Ann Surg. 2014;260(2):396-401. http://dx.doi.org/10.1097/SLA.0000000000000541 PMid:24424141.
  » http://dx.doi.org/10.1097/SLA.0000000000000541
• ¹⁰⁷
  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. http://dx.doi.org/10.1002/bjs.5263 PMid:16432810.
  » http://dx.doi.org/10.1002/bjs.5263
• ¹⁰⁸
  Marsden G, Perry M, Bradbury A, et al. A Cost-effectiveness analysis of surgery, endothermal ablation, ultrasound-guided foam sclerotherapy and compression stockings for symptomatic varicose veins. Eur J Vasc Endovasc Surg. 2015;50(6):794-801. http://dx.doi.org/10.1016/j.ejvs.2015.07.034 PMid:26433594.
  » http://dx.doi.org/10.1016/j.ejvs.2015.07.034
• ¹⁰⁹
  Malskat WSJ, Engels LK, Hollestein LM, Nijsten T, van den Bos RR. Commonly used endovenous laser ablation (evla) parameters do not influence efficacy: results of a systematic review and meta-analysis. Eur J Vasc Endovasc Surg. 2019;58(2):230-42. http://dx.doi.org/10.1016/j.ejvs.2018.10.036 PMid:31230868.
  » http://dx.doi.org/10.1016/j.ejvs.2018.10.036
• ¹¹⁰
  Lawson JA, Gauw SA, van Vlijmen CJ, et al. Prospective comparative cohort study evaluating incompetent great saphenous vein closure using radiofrequency-powered segmental ablation or 1470-nm endovenous laser ablation with radial-tip fibers (Varico 2 study). J Vasc Surg Venous Lymphat Disord. 2018;6(1):31-40. http://dx.doi.org/10.1016/j.jvsv.2017.06.016 PMid:29248107.
  » http://dx.doi.org/10.1016/j.jvsv.2017.06.016
• ¹¹¹
  Malskat WSJ, Giang J, De Maeseneer MGR, Nijsten TEC, van den Bos RR. Randomized clinical trial of 940- versus 1470-nm endovenous laser ablation for great saphenous vein incompetence. Br J Surg. 2016;103(3):192-8. http://dx.doi.org/10.1002/bjs.10035 PMid:26661521.
  » http://dx.doi.org/10.1002/bjs.10035
• ¹¹²
  Sandhya PA, Mohil RS, Sricharan R. Randomised controlled study to compare radiofrequency ablation with minimally invasive ultrasound-guided non-flush ligation and stripping of great saphenous vein in the treatment of varicose veins. Ann R Coll Surg Engl. 2020;102(7):525-31. http://dx.doi.org/10.1308/rcsann.2020.0116 PMid:32538106.
  » http://dx.doi.org/10.1308/rcsann.2020.0116
• ¹¹³
  Beteli CB, Rossi FH, de Almeida BL, et al. Prospective, double-blind, randomized controlled trial comparing electrocoagulation and radiofrequency in the treatment of patients with great saphenous vein insufficiency and lower limb varicose veins. J Vasc Surg Venous Lymphat Disord. 2018;6(2):212-9. http://dx.doi.org/10.1016/j.jvsv.2017.09.010 PMid:29229466.
  » http://dx.doi.org/10.1016/j.jvsv.2017.09.010
• ¹¹⁴
  Flessenkämper I, Hartmann M, Hartmann K, Stenger D, Roll S. Endovenous laser ablation with and without high ligation compared to high ligation and stripping for treatment of great saphenous varicose veins: Results of a multicentre randomised controlled trial with up to 6 years follow-up. Phlebology. 2016;31(1):23-33. http://dx.doi.org/10.1177/0268355514555547 PMid:25342648.
  » http://dx.doi.org/10.1177/0268355514555547
• ¹¹⁵
  Erzinger FL, de Araujo WJB, Nejm CS, Caron FC, Timi JRR. Estudo comparativo da termoablação da veia safena magna na coxa, com e sem tumescência. J Vasc Bras. 2016;15(3):217-23. http://dx.doi.org/10.1590/1677-5449.004616 PMid:29930593.
  » http://dx.doi.org/10.1590/1677-5449.004616
• ¹¹⁶
  Paravastu SC, Horne M, Dodd PD. Endovenous ablation therapy (laser or radiofrequency) or foam sclerotherapy versus conventional surgical repair for short saphenous varicose veins. Cochrane Database Syst Rev. 2016;11(11):CD010878. http://dx.doi.org/10.1002/14651858.CD010878.pub2 PMid:27898181.
  » http://dx.doi.org/10.1002/14651858.CD010878.pub2
• ¹¹⁷
  O’Donnell TF, Balk EM, Dermody M, Tangney E, Iafrati MD. Recurrence of varicose veins after endovenous ablation of the great saphenous vein in randomized trials. J Vasc Surg Venous Lymphat Disord. 2016;4(1):97-105. http://dx.doi.org/10.1016/j.jvsv.2014.11.004 PMid:26946904.
  » http://dx.doi.org/10.1016/j.jvsv.2014.11.004
• ¹¹⁸
  Darwood RJ, Theivacumar N, Dellagrammaticas D, Mavor AID, 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. http://dx.doi.org/10.1002/bjs.6101 PMid:18278775.
