Diagnosis and treatment of varicose veins in the legs
Authors: Allen Felicity , Kroes Michel , Mitchell Stephen , Mambourg Françoise , Paulus Dominique 
Published: January 2025

1 INTRODUCTION 5 -- 1.1 BACKGROUND OF THE STUDY 5 -- 1.1.1 Necessary update of billing codes 5 -- 1.1.2 Use of obsolete diagnostic techniques 5 -- 1.2 CLINICAL BACKGROUND: VARICOSE VEINS 6 -- 1.2.1 Definition 6 -- 1.2.2 Prevalence 6 -- 1.2.3 Aetiology and risk factors 6 -- 1.2.4 Disease severity: CEAP Classification 6 -- 1.3 RESEARCH QUESTIONS 7 -- 1.3.1 First research question: diagnostic procedures 7 -- 1.3.2 Second research question: effectiveness and safety of treatments 8 -- 1.3.3 Third research question: type of anaesthetic for each intervention 8 -- 1.4 DIAGNOSIS OF VARICOSE VEINS 8 -- 1.5 TREATMENT OPTIONS FOR VARICOSE VEINS 9 -- 1.5.1 Traditional surgical procedures 9 -- 1.5.2 Endovenous Laser Therapy 10 -- 1.5.3 Radiofrequency Ablation 10 -- 1.5.4 Sclerotherapy 10 -- 1.5.5 Mixed treatments 10 -- 2 METHODS 11 -- 2.1 SEARCH STRATEGIES 11 -- 2.1.1 Diagnostic techniques for varicose veins 11 -- 2.1.2 Treatment of varicose veins 11 -- 2.2 ASSESSING METHODOLOGICAL QUALITY AND RISK OF BIAS 12 -- 2.2.1 Diagnostic studies 12 -- 2.2.2 Systematic reviews 12 -- 2.2.3 Randomised controlled trials 12 -- 2.3 DATA EXTRACTION 12 -- 2.3.1 Diagnostic studies 12 -- 2.3.2 Systematic reviews 13 -- 2.3.3 Randomised controlled trials 13 -- 3 RESULTS: DIAGNOSTIC PROCEDURES FOR VARICOSE VEINS 14 -- 3.1 IDENTIFIED STUDIES AND QUALITY APPRAISAL 14 -- 3.1.1 Selection of two diagnostic studies 14 -- 3.1.2 Quality appraisal of diagnostic studies 16 -- 3.2 OVERVIEW OF INCLUDED DIAGNOSTIC STUDIES 16 -- 3.3 PRE-OPERATIVE DUPLEX ULTRASOUND COMPARED WITH NO SCAN 16 -- 3.4 COMPUTED TOMOGRAPHY VERSUS DUPLEX 17 -- 4 RESULTS: INTERVENTIONS FOR THE TREATMENT OF VARICOSE VEINS .. 18 -- 4.1 IDENTIFIED STUDIES AND QUALITY APPRAISAL 18 -- 4.1.1 Systematic reviews 18 -- 4.1.2 Randomised controlled trials 20 -- 4.2 OVERVIEW OF INCLUDED SYSTEMATIC REVIEWS 22 -- 4.2.1 Systematic reviews on multiple treatments 22 -- 4.2.2 Endovenous laser therapy 23 -- 4.2.3 Radiofrequency ablation 23 -- 4.2.4 Sclerotherapy 23 -- 4.2.5 Surgery 23 -- 4.2.6 Compression hosiery 23 -- 4.3 OVERVIEW OF INCLUDED RCTS 23 -- 5 RESULTS BY INTERVENTION 25 -- 5.1 ENDOVENOUS LASER THERAPY 25 -- 5.1.1 Results from systematic reviews 25 -- 5.1.2 Results from randomised controlled trials 25 -- 5.1.3 Summary: Endovenous Laser Therapy 27 -- 5.2 RADIOFREQUENCY ABLATION 27 -- 5.2.1 Results from systematic reviews 27 -- 5.2.2 Results from randomised controlled trials 27 -- 5.2.3 Summary: Radiofrequency ablation 29 -- 5.3 SCLEROTHERAPY 29 -- 5.3.1 Results from systematic reviews 29 -- 5.3.2 Results from randomised controlled trials 29 -- 5.3.3 Summary: Sclerotherapy 30 -- 5.4 SURGERY 31 -- 5.5 COMPRESSION HOSIERY 31 -- 5.6 DRUGS 32 -- 5.6.1 One Cochrane review on the effect of phlebotonics for chronic venous insufficiency .. 