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'''Varicose veins''' are veins that have become enlarged and twisted. The term commonly refers to the veins on the leg,<ref>[http://www.mountsinai.org/Patient%20Care/Service%20Areas/Heart/Diseases%20and%20Conditions?citype=Disease&ciid=Varicose%20veins Varicose veins] [[Mount Sinai Hospital, New York]]</ref> although varicose veins occur [[varices|elsewhere]]. Veins have leaflet valves to prevent blood from flowing backwards (retrograde). Leg muscles pump the veins to return blood to the heart. When veins become enlarged, the leaflets of the valves no longer meet properly, and the valves don't work. The blood collects in the veins and they enlarge even more. Varicose veins are common in the superficial veins of the legs, which are subject to high pressure when standing. Besides cosmetic problems, varicose veins are often painful, especially when standing or walking. They often itch, and scratching them can cause [[Ulcer (dermatology)|ulcers]]. Serious complications are rare. Non-surgical treatments include [[sclerotherapy]], elastic stockings, elevating the legs, and exercise. The traditional surgical treatment has been [[vein stripping]] to remove the affected veins. Newer, less invasive treatments, such as [[radiofrequency ablation]] and [[endovenous laser treatment]], are slowly replacing traditional surgical treatments. Because most of the blood in the legs is returned by the deep veins, the [[superficial vein]]s, which return only about 10 per cent of the total blood of the legs, can usually be removed or ablated without serious harm.<ref>Merck Manual Home Edition, 2nd ed.[http://www.merck.com/mmhe/sec03/ch036/ch036d.html] </ref><ref>NHS Direct[http://www.nhsdirect.nhs.uk/articles/article.aspx?articleId=387&sectionId=28131] </ref> Varicose veins are distinguished from reticular veins (blue veins) and [[spider veins|telangiectasias]] (spider veins), which also involve valvular insufficiency,<ref>Weiss R A, Weiss M A, Doppler Ultrasound Findings in Reticular Veins of the Thigh Subdermic Lateral Venous System and Implications for Sclerotherapy, Journal of Derm Surg Onc, Vol 19 No 10 (October 1993) p947-951.</ref> by the size and location of the veins.
'''Varicose veins''' are veins that have become enlarged and twisted. The term commonly refers to the veins on the leg,<ref>[http://www.mountsinai.org/Patient%20Care/Service%20Areas/Heart/Diseases%20and%20Conditions?citype=Disease&ciid=Varicose%20veins Varicose veins] [[Mount Sinai Hospital, New York]]</ref> although varicose veins occur [[varices|elsewhere]]. Veins have leaflet valves to prevent blood from flowing backwards (retrograde). Leg muscles pump the veins to return blood to the heart. When veins become enlarged, the leaflets of the valves no longer meet properly, and the valves don't work. The blood collects in the veins and they enlarge even more. Varicose veins are common in the superficial veins of the legs, which are subject to high pressure when standing. Besides cosmetic problems, varicose veins are often painful, especially when standing or walking. They often itch, and scratching them can cause [[Ulcer (dermatology)|ulcers]]. Serious complications are rare. Non-surgical treatments include [[sclerotherapy]], elastic stockings, elevating the legs, and exercise. The traditional surgical treatment has been [[vein stripping]] to remove the affected veins. Newer, less invasive treatments, such as [[radiofrequency ablation]] and [[endovenous laser treatment]], are slowly replacing traditional surgical treatments. Because most of the blood in the legs is returned by the deep veins, the [[superficial vein]]s, which return only about 10 per cent of the total blood of the legs, can usually be removed or ablated without serious harm.<ref>[http://www.merck.com/mmhe/sec03/ch036/ch036d.html Merck Manual Home Edition, 2nd ed.] </ref><ref>[http://www.nhsdirect.nhs.uk/articles/article.aspx?articleId=387&sectionId=28131 NHS Direct] </ref> Varicose veins are distinguished from reticular veins (blue veins) and [[spider veins|telangiectasias]] (spider veins), which also involve valvular insufficiency,<ref>{{cite journal |author=Weiss RA, Weiss MA |title=Doppler ultrasound findings in reticular veins of the thigh subdermic lateral venous system and implications for sclerotherapy |journal=J Dermatol Surg Oncol |volume=19 |issue=10 |pages=947–51 |year=1993 |month=October |pmid=8408914 |doi= |url=http://openurl.ebscohost.com/linksvc/linking.aspx?genre=article&sid=PubMed&issn=0148-0812&title=J%20Dermatol%20Surg%20Oncol&volume=19&issue=10&spage=947&atitle=Doppler%20ultrasound%20findings%20in%20reticular%20veins%20of%20the%20thigh%20subdermic%20lateral%20venous%20system%20and%20implications%20for%20sclerotherapy.&aulast=Weiss&date=1993}}</ref> by the size and location of the veins.