  » http://dx.doi.org/10.1002/bjs.6101
• ¹¹⁹
  Hamann SAS, Giang J, De Maeseneer MGR, Nijsten TEC, van den Bos RR. Editor’s Choice - five year results of great saphenous vein treatment: a meta-analysis. Eur J Vasc Endovasc Surg. 2017;54(6):760-70. http://dx.doi.org/10.1016/j.ejvs.2017.08.034 PMid:29033337.
  » http://dx.doi.org/10.1016/j.ejvs.2017.08.034
• ¹²⁰
  Kheirelseid EAH, Crowe G, Sehgal R, et al. Systematic review and meta-analysis of randomized controlled trials evaluating long-term outcomes of endovenous management of lower extremity varicose veins. J Vasc Surg Venous Lymphat Disord. 2018;6(2):256-70. http://dx.doi.org/10.1016/j.jvsv.2017.10.012 PMid:29292115.
  » http://dx.doi.org/10.1016/j.jvsv.2017.10.012
• ¹²¹
  Burihan MC. Endovenous ablation (radiofrequency and laser) and foam sclerotherapy versus conventional surgery for great saphenous vein varices. Sao Paulo Med J. 2014;132(1):69. http://dx.doi.org/10.1590/1516-3180.20141321T2 PMid:24474085.
  » http://dx.doi.org/10.1590/1516-3180.20141321T2
• ¹²²
  Gauw SA, Lawson JA, van Vlijmen-van Keulen CJ, Pronk P, Gaastra MT, Mooij MC. Five-year follow-up of a randomized, controlled trial comparing saphenofemoral ligation and stripping of the great saphenous vein with endovenous laser ablation (980 nm) using local tumescent anesthesia. J Vasc Surg. 2016;63(2):420-8. http://dx.doi.org/10.1016/j.jvs.2015.08.084 PMid:26602795.
  » http://dx.doi.org/10.1016/j.jvs.2015.08.084
• ¹²³
  Sandhya PA, Mohil RS, Sricharan R. Randomised controlled study to compare radiofrequency ablation with minimally invasive ultrasound-guided non-flush ligation and stripping of great saphenous vein in the treatment of varicose veins. Ann R Coll Surg Engl. 2020;102(7):525-31. http://dx.doi.org/10.1308/rcsann.2020.0116 PMid:32538106.
  » http://dx.doi.org/10.1308/rcsann.2020.0116
• ¹²⁴
  Rass K, Frings N, Glowacki P, Gräber S, Tilgen W, Vogt T. Same site recurrence is more frequent after endovenous laser ablation compared with high ligation and stripping of the great saphenous vein: 5 year Results of a Randomized Clinical Trial (RELACS Study). Eur J Vasc Endovasc Surg. 2015;50(5):648-56. http://dx.doi.org/10.1016/j.ejvs.2015.07.020 PMid:26319476.
  » http://dx.doi.org/10.1016/j.ejvs.2015.07.020
• ¹²⁵
  Myers KA, Jolley D, Clough A, Kirwan J. Outcome of ultrasound-guided sclerotherapy for varicose veins: medium-term results assessed by ultrasound surveillance. Eur J Vasc Endovasc Surg. 2007;33(1):116-21. http://dx.doi.org/10.1016/j.ejvs.2006.09.005 PMid:17067832.
  » http://dx.doi.org/10.1016/j.ejvs.2006.09.005
• ¹²⁶
  Watanabe S, Okamura A, Iwamoto M, et al. A randomized controlled trial to evaluate the safety and efficacy of transluminal injection of foam sclerotherapy compared with ultrasound-guided foam sclerotherapy during endovenous catheter ablation in patients with varicose veins. J Vasc Surg Venous Lymphat Disord. 2022;10(1):75-81.e1. http://dx.doi.org/10.1016/j.jvsv.2021.06.017 PMid:34252576.
  » http://dx.doi.org/10.1016/j.jvsv.2021.06.017
• ¹²⁷
  Li X, Yang B, Li X, Ren S. Prospective comparison of effect of ligation and foam sclerotherapy with foam sclerotherapy alone for varicose veins. Ann Vasc Surg. 2018;49:75-9. http://dx.doi.org/10.1016/j.avsg.2018.01.004 PMid:29428536.
  » http://dx.doi.org/10.1016/j.avsg.2018.01.004
• ¹²⁸
  Darvall KA, Bate GR, Bradbury AW. Patient-reported outcomes 5-8 years after ultrasound-guided foam sclerotherapy for varicose veins. Br J Surg. 2014;101(9):1098-104. http://dx.doi.org/10.1002/bjs.9581 PMid:24962055.
  » http://dx.doi.org/10.1002/bjs.9581
• ¹²⁹
  van der Velden SK, Biemans AA, De Maeseneer MG, et al. 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. http://dx.doi.org/10.1002/bjs.9867 PMid:26132315.
  » http://dx.doi.org/10.1002/bjs.9867
• ¹³⁰
  Shadid N, Nelemans P, Lawson J, Sommer A. Predictors of recurrence of great saphenous vein reflux following treatment with ultrasound-guided foam 155sclerotherapy. Phlebology. 2015;30(3):194-9. http://dx.doi.org/10.1177/0268355514521183 PMid:24474721.