32 -- 5.6.2 Lack of evidence in one RCT 32 -- 5.7 OTHER CONSERVATIVE TREATMENTS 32 -- 6 SAFETY CONSIDERATIONS 33 -- 6.1 ENDOVENOUS LASER THERAPY 33 -- 6.2 RADIOFREQUENCY ABLATION 33 -- 6.3 SCLEROTHERAPY 34 -- 6.4 SURGERY 34 -- 6.5 SUMMARY: SAFETY 35 -- 7 ANAESTHESIA 36 -- 7.1 DESCRIPTION OF ANAESTHESIA IN THE INCLUDED RCTS 36 -- 7.2 ANAESTHESIA SUMMARY 36 -- 8 SUMMARY OF FINDINGS AND DISCUSSION 38 -- 8.1 SUMMARY OF FINDINGS 38 -- 8.1.1 Diagnostic: duplex ultrasound is the standard procedure 38 -- 8.1.2 Treatment options: comparable efficacy and complications 38 -- 8.1.3 Heterogenous anaesthetic procedures 38 -- 8.1.4 Coherence of the results with other recent publications 39 -- 8.2 TRANSFERABILITY OF RESULTS TO THE BELGIAN HEALTH CARE SETTING ? 39 -- 8.3 STRENGTHS AND LIMITATIONS OF THIS SYSTEMATIC REVIEW 39 -- 8.3.1 Strengths of this review 39 -- 8.3.2 Methodological limitations of the included studies 39 -- 8.4 SUGGESTIONS FOR FURTHER RESEARCH 40 -- 8.5 KEY POINTS OF THE REPORT 41 -- 9 APPENDICES 42 -- 9.1 ADDITIONAL HANDSEARCHING 42 -- 9.2 DIAGNOSTIC STUDIES: QUALITY APPRAISAL AND DETAILED RESULTS ABOUT THE -- USE OF HAND-HELD DOPPLER 44 -- 9.2.1 Quality items derived from QUADAS tool 44 -- 9.2.2 Quality appraisal of varicose vein diagnostic studies 45 -- 9.2.3 Data extraction table for Diagnostic studies (including hand-held Doppler) 46 -- 9.2.4 Overview of included diagnostic studies for hand-held Doppler 57 -- 9.2.5 Clinical Consequences of the findings: hand-held Doppler versus Colour duplex -- ultrasound 60 -- 9.3 QUALITY APPRAISAL FOR INCLUDED SYSTEMATIC REVIEWS 62 -- 9.4 DATA EXTRACTION TABLE FOR INCLUDED SYSTEMATIC REVIEWS 66 -- 9.4.1 Reviews evaluating multiple treatments 66 -- 9.4.2 Reviews evaluating EVLT 69 -- 9.4.3 EVLT RCTs from the review of Rees et al., 2009 29 70 -- 9.4.4 Reviews evaluating RFA 71 -- 9.4.5 RFA RCTs from Rees et al., 2009 29 72 -- 9.4.6 Reviews evaluating sclerotherapy 73 -- 9.4.7 Sclerotherapy RCTs from Rees et al., 2009 29 75 -- 9.4.8 Reviews focused on surgery evaluation, 77 -- 9.4.9 Reviews evaluating hosiery 77 -- 9.4.10 Reviews evaluating drugs 77 -- 9.5 QUALITY APPRAISAL FOR INCLUDED PRIMARY STUDIES 78 -- 9.5.1 Quality appraisal tool 78 -- 9.5.2 Quality appraisal of treatment RCTs: results 79 -- 9.6 DATA EXTRACTION TABLES OF INCLUDED RCTS 88 -- 9.6.1 Included RCTs evaluating EVLT 88 -- 9.6.2 Included RCTs evaluating RFA 91 -- 9.6.3 Included RCTs evaluating sclerotherapy 95 -- 9.6.4 Included RCT evaluating compression hosiery 98 -- 9.6.5 Included RCT evaluating drugs 99 -- 9.7 STUDIES EVALUATING THE SAFETY OF VARICOSE VEIN TREATMENTS 100 -- 10 REFERENCES 104 --