==Symptoms==
==Symptoms==
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The symptoms of varicose veins can be controlled to an extent with the following:
The symptoms of varicose veins can be controlled to an extent with the following:
*Elevating the legs often provides temporary symptomatic relief.
*Elevating the legs often provides temporary symptomatic relief.
*"Advice about regular exercise sounds sensible but is not supported by any evidence."<ref>BMJ 2006;333:287-292 (5 August), Varicose veins and their management, Bruce Campbell [http://www.bmj.com/cgi/content/full/333/7562/287 (subscription)]</ref>
*"Advice about regular exercise sounds sensible but is not supported by any evidence."<ref>{{cite journal |author=Campbell B |title=Varicose veins and their management |journal=BMJ |volume=333 |issue=7562 |pages=287–92 |year=2006 |month=August |pmid=16888305 |pmc=1526945 |doi=10.1136/bmj.333.7562.287 |url=}}</ref>
*The wearing of graduated [[compression stockings]] with a pressure of 30–40&nbsp;mmHg has been shown to correct the swelling, nutritional exchange, and improve the microcirculation in legs affected by varicose veins.<ref>Curri SB et al. Changes of cutaneous microcirculation from elasto-compression in chronic venous insufficiency. In Davy A and Stemmer R, editors: Phlebology '89, Montrouge, France, 1989, John Libbey Eurotext.</ref> They also often provide relief from the discomfort associated with this disease. Caution should be exercised in their use in patients with concurrent arterial disease.
*The wearing of graduated [[compression stockings]] with a pressure of 30–40&nbsp;mmHg has been shown to correct the swelling, nutritional exchange, and improve the microcirculation in legs affected by varicose veins.<ref>Curri SB et al. Changes of cutaneous microcirculation from elasto-compression in chronic venous insufficiency. In Davy A and Stemmer R, editors: Phlebology '89, Montrouge, France, 1989, John Libbey Eurotext.</ref> They also often provide relief from the discomfort associated with this disease. Caution should be exercised in their use in patients with concurrent arterial disease.
*anti-inflammatory medication such as [[ibuprofen]] or [[aspirin]] can be used as part of treatment for superficial thrombophlebitis along with graduated compression hosiery &ndash; but there is a risk of intestinal bleeding. In extensive superficial thrombophlebitis, consideration should be given to anti-coagulation, thrombectomy or sclerotherapy of the involved vein.
*anti-inflammatory medication such as [[ibuprofen]] or [[aspirin]] can be used as part of treatment for superficial thrombophlebitis along with graduated compression hosiery &ndash; but there is a risk of intestinal bleeding. In extensive superficial thrombophlebitis, consideration should be given to anti-coagulation, thrombectomy or sclerotherapy of the involved vein.
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====Stripping====
====Stripping====
Stripping consists in a removal of all the saphena vein main trunk from the groin down to the ankle.The complications include deep vein thrombosis (5.3%),<ref>van Rij AM et al. Incidence of Deep Venous Thrombosis after Varicose Vein Surgery, Br J Surg 2004 Dec;91(12):1582-5</ref> pulmonary embolism (0.06%), and wound complications including infection (2.2%). For traditional surgery, reported recurrence rates, which have been tracked for 10 years, range from 5-60%. In addition, since stripping removes the saphenous main trunks, they are no longer availlable for venous by-pass in the future (coronary and/or leg artery vital disease)<ref>Hammarsten J, Pedersen P, Cederlund CG, Campanello M.
Stripping consists in a removal of all the saphena vein main trunk from the groin down to the ankle.The complications include deep vein thrombosis (5.3%),<ref>{{cite journal |author=van Rij AM, Chai J, Hill GB, Christie RA |title=Incidence of deep vein thrombosis after varicose vein surgery |journal=Br J Surg |volume=91 |issue=12 |pages=1582–5 |year=2004 |month=December |pmid=15386324 |doi=10.1002/bjs.4701 |url=}}</ref> pulmonary embolism (0.06%), and wound complications including infection (2.2%). For traditional surgery, reported recurrence rates, which have been tracked for 10 years, range from 5-60%. In addition, since stripping removes the saphenous main trunks, they are no longer availlable for venous by-pass in the future (coronary and/or leg artery vital disease)<ref>{{cite journal |author=Hammarsten J, Pedersen P, Cederlund CG, Campanello M |title=Long saphenous vein saving surgery for varicose veins. A long-term follow-up |journal=Eur J Vasc Surg |volume=4 |issue=4 |pages=361–4 |year=1990 |month=August |pmid=2204548 |doi= |url=http://www.nlm.nih.gov/medlineplus/varicoseveins.html}}</ref>
Department of Surgery and Radiology, Hospital of Varberg, Sweden
Long saphenous vein saving surgery for varicose veins. A long-term follow-up. Eur J Vasc Surg. 1990 Aug;4(4):361-4.
</ref>