  » http://dx.doi.org/10.1177/0268355514521183
• ¹³¹
  Silva MAM, Araujo ÁZP, do Amaral JF, de Jesus-Silva SG, Cardoso RS, Miranda F. Júnior. Impacto da escleroterapia com espuma de polidocanol guiada por ultrassom em pacientes com úlcera venosa. J Vasc Bras. 2017;16(3):239-43. http://dx.doi.org/10.1590/1677-5449.002717 PMid:29930653.
  » http://dx.doi.org/10.1590/1677-5449.002717
• ¹³²
  Marsden G, Perry M, Bradbury A, et al. A cost-effectiveness analysis of surgery, endothermal ablation, ultrasound-guided foam sclerotherapy and compression stockings for symptomatic varicose veins. Eur J Vasc Endovasc Surg. 2015;50(6):794-801. http://dx.doi.org/10.1016/j.ejvs.2015.07.034 PMid:26433594.
  » http://dx.doi.org/10.1016/j.ejvs.2015.07.034
• ¹³³
  Lim SY, Tan JX, D’Cruz RT, Syn N, Chong TT, Tang TY. Catheter-directed foam sclerotherapy, an alternative to ultrasound-guided foam sclerotherapy for varicose vein treatment: a systematic review and meta-analysis. Phlebology. 2020;35(6):369-83. http://dx.doi.org/10.1177/0268355519898309 PMid:31918640.
  » http://dx.doi.org/10.1177/0268355519898309
• ¹³⁴
  Vähäaho S, Halmesmäki K, Mahmoud O, Albäck A, Noronen K, Venermo M. Three-year results of a randomized controlled trial comparing mechanochemical and thermal ablation in the treatment of insufficient great saphenous veins. J Vasc Surg Venous Lymphat Disord. 2021;9(3):652-9. http://dx.doi.org/10.1016/j.jvsv.2020.08.007 PMid:32795619.
  » http://dx.doi.org/10.1016/j.jvsv.2020.08.007
• ¹³⁵
  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(3):364-74. http://dx.doi.org/10.1016/j.jvsv.2018.12.014 PMid:31000063.
  » http://dx.doi.org/10.1016/j.jvsv.2018.12.014
• ¹³⁶
  Mohamed AH, Leung C, Wallace T, Smith G, Carradice D, Chetter I. A randomized controlled trial of endovenous laser ablation versus mechanochemical ablation with ClariVein in the Management of Superficial Venous Incompetence (LAMA Trial). Ann Surg. 2021;273(6):e188-95. http://dx.doi.org/10.1097/SLA.0000000000003749 PMid:31977509.
  » http://dx.doi.org/10.1097/SLA.0000000000003749
• ¹³⁷
  Vos CG, Ünlü Ç, Bosma J, van Vlijmen CJ, de Nie AJ, Schreve MA. A systematic review and meta-analysis of two novel techniques of nonthermal endovenous ablation of the great saphenous vein. J Vasc Surg Venous Lymphat Disord. 2017;5(6):880-96. http://dx.doi.org/10.1016/j.jvsv.2017.05.022 PMid:29037363.
  » http://dx.doi.org/10.1016/j.jvsv.2017.05.022
• ¹³⁸
  Chen AJ, Ulloa JG, Torrez T, et al. Mechanochemical endovenous ablation of the saphenous vein: a look at contemporary outcomes. Ann Vasc Surg. 2022;82:7-12. http://dx.doi.org/10.1016/j.avsg.2021.11.019 PMid:34933109.
  » http://dx.doi.org/10.1016/j.avsg.2021.11.019
• ¹³⁹
  Tawfik AM, Sorour WA, El-Laboudy ME. Laser ablation versus mechanochemical ablation in the treatment of primary varicose veins: a randomized clinical trial. J Vasc Surg Venous Lymphat Disord. 2020;8(2):211-5. http://dx.doi.org/10.1016/j.jvsv.2019.10.025 PMid:31864932.
  » http://dx.doi.org/10.1016/j.jvsv.2019.10.025
• ¹⁴⁰
  Alozai T, Huizing E, Schreve M, et al. A systematic review and meta-analysis of mechanochemical endovenous ablation using Flebogrif for varicose veins. J Vasc Surg Venous Lymphat Disord. 2022;10(1):248-257.e2. http://dx.doi.org/10.1016/j.jvsv.2021.05.010 PMid:34091106.
  » http://dx.doi.org/10.1016/j.jvsv.2021.05.010
• ¹⁴¹
  Apruzzi L, Bilman V, Ardita V, et al. Comparison of mechanochemical ablation versus ligation and stripping for the treatment of incompetent small saphenous vein. Phlebology. 2022;37(1):48-54. http://dx.doi.org/10.1177/02683555211045191 PMid:34505545.
  » http://dx.doi.org/10.1177/02683555211045191
• ¹⁴²
  González Cañas E, Florit López S, Vilagut RV, et al. A randomized controlled noninferiority trial comparing radiofrequency with stripping and conservative hemodynamic cure for venous insufficiency technique for insufficiency of the great saphenous vein. J Vasc Surg Venous Lymphat Disord. 2021;9(1):101-12. http://dx.doi.org/10.1016/j.jvsv.2020.04.019 PMid:32353592.
  » http://dx.doi.org/10.1016/j.jvsv.2020.04.019
• ¹⁴³
  Zmudzinski M, Malo P, Hall C, Hayashi A. CHIVA - a prospective study of a vein sparing technique for the management of varicose vein disease. Am J Surg. 2017;213(5):967-9. http://dx.doi.org/10.1016/j.amjsurg.2017.03.025 PMid:28431588.
