Intended for healthcare professionals

Clinical Review

The management of superficial venous incompetence

BMJ 2011; 343 doi: (Published 03 August 2011) Cite this as: BMJ 2011;343:d4489
  1. P B van den Boezem, surgical resident1,
  2. T M A L Klem, surgeon2,
  3. E le Cocq d’Armandville, medical doctor3,
  4. C H A Wittens, professor of venous surgery4
  1. 1Department of Surgery, Gelderse Vallei Hospital, Ede, Netherlands
  2. 2Department of Surgery, Sint Franciscus Gasthuis, Rotterdam, Netherlands
  3. 3Surgical Venous Research Foundation, Rotterdam, Netherlands
  4. 4Maastricht University Centre, Netherlands and Department of Vascular Surgery, University Hospital RWTH Aachen, Nordrhein-Westfalen, Germany
  1. Correspondence to: P B van den Boezem boezem{at}
  • Accepted 11 July 2011

Summary points

  • Venous disease should be categorised according to the CEAP (clinical, (a)etiology, anatomy, pathophysiology) classification

  • Duplex ultrasound is the gold standard for diagnosis of superficial venous incompetence

  • The aim of treatment is to reduce symptoms

  • All treatment modalities seem to be safe and effective at short term and midterm follow-up

  • Postoperative recovery is faster with endovenous procedures than with conventional surgery

  • With the use of tumescent anaesthesia, no differences in patient recovery are seen between surgical stripping and endovenous procedures

Superficial venous disease of the leg is common, disabling, and costly, and it has a negative effect on patients’ quality of life.1 A cross sectional survey from the United Kingdom found a prevalence of trunk varicosities of more than 30%.2 Trunk varicosities originate from the great saphenous vein in almost 50% of cases, the small saphenous vein in 30%, and both veins in 20% (fig 1).3

Fig 1 Venous anatomy of the leg

We review the management of superficial venous incompetence of the leg, focusing on the effectiveness of the procedures most commonly used and their complication rates.

Sources and selection criteria

We searched PubMed, Medline, the Cochrane Library, and Embase for the terms “varicose” or “saphenous” and extracted data from the most valid prospective cohort studies and randomised controlled trials of the past 25 years. Efficacy of treatment was assessed by recurrence rate, quality of life, pain scores, and return to daily activities and work.

In many of the trials that compared treatment modalities patient numbers were low, a clinically relevant primary outcome was absent, and the manufacturer was involved in the trial. Several studies reported difficulty in recruiting patients because many expressed a preference for endovenous procedures. In all of the randomised trials, neither the investigators nor the patients were blinded to the treatment method. These problems probably …

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