====CHIVA====
====CHIVA====
CHIVA is the acronym for Conservative and Haemodynamic cure of Incompetent Varicose veins in Ambulatory patients translated from the French cure "Conservatrice et Hémodynamique de l'Insuffisance Veineuse en Ambulatoire"<ref name>claude Franceschi, Cure CHIVA, 1988, Editions de L'Armançon, 21390 Precy-Sous-Thil France</ref> published in France in 1988. Lurie<ref name="Lurie">Lurie F, Venous Haemodynamics:What we know and don't know, Phlebology, Vol 24, no 1, 2009</ref> in his analysis of Chiva states that "CHIVA definitely falls into a research category and should be continued as such until sufficient evidence of its validity is generated".
CHIVA is the acronym for Conservative and Haemodynamic cure of Incompetent Varicose veins in Ambulatory patients translated from the French cure "Conservatrice et Hémodynamique de l'Insuffisance Veineuse en Ambulatoire"<ref name>claude Franceschi, Cure CHIVA, 1988, Editions de L'Armançon, 21390 Precy-Sous-Thil France</ref> published in France in 1988. Lurie<ref name="Lurie">{{cite journal |author=Lurie F |title=Venous haemodynamics: what we know and don't know |journal=Phlebology |volume=24 |issue=1 |pages=3–7 |year=2009 |month=February |pmid=19155334 |doi=10.1258/phleb.2008.008055 |url=}}</ref> in his analysis of Chiva states that "CHIVA definitely falls into a research category and should be continued as such until sufficient evidence of its validity is generated".
;Pathophysiological principles
;Pathophysiological principles
To be achieved properly,the CHIVA method needs a comprehensive knowledge of both hemodynamics and Ultrasound venous investigation. CHIVA relies on an hemodynamic impairment assessed by data and evidences depicted through Ultrasound dynamic venous investigations. According to this new concept, the clinical symptoms of venous insufficiency are not the cause but the consequence of various abnormalities of the venous system. For example,a varicose vein being overloaded, may be dilated not only because of valvular incompetence (the most frequent) but because of a venous block (thombosis) or arterio-venous fistulae...and so the treatment has to be tailored according the hemodynamic feature.
To be achieved properly,the CHIVA method needs a comprehensive knowledge of both hemodynamics and Ultrasound venous investigation. CHIVA relies on an hemodynamic impairment assessed by data and evidences depicted through Ultrasound dynamic venous investigations. According to this new concept, the clinical symptoms of venous insufficiency are not the cause but the consequence of various abnormalities of the venous system. For example,a varicose vein being overloaded, may be dilated not only because of valvular incompetence (the most frequent) but because of a venous block (thombosis) or arterio-venous fistulae...and so the treatment has to be tailored according the hemodynamic feature.
;Procedure and outcomes
;Procedure and outcomes
It generally consists in 1 to 4 small incisions under local anaestesia in order to disconnect the varicose veins from the abnormal flow due to valvular incompetence which dilates them.<ref>[http://www.dailymotion.com/3d4050d0c5d14ae36f61e4639/video/9617821]</ref> The patient is dismissed the same day. This method leads to an improvement of the venous function {{Fact|date=January 2009}} in order to:
It generally consists in 1 to 4 small incisions under local anaestesia in order to disconnect the varicose veins from the abnormal flow due to valvular incompetence which dilates them.<ref>[http://www.dailymotion.com/3d4050d0c5d14ae36f61e4639/video/9617821]</ref> The patient is dismissed the same day. This method leads to an improvement of the venous function {{Fact|date=January 2009}} in order to:
* Cure the symptoms of venous insufficiency as varicose veins, legs swelling, ulcers.<ref>Maeso and all, Comparision of clinical outcome of Stripping and CHIVA for Treatment of varicose veins in Lower Extremities, Ann Vasc Surg 2001; 15: 661-665 </ref><ref>"
* Cure the symptoms of venous insufficiency as varicose veins, legs swelling, ulcers.<ref>{{cite journal |author=Maeso J, Juan J, Escribano J, ''et al'' |title=Comparison of clinical outcome of stripping and CHIVA for treatment of varicose veins in the lower extremities |journal=Ann Vasc Surg |volume=15 |issue=6 |pages=661–5 |year=2001 |month=November |pmid=11769147 |doi=10.1007/s10016-001-0009-8 |url=}}</ref><ref>{{cite journal |author=Zamboni P, Cisno C, Marchetti F, ''et al'' |title=Minimally invasive surgical management of primary venous ulcers vs. compression treatment: a randomized clinical trial |journal=Eur J Vasc Endovasc Surg |volume=25 |issue=4 |pages=313–8 |year=2003 |month=April |pmid=12651168 |doi=10.1053/ejvs.2002.1871 |url=}}</ref><br />
⚫
* Prevent varicose recurrence due to progressive enlargement of collateral veins which replace and overtake the destroyed veins: CHIVA vs Stripping: varicose recurrence divided by 2 to 5 at 10 years.<ref name="Carandina">{{cite journal |author=Carandina S, Mari C, De Palma M, ''et al'' |title=Varicose vein stripping vs haemodynamic correction (CHIVA): a long term randomised trial |journal=Eur J Vasc Endovasc Surg |volume=35 |issue=2 |pages=230–7 |year=2008 |month=February |pmid=17964822 |doi=10.1016/j.ejvs.2007.09.011 |url=}}</ref>
Zamboni and all: Minimally Invasive Surgical management of primary Venous Ulcers vs Compression Treatment: a randomized Clinical Trial. Eur J Vasc Endovsc Surg 00,1-6 (2003)</ref><br />
⚫
* Prevent varicose recurrence due to progressive enlargement of collateral veins which replace and overtake the destroyed veins: CHIVA vs Stripping: varicose recurrence divided by 2 to 5 at 10 years.<ref>Varicose Vein Stripping vs. Haemodynamic Correction
(C.H.I.V.A.): a Long Term Randomised Trial
S. Carandina and all; Eur J Vasc Endovasc Surg xx, 1e8 (2007)
doi:10.1016/j.ejvs.2007.09.011, online http://www.sciencedirect.com</ref>
* Preserve the superficial venous capital for unpredictable but possible need for coronary or leg artery vital by-pass which increases with ageing.
* Preserve the superficial venous capital for unpredictable but possible need for coronary or leg artery vital by-pass which increases with ageing.
Unfortunately at this stage, the best available publication of CHIVA outcomes that meets current methological standards<ref name="Lurie" /> is a study by Carandina et al. <ref> Caranadina S, Mari C, De PM, et al Varicose Vein Stripping vs Haemodynamic Correction (CHIVA): A Long Term randomised trial. Eur J Vasc Surg 2008;35:230-7></ref>. The authors estimate that only 30-35% of patients with varicose veins can be treated with CHIVA. This study showed that there were recurrent varices in 18% of cases treated by CHIVA despite there being some bias in the selection of patients favoring CHIVA.<ref name="Lurie" />
Unfortunately at this stage, the best available publication of CHIVA outcomes that meets current methological standards<ref name="Lurie" /> is a study by Carandina et al. <ref name="Carandina"/>. The authors estimate that only 30-35% of patients with varicose veins can be treated with CHIVA. This study showed that there were recurrent varices in 18% of cases treated by CHIVA despite there being some bias in the selection of patients favoring CHIVA.<ref name="Lurie" />