  » http://dx.doi.org/10.1016/j.amjsurg.2017.03.025
• ¹⁴⁴
  Onida S, Davies AH. CHIVA, ASVAL and related techniques--concepts and evidence. Phlebology. 2015;30(2, Suppl):42-5. http://dx.doi.org/10.1177/0268355515591439 PMid:26556702.
  » http://dx.doi.org/10.1177/0268355515591439
• ¹⁴⁵
  Faccini FP, Ermini S, Franceschi C. CHIVA to treat saphenous vein insufficiency in chronic venous disease: characteristics and results. J Vasc Bras. 2019;18:e20180099. http://dx.doi.org/10.1590/1677-5449.009918 PMid:31191629.
  » http://dx.doi.org/10.1590/1677-5449.009918
• ¹⁴⁶
  Yun S. Ultrasound-based topographic analysis of tributary vein connection with the saphenous vein during ambulatory conservative hemodynamic correction of chronic venous insufficiency. J Vasc Surg Venous Lymphat Disord. 2019;7(3):356-63. http://dx.doi.org/10.1016/j.jvsv.2018.09.011 PMid:30777672.
  » http://dx.doi.org/10.1016/j.jvsv.2018.09.011
• ¹⁴⁷
  Tenezaca-Sari X, García-Reyes M, Escribano-Ferrer JM, Marrero C, Bellmunt-Montoya S. The CHIVA strategy applied to large-diameter saphenous veins. Int Angiol. 2022;41(4):332-7. http://dx.doi.org/10.23736/S0392-9590.22.04831-3 PMid:35373939.
  » http://dx.doi.org/10.23736/S0392-9590.22.04831-3
• ¹⁴⁸
  Zolotukhin IA, Seliverstov EI, Zakharova EA, Kirienko AI. Short-term results of isolated phlebectomy with preservation of incompetent great saphenous vein (ASVAL procedure) in primary varicose veins disease. Phlebology. 2017;32(9):601-7. http://dx.doi.org/10.1177/0268355516674415 PMid:27760806.
  » http://dx.doi.org/10.1177/0268355516674415
• ¹⁴⁹
  Kuyumcu G, Salazar GM, Prabhakar AM, Ganguli S. Minimally invasive treatments for perforator vein insufficiency. Cardiovasc Diagn Ther. 2016;6(6):593-8. http://dx.doi.org/10.21037/cdt.2016.11.12 PMid:28123979.
  » http://dx.doi.org/10.21037/cdt.2016.11.12
• ¹⁵⁰
  Gibson K, Elias S, Adelman M, et al. A prospective safety and effectiveness study using endovenous laser ablation with a 400-μm optical fiber for the treatment of pathologic perforator veins in patients with advanced venous disease (SeCure trial). J Vasc Surg Venous Lymphat Disord. 2020;8(5):805-13. http://dx.doi.org/10.1016/j.jvsv.2020.01.014 PMid:32205128.
  » http://dx.doi.org/10.1016/j.jvsv.2020.01.014
• ¹⁵¹
  Lawrence PF, Alktaifi A, Rigberg D, DeRubertis B, Gelabert H, Jimenez JC. Endovenous ablation of incompetent perforating veins is effective treatment for recalcitrant venous ulcers. J Vasc Surg. 2011;54(3):737-42. http://dx.doi.org/10.1016/j.jvs.2011.02.068 PMid:21658887.
  » http://dx.doi.org/10.1016/j.jvs.2011.02.068
• ¹⁵²
  Kishore R, Sankar TB, Anandi A, Nedunchezhian S, Murugan V. A prospective study in comparison of ambulatory phlebectomy and duplex guided foam sclerotherapy in the management of varicosities with isolated perforator incompetence. Indian J Surg. 2016;78(5):356-63. http://dx.doi.org/10.1007/s12262-016-1481-2 PMid:27994330.
  » http://dx.doi.org/10.1007/s12262-016-1481-2
• ¹⁵³
  Schuller-Petrović S, Pavlović MD, Schuller S, Schuller-Lukic B, Adamic M. Telangiectasias resistant to sclerotherapy are commonly connected to a perforating vessel. Phlebology. 2013;28(6):320-3. http://dx.doi.org/10.1258/phleb.2012.012019 PMid:22865418.
  » http://dx.doi.org/10.1258/phleb.2012.012019
• ¹⁵⁴
  Aurshina A, Ascher E, Mount L, Hingorani A, Marks N, Hingorani A. Success rate and factors predictive of redo radiofrequency ablation of perforator veins. J Vasc Surg Venous Lymphat Disord. 2018;6(5):621-5. http://dx.doi.org/10.1016/j.jvsv.2018.01.014 PMid:29678685.
  » http://dx.doi.org/10.1016/j.jvsv.2018.01.014
• ¹⁵⁵
  Ozsvath K, Hager E, Harlander-Locke M, Masuda E, Elias S, Dillavou ED. Current techniques to treat pathologic perforator veins. J Vasc Surg Venous Lymphat Disord. 2017;5(2):293-6. http://dx.doi.org/10.1016/j.jvsv.2016.10.085 PMid:28214499.
