Selected treatments for varicose veins

Policy context

A variety of treatments for varicose veins are available. Treatment goals include reducing pain or discomfort and for cosmetic reasons. The topic is identified based on uncertainties related to the safety, efficacy, and value of the certain procedures including chemical ablation, stab phlebectomy and laser ablation.

Primary criteria ranking

• Safety = Medium
• Efficacy = High
• Cost = Medium

Documents

• Draft key questions: comments and response
• Final key questions
• Draft report: comment and response
• Final evidence report
• Final findings and decision

Background

The National Heart, Lung, Blood Institute provides the following information about varicose veins (http://www.nhlbi.nih.gov/health/health-topics/topics/vv). Varicose veins are swollen, twisted veins visible under the surface of the skin. Veins have one-way valves that help keep blood flowing toward the heart. If the valves are weak or damaged, blood can back up and pool in veins. This causes the veins to swell, which can lead to varicose veins. These veins usually occur in the legs, but can also form in other parts of the body. Varicose veins are a common condition, affecting approximately 25 million people in the United States (Eberhardt and Raffetto, Circulation. 2014;130:333-346).

The signs and symptoms of varicose veins include:

• Large veins visible just under the surface of the skin.
• Mild swelling of ankles and feet.
• Painful, achy, or "heavy" legs.
• Throbbing or cramping in legs.
• Itchy legs, especially on the lower leg and ankle.
• Discolored skin in the area around the varicose vein.

Many factors can raise a person's risk for varicose veins. Examples of these factors include family history, older age, gender, pregnancy, overweight or obesity, lack of movement, and leg trauma.

Sometimes varicose veins cause pain, blood clots, skin ulcers, or other problems. Varicose veins can lead to dermatitis, an itchy rash. Dermatitis can cause bleeding or skin ulcers (sores) if the skin is scratched or irritated. Varicose veins also can lead to a condition called superficial thrombophlebitis, a blood clot in a vein close to the surface of the skin. This type of blood clot may cause pain and other problems in the affected area.

Varicose veins are treated with lifestyle changes and medical procedures. The goals of treatment are to relieve symptoms, prevent complications, and improve appearance. Medical procedures are done either to remove varicose veins or to close them. Examples of medical procedures are:

• Sclerotherapy: injection of a liquid (or foam) chemical to close off a varicose vein
• Endovenous ablation: use of lasers or radio waves to create heat to close off a varicose vein
• Ambulatory phlebectomy: the use of small cuts in the skin to remove small varicose veins
• Vein stripping and ligation: tying shut and removing veins through small cuts in the skin