===Non-surgical treatment===
===Non-surgical treatment===
====Sclerotherapy====
====Sclerotherapy====
A commonly performed non-surgical treatment for varicose and "spider" leg veins is [[sclerotherapy]] in which medicine is injected into the veins to make them shrink. It has been used in the treatment of varicose veins for over 150 years.<ref>Goldman M, Sclerotherapy Treatment of varicose and telangiectatic leg vein, Hardcover Text, 2nd Ed, 1995</ref> Sclerotherapy is often used for telangiectasias (spider veins) and varicose veins that persist or recur after vein stripping.<ref>"Veins & Lymphatics," L. K. Pak et al, ''in'' Lange's Current Surgical Diagnosis & Treatment, 11th ed., McGraw-Hill, </ref><ref>Tisi PV, Beverley C, Rees A. Injection sclerotherapy for varicose veins. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD001732.</ref> Sclerotherapy can also be performed using microfoam sclerosants under ultrasound guidance to treat larger varicose veins, including the great and short saphenous veins.<ref>Paul Thibault, Sclerotherapy and Ultrasound-Guided Sclerotherapy, The Vein Book / editor, John J. Bergan, 2007.</ref><ref>Padbury A, Benveniste G L, Foam echosclerotherapy of the small saphenous vein, Australian and New Zealand Journal of Phlebology Vol 8, Number 1 (December 2004)</ref> A study by Kanter and Thibault in 1996 reported a 76% success rate at 24 months in treating saphenofemoral junction and great saphenous vein incompetence with STS 3% solution.<ref>Kanter A, Thibault P. Saphenofemoral junction incompetence treated by ultrasound-guided sclerotherapy, Dermatol Surg. 1996. 22: 648-652.</ref> A Cochrane Collaboration review<ref>http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD001732/abstract.html</ref> concluded sclerotherapy was better than surgery in the short term (1 year) for its treatment success, complication rate and cost, but surgery was better after 5 years, although the research is weak.<ref>Rigby KA, Palfreyman SJ, Beverley C, Michaels JA. Surgery versus sclerotherapy for the treatment of varicose veins. Cochrane Database of Systematic Reviews 2004, Issue 4. Art. No.: CD004980. [http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD004980/abstract.html]</ref>
A commonly performed non-surgical treatment for varicose and "spider" leg veins is [[sclerotherapy]] in which medicine is injected into the veins to make them shrink. It has been used in the treatment of varicose veins for over 150 years.<ref>Goldman M, Sclerotherapy Treatment of varicose and telangiectatic leg vein, Hardcover Text, 2nd Ed, 1995</ref> Sclerotherapy is often used for telangiectasias (spider veins) and varicose veins that persist or recur after vein stripping.<ref>"Veins & Lymphatics," L. K. Pak et al, ''in'' Lange's Current Surgical Diagnosis & Treatment, 11th ed., McGraw-Hill, </ref><ref>{{cite journal |author=Tisi PV, Beverley C, Rees A |title=Injection sclerotherapy for varicose veins |journal=Cochrane Database Syst Rev |volume= |issue=4 |pages=CD001732 |year=2006 |pmid=17054141 |doi=10.1002/14651858.CD001732.pub2 |url=}}</ref> Sclerotherapy can also be performed using microfoam sclerosants under ultrasound guidance to treat larger varicose veins, including the great and short saphenous veins.<ref>Paul Thibault, Sclerotherapy and Ultrasound-Guided Sclerotherapy, The Vein Book / editor, John J. Bergan, 2007.</ref><ref>Padbury A, Benveniste G L, Foam echosclerotherapy of the small saphenous vein, Australian and New Zealand Journal of Phlebology Vol 8, Number 1 (December 2004)</ref> A study by Kanter and Thibault in 1996 reported a 76% success rate at 24 months in treating saphenofemoral junction and great saphenous vein incompetence with STS 3% solution.<ref>{{cite journal |author=Kanter A, Thibault P |title=Saphenofemoral incompetence treated by ultrasound-guided sclerotherapy |journal=Dermatol Surg |volume=22 |issue=7 |pages=648–52 |year=1996 |month=July |pmid=8680788 |doi= |url=http://openurl.ebscohost.com/linksvc/linking.aspx?genre=article&sid=PubMed&issn=1076-0512&title=Dermatol%20Surg&volume=22&issue=7&spage=648&atitle=Saphenofemoral%20incompetence%20treated%20by%20ultrasound-guided%20sclerotherapy.&aulast=Kanter&date=1996}}</ref> A Cochrane Collaboration review<ref>http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD001732/abstract.html</ref> concluded sclerotherapy was better than surgery in the short term (1 year) for its treatment success, complication rate and cost, but surgery was better after 5 years, although the research is weak.<ref>{{cite journal |author=Rigby KA, Palfreyman SJ, Beverley C, Michaels JA |title=Surgery versus sclerotherapy for the treatment of varicose veins |journal=Cochrane Database Syst Rev |volume= |issue=4 |pages=CD004980 |year=2004 |pmid=15495134 |doi=10.1002/14651858.CD004980 |url=http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD004980/abstract.html}}</ref>
A Health Technology Assessment found that sclerotherapy provided less benefit than surgery, but is likely to provide a small benefit in varicose veins without reflux.<ref>Michaels JA, Campbell WB, Brazier JE, MacIntyre JB, Palfreyman SJ, Ratcliffe J, et al. Randomized clinical trial, observational study and assessment of cost-effectiveness of the treatment of varicose veins (REACTIV trial). Health Technol Assess 2006;10(13). [http://www.hta.ac.uk/fullmono/mon1013.pdf] This Health Technology Assessment monograph includes reviews of the epidemiology, assessment, and treatment of varicose veins, as well as a study on clinical and cost effectiveness of surgery and sclerotherapy</ref> Complications of sclerotherapy are rare but can include blood clots and ulceration. [[Anaphylaxis|Anaphylactic]] reactions are "extraordinarily rare but can be life-threatening," and doctors should have resuscitation equipment ready.<ref>William R. Finkelmeier, Sclerotherapy, Ch. 12, ACS Surgery: Principles & Practice, 2004, WebMD (hardcover book)</ref> <ref>{{cite journal |author=Scurr JR, Fisher RK, Wallace SB |title=Anaphylaxis Following Foam Sclerotherapy: A Life Threatening Complication of Non Invasive Treatment For Varicose Veins |journal=EJVES Extra |volume=13 |issue=6 |pages=87–89 |year=2007|doi=10.1016/j.ejvsextra.2007.02.005}}</ref> There has been one reported case of stroke after ultrasound guided sclerotherapy when an unusually large dose of sclerosant foam was injected.
A Health Technology Assessment found that sclerotherapy provided less benefit than surgery, but is likely to provide a small benefit in varicose veins without reflux.<ref>{{cite journal |author=Michaels JA, Campbell WB, Brazier JE, ''et al'' |title=Randomised clinical trial, observational study and assessment of cost-effectiveness of the treatment of varicose veins (REACTIV trial) |journal=Health Technol Assess |volume=10 |issue=13 |pages=1–196, iii–iv |year=2006 |month=April |pmid=16707070 |doi= |url=http://www.hta.ac.uk/execsumm/summ1013.htm}}</ref> This Health Technology Assessment monograph includes reviews of the epidemiology, assessment, and treatment of varicose veins, as well as a study on clinical and cost effectiveness of surgery and sclerotherapy</ref> Complications of sclerotherapy are rare but can include blood clots and ulceration. [[Anaphylaxis|Anaphylactic]] reactions are "extraordinarily rare but can be life-threatening," and doctors should have resuscitation equipment ready.<ref>William R. Finkelmeier, Sclerotherapy, Ch. 12, ACS Surgery: Principles & Practice, 2004, WebMD (hardcover book)</ref> <ref>{{cite journal |author=Scurr JR, Fisher RK, Wallace SB |title=Anaphylaxis Following Foam Sclerotherapy: A Life Threatening Complication of Non Invasive Treatment For Varicose Veins |journal=EJVES Extra |volume=13 |issue=6 |pages=87–89 |year=2007|doi=10.1016/j.ejvsextra.2007.02.005}}</ref> There has been one reported case of stroke after ultrasound guided sclerotherapy when an unusually large dose of sclerosant foam was injected.