  » http://dx.doi.org/10.1016/j.jvsv.2016.10.085
• ¹⁵⁶
  Hager ES, Washington C, Steinmetz A, Wu T, Singh M, Dillavou E. Factors that influence perforator vein closure rates using radiofrequency ablation, laser ablation, or foam sclerotherapy. J Vasc Surg Venous Lymphat Disord. 2016;4(1):51-6. http://dx.doi.org/10.1016/j.jvsv.2015.08.004 PMid:26946896.
  » http://dx.doi.org/10.1016/j.jvsv.2015.08.004
• ¹⁵⁷
  Lane TR, Kelleher D, Shepherd AC, Franklin IJ, Davies AH. Ambulatory varicosity avulsion later or synchronized (AVULS): a randomized clinical trial. Ann Surg. 2015;261(4):654-61. http://dx.doi.org/10.1097/SLA.0000000000000790 PMid:24950277.
  » http://dx.doi.org/10.1097/SLA.0000000000000790
• ¹⁵⁸
  Andrews RH, Dixon RG. Ambulatory Phlebectomy and Sclerotherapy as Tools for the Treatment of Varicose Veins and Telangiectasias. Semin Intervent Radiol. 2021;38(2):160-6. http://dx.doi.org/10.1055/s-0041-1727151 PMid:34108801.
  » http://dx.doi.org/10.1055/s-0041-1727151
• ¹⁵⁹
  Geersen DF, Shortell CEK. Phlebectomy techniques for varicose veins. Surg Clin North Am. 2018;98(2):401-14. http://dx.doi.org/10.1016/j.suc.2017.11.008 PMid:29502780.
  » http://dx.doi.org/10.1016/j.suc.2017.11.008
• ¹⁶⁰
  Hager ES, Ozvath KJ, Dillavou ED. Evidence summary of combined saphenous ablation and treatment of varicosities versus staged phlebectomy. J Vasc Surg Venous Lymphat Disord. 2017;5(1):134-7. http://dx.doi.org/10.1016/j.jvsv.2016.07.009 PMid:27987603.
  » http://dx.doi.org/10.1016/j.jvsv.2016.07.009
• ¹⁶¹
  de Roos KP, Nieman FH, Neumann HA. Ambulatory phlebectomy versus compression sclerotherapy: results of a randomized controlled trial. Dermatol Surg. 2003;29(3):221-6. http://dx.doi.org/10.1097/00042728-200303000-00004 PMid:12614412.
  » http://dx.doi.org/10.1097/00042728-200303000-00004
• ¹⁶²
  Harlander-Locke M, Jimenez JC, Lawrence PF, Derubertis BG, Rigberg DA, Gelabert HA. Endovenous ablation with concomitant phlebectomy is a safe and effective method of treatment for symptomatic patients with axial reflux and large incompetent tributaries. J Vasc Surg. 2013;58(1):166-72. http://dx.doi.org/10.1016/j.jvs.2012.12.054 PMid:23571079.
  » http://dx.doi.org/10.1016/j.jvs.2012.12.054
• ¹⁶³
  Wang JC, Li Y, Li GY, et al. A comparison of concomitant tributary laser ablation and foam sclerotherapy in patients undergoing truncal endovenous laser ablation for lower limb varicose veins. J Vasc Interv Radiol. 2018;29(6):781-9. http://dx.doi.org/10.1016/j.jvir.2018.01.774 PMid:29705225.
  » http://dx.doi.org/10.1016/j.jvir.2018.01.774
• ¹⁶⁴
  Müller L, Alm J. Feasibility and technique of endovenous laser ablation (EVLA) of recurrent varicose veins deriving from the sapheno-femoral junction-A case series of 35 consecutive procedures. PLoS One. 2020;15(7):e0235656. http://dx.doi.org/10.1371/journal.pone.0235656 PMid:32628724.
  » http://dx.doi.org/10.1371/journal.pone.0235656
• ¹⁶⁵
  Müller L, Alm J. Feasibility and potential significance of prophylactic ablation of the major ascending tributaries in endovenous laser ablation (EVLA) of the great saphenous vein: a case series. PLoS One. 2021;16(1):e0245275. http://dx.doi.org/10.1371/journal.pone.0245275 PMid:33412566.
  » http://dx.doi.org/10.1371/journal.pone.0245275
• ¹⁶⁶
  Ashpitel HF, Dabbs EB, Nemchand JL, La Ragione RM, Salguero FJ, Whiteley MS. Histological and immunofluorescent analysis of a large tributary of the great saphenous vein treated with a 1920 nm endovenous laser: preliminary findings. EJVES Short Rep. 2018;39:7-11. http://dx.doi.org/10.1016/j.ejvssr.2018.03.003 PMid:29988869.
  » http://dx.doi.org/10.1016/j.ejvssr.2018.03.003
• ¹⁶⁷
  Myers KA, Clough A, Tilli H. Endovenous laser ablation for major varicose tributaries. Phlebology. 2013;28(4):180-3. http://dx.doi.org/10.1258/phleb.2011.011088 PMid:22490724.
  » http://dx.doi.org/10.1258/phleb.2011.011088
• ¹⁶⁸
  Zhang J, Jing Z, Schliephake DE, Otto J, Malouf GM, Gu YQ. Efficacy and safety of Aethoxysklerol® (polidocanol) 0.5%, 1% and 3% in comparison with placebo solution for the treatment of varicose veins of the lower extremities in Chinese patients (ESA-China Study). Phlebology. 2012;27(4):184-90. http://dx.doi.org/10.1258/phleb.2011.010094 PMid:22045827.