====Endovenous laser and radiofrequency ablation====
====Endovenous laser and radiofrequency ablation====
The Australian Medical Services Advisory Committee (MSAC) in 2008 has determined that endovenous laser treatment for varicose veins "appears to be more effective in the short term, and at least as effective overall, as the comparative procedure of junction ligation and vein stripping for the treatment of varicose veins."<ref>Medical Services Advisory Committee, Endovenous laser therapy (ELT) for varicose veins. MSAC application 1113, Dept of Health and Ageing, Commonwealth of Australia, 2008. http://www.msac.gov.au/internet/msac/publishing.nsf/Content/2E0BACBB8704139ACA25745E001C2F21/$File/1113report.pdf</ref> It also found in its assessment of available literature, that "occurrence rates of more severe complications such as DVT, nerve injury and paraesthesia, post-operative infections and haematomas, appears to be greater after ligation and stripping than after EVLT". Complications for endovenous laser treatment include minor skin burns (0.4%)<ref name="Elmore"> Elmore FA and Lackey D, Effectiveness of laser treatment in eliminating superficial venous reflux, Phlebology 2008 :23 :21-31</ref> and temporary paraesthesia (2.1%).<ref name="Elmore"/> The longest study of endovenous laser ablation is 39 months.
The Australian Medical Services Advisory Committee (MSAC) in 2008 has determined that endovenous laser treatment for varicose veins "appears to be more effective in the short term, and at least as effective overall, as the comparative procedure of junction ligation and vein stripping for the treatment of varicose veins."<ref>Medical Services Advisory Committee, [http://www.msac.gov.au/internet/msac/publishing.nsf/Content/2E0BACBB8704139ACA25745E001C2F21/$File/1113report.pdf Endovenous laser therapy (ELT) for varicose veins]. MSAC application 1113, Dept of Health and Ageing, Commonwealth of Australia, 2008.</ref> It also found in its assessment of available literature, that "occurrence rates of more severe complications such as DVT, nerve injury and paraesthesia, post-operative infections and haematomas, appears to be greater after ligation and stripping than after EVLT". Complications for endovenous laser treatment include minor skin burns (0.4%)<ref name="Elmore">{{cite journal |author=Elmore FA, Lackey D |title=Effectiveness of endovenous laser treatment in eliminating superficial venous reflux |journal=Phlebology |volume=23 |issue=1 |pages=21–31 |year=2008 |pmid=18361266 |doi= |url=http://openurl.ebscohost.com/linksvc/linking.aspx?genre=article&sid=PubMed&issn=0268-3555&title=Phlebology&volume=23&issue=1&spage=21&atitle=Effectiveness%20of%20endovenous%20laser%20treatment%20in%20eliminating%20superficial%20venous%20reflux.&aulast=Elmore&date=2008}}</ref> and temporary paraesthesia (2.1%). The longest study of endovenous laser ablation is 39 months.


Two prospective randomized trials found speedier recovery and fewer complications after radiofrequency obliteration (AKA radiofrequency ablation) compared to open surgery.<ref>Rautio, T, et al., Endovenous oblitration versus conventional stripping operation in the treatment of primary varicose veins, J Vasc Surg 2002:35:958-65</ref><ref>Lurie F, et al., Prospective randomized study of endovenous radiofrequency oblitration (closure) versus ligation and vein stripping (EVOLVeS: two-year follow-up. Eur J Vasc Endovasc Surg 2005;29:67-73</ref> Myers<ref>Kenneth Myers, An opinion —surgery for small saphenous reflux is obsolete!" Australian and New Zealand Journal of Phlebology, Vol 8, Number 1 (December 2004)</ref> wrote that open surgery for [[small saphenous vein]] reflux is obsolete. Myers said these veins should be treated with endovenous techniques, citing high recurrence rates after surgical management, and risk of nerve damage up to 15%. In comparison, radiofrequency ablation has been shown to control 80% of cases of small saphenous vein reflux at 4 years, said Myers. Complications for radiofrequency ablation include burns, paraesthesia, clinical phlebitis, and slightly higher rates of deep vein thrombosis (0.57%) and pulmonary embolism (0.17%).One 3-year study compared radiofrequency, with a recurrence rate of 33%, to open surgery, which had a recurrence rate of 23%.
Two prospective randomized trials found speedier recovery and fewer complications after radiofrequency obliteration (AKA radiofrequency ablation) compared to open surgery<ref>{{cite journal |author=Rautio TT, Perälä JM, Wiik HT, Juvonen TS, Haukipuro KA |title=Endovenous obliteration with radiofrequency-resistive heating for greater saphenous vein insufficiency: a feasibility study |journal=J Vasc Interv Radiol |volume=13 |issue=6 |pages=569–75 |year=2002 |month=June |pmid=12050296 |doi= |url=http://openurl.ebscohost.com/linksvc/linking.aspx?genre=article&sid=PubMed&issn=1051-0443&title=J%20Vasc%20Interv%20Radiol&volume=13&issue=6&spage=569&atitle=Endovenous%20obliteration%20with%20radiofrequency-resistive%20heating%20for%20greater%20saphenous%20vein%20insufficiency:%20a%20feasibility%20study.&aulast=Rautio&date=2002}}</ref><ref>{{cite journal |author=Lurie F, Creton D, Eklof B, ''et al'' |title=Prospective randomised study of endovenous radiofrequency obliteration (closure) versus ligation and vein stripping (EVOLVeS): two-year follow-up |journal=Eur J Vasc Endovasc Surg |volume=29 |issue=1 |pages=67–73 |year=2005 |month=January |pmid=15570274 |doi=10.1016/j.ejvs.2004.09.019 |url=}}</ref>. Myers<ref>Kenneth Myers, An opinion —surgery for small saphenous reflux is obsolete!" Australian and New Zealand Journal of Phlebology, Vol 8, Number 1 (December 2004)</ref> wrote that open surgery for [[small saphenous vein]] reflux is obsolete. Myers said these veins should be treated with endovenous techniques, citing high recurrence rates after surgical management, and risk of nerve damage up to 15%. In comparison, radiofrequency ablation has been shown to control 80% of cases of small saphenous vein reflux at 4 years, said Myers. Complications for radiofrequency ablation include burns, paraesthesia, clinical phlebitis, and slightly higher rates of deep vein thrombosis (0.57%) and pulmonary embolism (0.17%).One 3-year study compared radiofrequency, with a recurrence rate of 33%, to open surgery, which had a recurrence rate of 23%.


Endovenous laser and radiofrequency ablation require specialized training for doctors and expensive equipment. Endovenous laser treatment is performed as an outpatient procedure and does not require the use of an operating theatre, nor does the patient need a general anaesthetic. Doctors must use ultrasound during the procedure to see what they are doing. Some practitioners also perform phlebectomy or ultrasound guided sclerotherapy at the time of endovenous treatment. Follow-up treatment to smaller branch varicose veins is often needed in the weeks after the initial procedure.
Endovenous laser and radiofrequency ablation require specialized training for doctors and expensive equipment. Endovenous laser treatment is performed as an outpatient procedure and does not require the use of an operating theatre, nor does the patient need a general anaesthetic. Doctors must use ultrasound during the procedure to see what they are doing. Some practitioners also perform phlebectomy or ultrasound guided sclerotherapy at the time of endovenous treatment. Follow-up treatment to smaller branch varicose veins is often needed in the weeks after the initial procedure.