  » http://dx.doi.org/10.1258/phleb.2011.010094
• ¹⁶⁹
  Vasquez M, Gasparis AP, Varithena® 017 Investigator Group. A multicenter, randomized, placebo-controlled trial of endovenous thermal ablation with or without polidocanol endovenous microfoam treatment in patients with great saphenous vein incompetence and visible varicosities. Phlebology. 2017;32(4):272-81. http://dx.doi.org/10.1177/0268355516637300 PMid:26957489.
  » http://dx.doi.org/10.1177/0268355516637300
• ¹⁷⁰
  Miranda LA, do Carmo RC, Sathler-Melo CC, de Castro-Santos G. Bilateral foam polidocanol sclerotherapy of great saphenous veins and their tributaries in synchronous procedure. J Vasc Bras. 2021;20:e20200178. http://dx.doi.org/10.1590/1677-5449.200178 PMid:34211536.
  » http://dx.doi.org/10.1590/1677-5449.200178
• ¹⁷¹
  Cartee TV, Wirth P, Greene A, et al. Ultrasound-guided foam sclerotherapy is safe and effective in the management of superficial venous insufficiency of the lower extremity. J Vasc Surg Venous Lymphat Disord. 2021;9(4):1031-40. http://dx.doi.org/10.1016/j.jvsv.2021.03.020 PMid:34144767.
  » http://dx.doi.org/10.1016/j.jvsv.2021.03.020
• ¹⁷²
  Lobastov K, Vorontsova A, Bargandzhiya A, et al. The frequency and clinical significance of nontarget superficial and deep vein occlusion after physician compounded foam sclerotherapy of varicose tributaries. Phlebology. 2020;35(6):430-9. http://dx.doi.org/10.1177/0268355519898595 PMid:31924136.
  » http://dx.doi.org/10.1177/0268355519898595
• ¹⁷³
  Reich-Schupke S, Weyer K, Altmeyer P, Stücker M. Treatment of varicose tributaries with sclerotherapy with polidocanol 0.5% foam. Vasa. 2010;39(2):169-74. http://dx.doi.org/10.1024/0301-1526/a000023 PMid:20464673.
  » http://dx.doi.org/10.1024/0301-1526/a000023
• ¹⁷⁴
  Ontas H, Yavuz T, Acar AN, Uysal D. Comparison of ultrasound results following endovenous laser ablation and radiofrequency ablation in the treatment of varicose veins. Ann Ital Chir. 2019;90:457-62. PMid:31661439.
• ¹⁷⁵
  Almeida CE. Vascular access: the impact of ultrasonography. Einstein (Sao Paulo). 2016;14(4):561-6. http://dx.doi.org/10.1590/s1679-45082016rw3129 PMid:28076607.
  » http://dx.doi.org/10.1590/s1679-45082016rw3129
• ¹⁷⁶
  Stolz LA, Stolz U, Howe C, Farrell IJ, Adhikari S. Ultrasound-guided peripheral venous access: a meta-analysis and systematic review. J Vasc Access. 2015;16(4):321-6. http://dx.doi.org/10.5301/jva.5000346 PMid:25656255.
  » http://dx.doi.org/10.5301/jva.5000346
• ¹⁷⁷
  Gibson K, Gunderson K. Liquid and foam sclerotherapy for spider and varicose veins. Surg Clin North Am. 2018;98(2):415-29. http://dx.doi.org/10.1016/j.suc.2017.11.010 PMid:29502781.
  » http://dx.doi.org/10.1016/j.suc.2017.11.010
• ¹⁷⁸
  Thomson L. Sclerotherapy of telangiectasias or spider veins in the lower limb: a review. J Vasc Nurs. 2016;34(2):61-2. http://dx.doi.org/10.1016/j.jvn.2016.04.002 PMid:27210454.
  » http://dx.doi.org/10.1016/j.jvn.2016.04.002
• ¹⁷⁹
  de Ávila Oliveira R, Riera R, Vasconcelos V, Baptista-Silva JC. Injection sclerotherapy for varicose veins. Cochrane Database Syst Rev. 2021;12(12):CD001732. PMid:34883526.
• ¹⁸⁰
  Bertanha M, Jaldin RG, Moura R, et al. Sclerotherapy for Reticular Veins in the Lower Limbs: A Triple-Blind Randomized Clinical Trial. JAMA Dermatol. 2017;153(12):1249-55. http://dx.doi.org/10.1001/jamadermatol.2017.3426 PMid:28973414.
  » http://dx.doi.org/10.1001/jamadermatol.2017.3426
• ¹⁸¹
  Bertanha M, Yoshida WB, Bueno de Camargo PA, et al. Polidocanol Plus Glucose Versus Glucose Alone for the Treatment of Telangiectasias: Triple Blind, Randomised Controlled Trial (PG3T). Eur J Vasc Endovasc Surg. 2021;61(1):128-135. http://dx.doi.org/10.1016/j.ejvs.2020.07.007 PMid:32778489.
  » http://dx.doi.org/10.1016/j.ejvs.2020.07.007
• ¹⁸²
  Munia MA, Wolosker N, Munia CG, Chao WS, Puech-Leão P. Comparison of laser versus sclerotherapy in the treatment of lower extremity telangiectases: a prospective study. Dermatol Surg. 2012;38(4):635-9. http://dx.doi.org/10.1111/j.1524-4725.2011.02226.x PMid:22221551.
  » http://dx.doi.org/10.1111/j.1524-4725.2011.02226.x
• ¹⁸³
  Parlar B, Blazek C, Cazzaniga S, et al. Treatment of lower extremity telangiectasias in women by foam sclerotherapy vs. Nd:YAG laser: a prospective, comparative, randomized, open-label trial. J Eur Acad Dermatol Venereol. 2015;29(3):549-54. http://dx.doi.org/10.1111/jdv.12627 PMid:25069999.
  » http://dx.doi.org/10.1111/jdv.12627
• ¹⁸⁴
  Ianosi G, Ianosi S, Calbureanu-Popescu MX, Tutunaru C, Calina D, Neagoe D. Comparative study in leg telangiectasias treatment with Nd:YAG laser and sclerotherapy. Exp Ther Med. 2019;17(2):1106-12. PMid:30679981.
• ¹⁸⁵
  Kaygin MA, Halici U. Evaluation of liquid or foam sclerotherapy in small varicose veins (ceap c1) with venous clinical severity score. Rev Assoc Med Bras. 2018;64(12):1117-21. http://dx.doi.org/10.1590/1806-9282.64.12.1117 PMid:30569988.
  » http://dx.doi.org/10.1590/1806-9282.64.12.1117
• ¹⁸⁶
  Bernstein EF, Noyaner-Turley A, Renton B. Treatment of spider veins of the lower extremity with a novel 532 nm KTP laser. Lasers Surg Med. 2014;46(2):81-8. http://dx.doi.org/10.1002/lsm.22178 PMid:24127163.
  » http://dx.doi.org/10.1002/lsm.22178
• ¹⁸⁷
  Mujadzic M, Ritter EF, Given KS. A novel approach for the treatment of spider veins. Aesthet Surg J. 2015;35(7):NP221-9. http://dx.doi.org/10.1093/asj/sjv004 PMid:26246022.
  » http://dx.doi.org/10.1093/asj/sjv004
• ¹⁸⁸
  Gold MH, Biron J, Sensing W. Evaluation of a new diode laser for the treatment of lower extremity leg veins. J Cosmet Dermatol. 2019;18(3):773-7. http://dx.doi.org/10.1111/jocd.12923 PMid:31116009.
  » http://dx.doi.org/10.1111/jocd.12923
• ¹⁸⁹
  Meesters AA, Pitassi LH, Campos V, Wolkerstorfer A, Dierickx CC. Transcutaneous laser treatment of leg veins. Lasers Med Sci. 2014;29(2):481-92. http://dx.doi.org/10.1007/s10103-013-1483-2 PMid:24220848.
  » http://dx.doi.org/10.1007/s10103-013-1483-2
• ¹⁹⁰
  Bush R, Bush P. Histological findings correlated with clinical outcomes in telangiectasia treated with ohmic thermolysis and 940 nm laser. J Cosmet Dermatol. 2018;17(5):779-82. http://dx.doi.org/10.1111/jocd.12761 PMid:30226025.
  » http://dx.doi.org/10.1111/jocd.12761
• ¹⁹¹
  Diken Aİ, Alemdaroğlu U, Özyalçın S, et al. Adjuvant radiofrequency thermocoagulation improves the outcome of liquid sclerotherapy in the treatment of spider veins of the leg: A pilot study. Phlebology. 2021;36(8):620-6. http://dx.doi.org/10.1177/02683555211006534 PMid:33813962.
  » http://dx.doi.org/10.1177/02683555211006534
• ¹⁹²
  Moreno-Moraga J, Smarandache A, Pascu ML, Royo J, Trelles MA. 1064 nm Nd:YAG long pulse laser after polidocanol microfoam injection dramatically improves the result of leg vein treatment: a randomized controlled trial on 517 legs with a three-year follow-up. Phlebology. 2014;29(10):658-66. http://dx.doi.org/10.1177/0268355513502786 PMid:23989971.
  » http://dx.doi.org/10.1177/0268355513502786
• ¹⁹³
  Miyake RK, Chi YW, Franklin IJ, Gianesini S. State of the art on cryo-laser cryo-sclerotherapy in lower limb venous aesthetic treatment. J Vasc Surg Venous Lymphat Disord. 2020;8(5):893-5. http://dx.doi.org/10.1016/j.jvsv.2020.01.003 PMid:32179040.
  » http://dx.doi.org/10.1016/j.jvsv.2020.01.003
• ¹⁹⁴
  Goldman MP, Fitzpatrick RE. Pulsed-dye laser treatment of leg telangiectasia: with and without simultaneous sclerotherapy. J Dermatol Surg Oncol. 1990;16(4):338-44. http://dx.doi.org/10.1111/j.1524-4725.1990.tb00045.x PMid:2324370.
  » http://dx.doi.org/10.1111/j.1524-4725.1990.tb00045.x
• ¹⁹⁵
  Tan MKH, Salim S, Onida S, Davies AH. Postsclerotherapy compression: a systematic review. J Vasc Surg Venous Lymphat Disord. 2021;9(1):264-74. http://dx.doi.org/10.1016/j.jvsv.2020.07.011 PMid:32791308.