Revision as of 11:16, 25 March 2009

For other uses, see varices.
Varicose veins
SpecialtyVascular surgery Edit this on Wikidata

Varicose veins are veins that have become enlarged and twisted. The term commonly refers to the veins on the leg,[1] although varicose veins occur elsewhere. Veins have leaflet valves to prevent blood from flowing backwards (retrograde). Leg muscles pump the veins to return blood to the heart. When veins become enlarged, the leaflets of the valves no longer meet properly, and the valves don't work. The blood collects in the veins and they enlarge even more. Varicose veins are common in the superficial veins of the legs, which are subject to high pressure when standing. Besides cosmetic problems, varicose veins are often painful, especially when standing or walking. They often itch, and scratching them can cause ulcers. Serious complications are rare. Non-surgical treatments include sclerotherapy, elastic stockings, elevating the legs, and exercise. The traditional surgical treatment has been vein stripping to remove the affected veins. Newer, less invasive treatments, such as radiofrequency ablation and endovenous laser treatment, are slowly replacing traditional surgical treatments. Because most of the blood in the legs is returned by the deep veins, the superficial veins, which return only about 10 per cent of the total blood of the legs, can usually be removed or ablated without serious harm.[2][3] Varicose veins are distinguished from reticular veins (blue veins) and telangiectasias (spider veins), which also involve valvular insufficiency,[4] by the size and location of the veins.

Symptoms

  • Aching, heavy legs (often worse at night and after exercise).
  • Appearance of spider veins (telangiectasia) in the affected leg.
  • Ankle swelling.
  • A brownish-blue shiny skin discoloration near the affected veins.
  • Redness, dryness, and itchiness of areas of skin - termed stasis dermatitis or venous eczema, because of waste products building up in the leg.
  • Minor injuries to the area may bleed more than normal and/or take a long time to heal.
  • In some people the skin above the ankle may shrink (lipodermatosclerosis) because the fat underneath the skin becomes hard.
  • Restless legs syndrome appears to be a common overlapping clinical syndrome in patients with varicose veins and other chronic venous insufficiency.
  • Whitened irregular "scar-like" patches can appear, especially at the ankles, "atrophie blanche".

Complications

Most varicose veins are relatively benign, but severe varicosities can lead to major complications, due to the poor circulation through the affected limb.

  • Pain, heaviness, inability to walk or stand for long hours thus hindering work
  • Skin conditions / Dermatitis which could predispose skin loss
  • Skin ulcers especially near the ankle, usually referred to as venous ulcers.
  • Development of carcinoma or sarcoma in longstanding venous ulcers. There have been over 100 reported cases of malignant transformation and the rate is reported as 0.4% to 1%.[5]
  • Severe bleeding from minor trauma, of particular concern in the elderly.
  • Blood clotting within affected veins. Termed superficial thrombophlebitis. These are frequently isolated to the superficial veins, but can extend into deep veins becoming a more serious problem.
  • Acute fat necrosis can occur, especially at the ankle of overweight patients with varicose veins. Females are more frequently affected than males.

Etiology/Epidemiology

Varicose veins are more common in women than in men, and are linked with heredity[6]. Other related factors are pregnancy, obesity, menopause, aging, prolonged standing, leg injury and abdominal straining. Varicose veins are bulging veins that are larger than spider veins, typically 3 mm or more in diameter.
Less commonly, but not exceptionally, varicose veins can be due to other causes, as post phlebitic obstruction and/or incomptence, venous and arteriovenous malformations[7].

Conservative treatment

The symptoms of varicose veins can be controlled to an extent with the following:

  • Elevating the legs often provides temporary symptomatic relief.
  • "Advice about regular exercise sounds sensible but is not supported by any evidence."[8]
  • The wearing of graduated compression stockings with a pressure of 30–40 mmHg has been shown to correct the swelling, nutritional exchange, and improve the microcirculation in legs affected by varicose veins.[9] They also often provide relief from the discomfort associated with this disease. Caution should be exercised in their use in patients with concurrent arterial disease.
  • anti-inflammatory medication such as ibuprofen or aspirin can be used as part of treatment for superficial thrombophlebitis along with graduated compression hosiery – but there is a risk of intestinal bleeding. In extensive superficial thrombophlebitis, consideration should be given to anti-coagulation, thrombectomy or sclerotherapy of the involved vein.
  • Diosmin 95 is a dietary supplement distributed in the U.S. by Nutratech, Inc. The U.S. Food and Drug Administration does not approve dietary supplements, and concluded that there was an "inadequate basis for reasonable expectation of safety." [10] [11]

Interventional treatment

Active medical intervention in varicose veins can be divided into surgical and non-surgical treatments. Some doctors favor traditional open surgery, while others prefer the newer methods. Newer methods for treating varicose veins, such as endovenous laser treatment (EVLT), radiofrequency ablation, and foam sclerotherapy are not as well studied, especially in the longer term.[12][13]

Surgical treatment

Several techniques have been performed for over a century, from the more invasive named "saphenous stripping" up to mini invasives like superficial phlectomies and CHIVA cure.

Stripping

Stripping consists in a removal of all the saphena vein main trunk from the groin down to the ankle.The complications include deep vein thrombosis (5.3%),[14] pulmonary embolism (0.06%), and wound complications including infection (2.2%). For traditional surgery, reported recurrence rates, which have been tracked for 10 years, range from 5-60%. In addition, since stripping removes the saphenous main trunks, they are no longer availlable for venous by-pass in the future (coronary and/or leg artery vital disease)[15]

CHIVA

CHIVA is the acronym for Conservative and Haemodynamic cure of Incompetent Varicose veins in Ambulatory patients translated from the French cure "Conservatrice et Hémodynamique de l'Insuffisance Veineuse en Ambulatoire"[16] published in France in 1988. Lurie[17] in his analysis of Chiva states that "CHIVA definitely falls into a research category and should be continued as such until sufficient evidence of its validity is generated".