  » http://dx.doi.org/10.1016/j.jvsv.2020.07.011
• ¹⁹⁶
  Weiss RA, Sadick NS, Goldman MP, Weiss MA. Post-sclerotherapy compression: controlled comparative study of duration of compression and its effects on clinical outcome. Dermatol Surg. 1999;25(2):105-8. http://dx.doi.org/10.1046/j.1524-4725.1999.08180.x PMid:10037513.
  » http://dx.doi.org/10.1046/j.1524-4725.1999.08180.x
• ¹⁹⁷
  Kern P, Ramelet AA, Wütschert R, Hayoz D. Compression after sclerotherapy for telangiectasias and reticular leg veins: a randomized controlled study. J Vasc Surg. 2007;45(6):1212-6. http://dx.doi.org/10.1016/j.jvs.2007.02.039 PMid:17467226.
  » http://dx.doi.org/10.1016/j.jvs.2007.02.039
• ¹⁹⁸
  Ivo CS, Ivo MB, Salles PG, Rosário RC, Nunes TA. Effect of the period of extrinsic mechanical compression following sclerotherapy in veins in rabbit ears. Acta Cir Bras. 2011;26(3):165-73. http://dx.doi.org/10.1590/S0102-86502011000300003 PMid:21537517.
  » http://dx.doi.org/10.1590/S0102-86502011000300003
• ¹⁹⁹
  Bayer A, Kuznik N, Langan EA, et al. Clinical outcome of short-term compression after sclerotherapy for telangiectatic varicose veins. J Vasc Surg Venous Lymphat Disord. 2021;9(2):435-43. http://dx.doi.org/10.1016/j.jvsv.2020.05.015 PMid:32502730.
  » http://dx.doi.org/10.1016/j.jvsv.2020.05.015
• ²⁰⁰
  Friedmann DP, Liolios AM, Wu DC, Goldman MP, Eimpunth SA. Randomized, double-blind, placebo-controlled study of the effect of a high-potency topical corticosteroid after sclerotherapy for reticular and telangiectatic veins of the lower extremities. Dermatol Surg. 2015;41(10):1158-63. http://dx.doi.org/10.1097/DSS.0000000000000467 PMid:26359998.
  » http://dx.doi.org/10.1097/DSS.0000000000000467
• ²⁰¹
  Ho D, Jagdeo J, Waldorf HA. Is there a role for arnica and bromelain in prevention of post-procedure ecchymosis or edema? A systematic review of the literature. Dermatol Surg. 2016;42(4):445-63. http://dx.doi.org/10.1097/DSS.0000000000000701 PMid:27035499.
  » http://dx.doi.org/10.1097/DSS.0000000000000701
• ²⁰²
  Izzo M, Coscia V. Assessment of a topical product based on a mixture of polysulfated galactosaminoglycan in the topical treatment of postoperative blood extravasation (ecchymosis-hematoma) in phlebology. Minerva Med. 2018;109(4):266-75. http://dx.doi.org/10.23736/S0026-4806.18.05642-2 PMid:29696939.
  » http://dx.doi.org/10.23736/S0026-4806.18.05642-2
• ²⁰³
  de Mello BAS, Beiriz YR, Bonatto AC, Maciel GSB, de Almeida LR, Corassa JM. Use of brimonidine tartrate to resolve telangiectatic matting: case report. J Vasc Bras. 2020;19:e20190159. http://dx.doi.org/10.1590/1677-5449.190159 PMid:34290750.
  » http://dx.doi.org/10.1590/1677-5449.190159
• ²⁰⁴
  Suggs AK, Macri A, Richmond H, Munavalli G, Friedman PM. Treatment of erythematotelangiectatic rosacea with pulsed-dye laser and oxymetazoline 1.0% cream: a retrospective study. Lasers Surg Med. 2020;52(1):38-43. http://dx.doi.org/10.1002/lsm.23176 PMid:31709571.
  » http://dx.doi.org/10.1002/lsm.23176
• ²⁰⁵
  Deaver Peterson J, Katz TM. Open-label study assessing the efficacy and tolerability of topical skin care and sun protection alone and in combination with intense pulsed light therapy. J Cosmet Dermatol. 2019;18(6):1758-64. http://dx.doi.org/10.1111/jocd.12952 PMid:31017734.
  » http://dx.doi.org/10.1111/jocd.12952
• ²⁰⁶
  Kiguchi MM, Hager ES, Winger DG, Hirsch SA, Chaer RA, Dillavou ED. Factors that influence perforator thrombosis and predict healing with perforator sclerotherapy for venous ulceration without axial reflux. J Vasc Surg. 2014;59(5):1368-76. http://dx.doi.org/10.1016/j.jvs.2013.11.007 PMid:24406088.
  » http://dx.doi.org/10.1016/j.jvs.2013.11.007
• ²⁰⁷
  Masuda EM, Kessler DM, Lurie F, Puggioni A, Kistner RL, Eklof B. The effect of ultrasound-guided sclerotherapy of incompetent perforator veins on venous clinical severity and disability scores. J Vasc Surg. 2006;43(3):551-6, discussion 556-7. http://dx.doi.org/10.1016/j.jvs.2005.11.038 PMid:16520171.
  » http://dx.doi.org/10.1016/j.jvs.2005.11.038

Publication Dates

• Publication in this collection
  06 Nov 2023
• Date of issue
  2023

History

• Received
  11 May 2023
• Accepted
  01 Aug 2023