Pathophysiological principles

To be achieved properly,the CHIVA method needs a comprehensive knowledge of both hemodynamics and Ultrasound venous investigation. CHIVA relies on an hemodynamic impairment assessed by data and evidences depicted through Ultrasound dynamic venous investigations. According to this new concept, the clinical symptoms of venous insufficiency are not the cause but the consequence of various abnormalities of the venous system. For example,a varicose vein being overloaded, may be dilated not only because of valvular incompetence (the most frequent) but because of a venous block (thombosis) or arterio-venous fistulae...and so the treatment has to be tailored according the hemodynamic feature.

Procedure and outcomes

It generally consists in 1 to 4 small incisions under local anaestesia in order to disconnect the varicose veins from the abnormal flow due to valvular incompetence which dilates them.[18] The patient is dismissed the same day. This method leads to an improvement of the venous function [citation needed] in order to:

  • Cure the symptoms of venous insufficiency as varicose veins, legs swelling, ulcers.[19][20]
  • Prevent varicose recurrence due to progressive enlargement of collateral veins which replace and overtake the destroyed veins: CHIVA vs Stripping: varicose recurrence divided by 2 to 5 at 10 years.[21]
  • Preserve the superficial venous capital for unpredictable but possible need for coronary or leg artery vital by-pass which increases with ageing.

Unfortunately at this stage, the best available publication of CHIVA outcomes that meets current methological standards[17] is a study by Carandina et al. [21]. The authors estimate that only 30-35% of patients with varicose veins can be treated with CHIVA. This study showed that there were recurrent varices in 18% of cases treated by CHIVA despite there being some bias in the selection of patients favoring CHIVA.[17]

Non-surgical treatment

Sclerotherapy

A commonly performed non-surgical treatment for varicose and "spider" leg veins is sclerotherapy in which medicine is injected into the veins to make them shrink. It has been used in the treatment of varicose veins for over 150 years.[22] Sclerotherapy is often used for telangiectasias (spider veins) and varicose veins that persist or recur after vein stripping.[23][24] Sclerotherapy can also be performed using microfoam sclerosants under ultrasound guidance to treat larger varicose veins, including the great and short saphenous veins.[25][26] A study by Kanter and Thibault in 1996 reported a 76% success rate at 24 months in treating saphenofemoral junction and great saphenous vein incompetence with STS 3% solution.[27] A Cochrane Collaboration review[28] concluded sclerotherapy was better than surgery in the short term (1 year) for its treatment success, complication rate and cost, but surgery was better after 5 years, although the research is weak.[29] A Health Technology Assessment found that sclerotherapy provided less benefit than surgery, but is likely to provide a small benefit in varicose veins without reflux.[30] This Health Technology Assessment monograph includes reviews of the epidemiology, assessment, and treatment of varicose veins, as well as a study on clinical and cost effectiveness of surgery and sclerotherapy</ref> Complications of sclerotherapy are rare but can include blood clots and ulceration. Anaphylactic reactions are "extraordinarily rare but can be life-threatening," and doctors should have resuscitation equipment ready.[31] [32] There has been one reported case of stroke after ultrasound guided sclerotherapy when an unusually large dose of sclerosant foam was injected.

Endovenous laser and radiofrequency ablation

The Australian Medical Services Advisory Committee (MSAC) in 2008 has determined that endovenous laser treatment for varicose veins "appears to be more effective in the short term, and at least as effective overall, as the comparative procedure of junction ligation and vein stripping for the treatment of varicose veins."[33] It also found in its assessment of available literature, that "occurrence rates of more severe complications such as DVT, nerve injury and paraesthesia, post-operative infections and haematomas, appears to be greater after ligation and stripping than after EVLT". Complications for endovenous laser treatment include minor skin burns (0.4%)[34] and temporary paraesthesia (2.1%). The longest study of endovenous laser ablation is 39 months.

Two prospective randomized trials found speedier recovery and fewer complications after radiofrequency obliteration (AKA radiofrequency ablation) compared to open surgery[35][36]. Myers[37] wrote that open surgery for small saphenous vein reflux is obsolete. Myers said these veins should be treated with endovenous techniques, citing high recurrence rates after surgical management, and risk of nerve damage up to 15%. In comparison, radiofrequency ablation has been shown to control 80% of cases of small saphenous vein reflux at 4 years, said Myers. Complications for radiofrequency ablation include burns, paraesthesia, clinical phlebitis, and slightly higher rates of deep vein thrombosis (0.57%) and pulmonary embolism (0.17%).One 3-year study compared radiofrequency, with a recurrence rate of 33%, to open surgery, which had a recurrence rate of 23%.

Endovenous laser and radiofrequency ablation require specialized training for doctors and expensive equipment. Endovenous laser treatment is performed as an outpatient procedure and does not require the use of an operating theatre, nor does the patient need a general anaesthetic. Doctors must use ultrasound during the procedure to see what they are doing. Some practitioners also perform phlebectomy or ultrasound guided sclerotherapy at the time of endovenous treatment. Follow-up treatment to smaller branch varicose veins is often needed in the weeks after the initial procedure.

Other

Other treatments are:

References

  1. ^ Varicose veins Mount Sinai Hospital, New York
  2. ^ Merck Manual Home Edition, 2nd ed.
  3. ^ NHS Direct
  4. ^ Weiss RA, Weiss MA (1993). "Doppler ultrasound findings in reticular veins of the thigh subdermic lateral venous system and implications for sclerotherapy". J Dermatol Surg Oncol. 19 (10): 947–51. PMID 8408914. {{cite journal}}: Unknown parameter |month= ignored (help)
  5. ^ Goldman M. Sclerotherapy, Treatment of Varicose and Telangiectatic Leg Veins. Hardcover Text, 2nd Ed, 1995
  6. ^ Ng M, Andrew T, Spector T, Jeffery S (2005). "Linkage to the FOXC2 region of chromosome 16 for varicose veins in otherwise healthy, unselected sibling pairs". J Med Genet. 42 (3): 235–9. doi:10.1136/jmg.2004.024075. PMID 15744037.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  7. ^ Claude Franceschi Physiopathologie Hémodynamique de l'Insuffisance veineuse in Chirurgie des veines des Membres Inférieurs, page 49, 1996, AERCV editions 23 rue Royale 75008 Paris France
  8. ^ Campbell B (2006). "Varicose veins and their management". BMJ. 333 (7562): 287–92. doi:10.1136/bmj.333.7562.287. PMC 1526945. PMID 16888305. {{cite journal}}: Unknown parameter |month= ignored (help)
  9. ^ Curri SB et al. Changes of cutaneous microcirculation from elasto-compression in chronic venous insufficiency. In Davy A and Stemmer R, editors: Phlebology '89, Montrouge, France, 1989, John Libbey Eurotext.
  10. ^ New Dietary Ingredients in Dietary Supplements, U. S. Food and Drug Administration Center for Food Safety and Applied Nutrition Office of Nutritional Products, Labeling, and Dietary Supplements February 2001 (Updated September 10, 2001), http://www.cfsan.fda.gov/~dms/ds-ingrd.html
  11. ^ Memorandum [1]
  12. ^ "Open Surgery Is Still The Best Technique To Ablate The Great Saphenous Vein," Vascular, Vol. 14 (November 2006), Suppl. 1, p. S. 25
  13. ^ Systematic review of foam sclerotherapy for varicose veins.Jia X, Mowatt G, Burr JM, Cassar K, Cook J, Fraser C. Br J Surg. 2007 Aug;94(8):925-36
  14. ^ van Rij AM, Chai J, Hill GB, Christie RA (2004). "Incidence of deep vein thrombosis after varicose vein surgery". Br J Surg. 91 (12): 1582–5. doi:10.1002/bjs.4701. PMID 15386324. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  15. ^ Hammarsten J, Pedersen P, Cederlund CG, Campanello M (1990). "Long saphenous vein saving surgery for varicose veins. A long-term follow-up". Eur J Vasc Surg. 4 (4): 361–4. PMID 2204548. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  16. ^ claude Franceschi, Cure CHIVA, 1988, Editions de L'Armançon, 21390 Precy-Sous-Thil France
  17. ^ a b c Lurie F (2009). "Venous haemodynamics: what we know and don't know". Phlebology. 24 (1): 3–7. doi:10.1258/phleb.2008.008055. PMID 19155334. {{cite journal}}: Unknown parameter |month= ignored (help)
  18. ^ [2]
  19. ^ Maeso J, Juan J, Escribano J; et al. (2001). "Comparison of clinical outcome of stripping and CHIVA for treatment of varicose veins in the lower extremities". Ann Vasc Surg. 15 (6): 661–5. doi:10.1007/s10016-001-0009-8. PMID 11769147. {{cite journal}}: Explicit use of et al. in: |author= (help); Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  20. ^ Zamboni P, Cisno C, Marchetti F; et al. (2003). "Minimally invasive surgical management of primary venous ulcers vs. compression treatment: a randomized clinical trial". Eur J Vasc Endovasc Surg. 25 (4): 313–8. doi:10.1053/ejvs.2002.1871. PMID 12651168. {{cite journal}}: Explicit use of et al. in: |author= (help); Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  21. ^ a b Carandina S, Mari C, De Palma M; et al. (2008). "Varicose vein stripping vs haemodynamic correction (CHIVA): a long term randomised trial". Eur J Vasc Endovasc Surg. 35 (2): 230–7. doi:10.1016/j.ejvs.2007.09.011. PMID 17964822. {{cite journal}}: Explicit use of et al. in: |author= (help); Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  22. ^ Goldman M, Sclerotherapy Treatment of varicose and telangiectatic leg vein, Hardcover Text, 2nd Ed, 1995
  23. ^ "Veins & Lymphatics," L. K. Pak et al, in Lange's Current Surgical Diagnosis & Treatment, 11th ed., McGraw-Hill,
  24. ^ Tisi PV, Beverley C, Rees A (2006). "Injection sclerotherapy for varicose veins". Cochrane Database Syst Rev (4): CD001732. doi:10.1002/14651858.CD001732.pub2. PMID 17054141.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  25. ^ Paul Thibault, Sclerotherapy and Ultrasound-Guided Sclerotherapy, The Vein Book / editor, John J. Bergan, 2007.
  26. ^ Padbury A, Benveniste G L, Foam echosclerotherapy of the small saphenous vein, Australian and New Zealand Journal of Phlebology Vol 8, Number 1 (December 2004)
  27. ^ Kanter A, Thibault P (1996). "Saphenofemoral incompetence treated by ultrasound-guided sclerotherapy". Dermatol Surg. 22 (7): 648–52. PMID 8680788. {{cite journal}}: Unknown parameter |month= ignored (help)
  28. ^ http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD001732/abstract.html
  29. ^ Rigby KA, Palfreyman SJ, Beverley C, Michaels JA (2004). "Surgery versus sclerotherapy for the treatment of varicose veins". Cochrane Database Syst Rev (4): CD004980. doi:10.1002/14651858.CD004980. PMID 15495134.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  30. ^ Michaels JA, Campbell WB, Brazier JE; et al. (2006). "Randomised clinical trial, observational study and assessment of cost-effectiveness of the treatment of varicose veins (REACTIV trial)". Health Technol Assess. 10 (13): 1–196, iii–iv. PMID 16707070. {{cite journal}}: Explicit use of et al. in: |author= (help); Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  31. ^ William R. Finkelmeier, Sclerotherapy, Ch. 12, ACS Surgery: Principles & Practice, 2004, WebMD (hardcover book)
  32. ^ Scurr JR, Fisher RK, Wallace SB (2007). "Anaphylaxis Following Foam Sclerotherapy: A Life Threatening Complication of Non Invasive Treatment For Varicose Veins". EJVES Extra. 13 (6): 87–89. doi:10.1016/j.ejvsextra.2007.02.005.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  33. ^ Medical Services Advisory Committee, Endovenous laser therapy (ELT) for varicose veins. MSAC application 1113, Dept of Health and Ageing, Commonwealth of Australia, 2008.
  34. ^ Elmore FA, Lackey D (2008). "Effectiveness of endovenous laser treatment in eliminating superficial venous reflux". Phlebology. 23 (1): 21–31. PMID 18361266.
  35. ^ Rautio TT, Perälä JM, Wiik HT, Juvonen TS, Haukipuro KA (2002). "Endovenous obliteration with radiofrequency-resistive heating for greater saphenous vein insufficiency: a feasibility study". J Vasc Interv Radiol. 13 (6): 569–75. PMID 12050296. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  36. ^ Lurie F, Creton D, Eklof B; et al. (2005). "Prospective randomised study of endovenous radiofrequency obliteration (closure) versus ligation and vein stripping (EVOLVeS): two-year follow-up". Eur J Vasc Endovasc Surg. 29 (1): 67–73. doi:10.1016/j.ejvs.2004.09.019. PMID 15570274. {{cite journal}}: Explicit use of et al. in: |author= (help); Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  37. ^ Kenneth Myers, An opinion —surgery for small saphenous reflux is obsolete!" Australian and New Zealand Journal of Phlebology, Vol 8, Number 1 (December 2004)

External links

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