Are there differences in guidelines for management of CVD between Europe and the US? Bo Eklöf, MD, PhD Lund University Sweden
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1 Are there differences in guidelines for management of CVD between Europe and the US? Bo Eklöf, MD, PhD Lund University Sweden
2 Disclosures No disclosures
3 Five sources for comparison SVS/AVF US guidelines 2011 MoLy review 2012 NICE UK guidelines 2013 EVF/UIP International guidelines 2014 ESVS European guidelines 2015 Information is excellent. READ THEM
4 SVS/AVF guidelines 2011 The care of patients with varicose veins and associated CVD Peter Gloviczki, Tony Comerota, Mike Dalsing, Bo Eklöf et al J Vasc Surg 2011, 53; suppl S 14 guidelines based on 375 references Using the GRADE system
5
6 European review and comment on the SVS/AVF guidelines Marzia Lugli, Modena, Italy Oscar Maleti, Modena, Italy Michel Perrin, Lyon, France Phlebolymphology 2012;19: MoLy
7
8 NICE UK guidelines 2013 Guidelines on varicose veins: diagnosis and management Alun Davies, Mustapha Azzam, Andrew Bradbury et al pages, 110 references Excluded leg ulcers, spider veins, pelvic veins and pharmacologic treatment Using the GRADE system
9 EVF/UIP international guidelines 2014 Management of CVD of the lower limbs. Guidelines according to scientific evidence Andrew Nicolaides, Stavros Kakkos, Bo Eklöf, Michel Perrin et al International Angiology 2014;33: ,097 references GRADE system
10 ESVS European guidelines 2015 Management of CVD. Clinical practice guidelines of the ESVS Cees Wittens, Alun Davies, Niels Baekgaard et al Eur J Vasc Endovasc Surg 2015;49: recommendations based on 588 references Using the European Society of Cardiology grading system: A-C marks the level of evidence; the recommendation is marked as I-III. Opposite to GRADE
11 Duplex scanning We (SVS/AVF) recommend that the clinical examination is complemented by duplex scanning of the deep and superficial veins: 1 A MoLy Agree NICE UK Agree EVF/UIP Agree ESVS Agree (IA strong recommendation)
12 Classification We recommend that the CEAP classification be used for patients with CVD. The basic CEAP for clinical practice, and the full CEAP for clinical research: 1 A MoLy Agree NICE UK Agree EVF/UIP Agree ESVS Agree IB
13 Medical treatment We suggest venoactive drugs (VAD) for patients with pain and swelling due to CVD, in countries where these drugs are available: 2 B MoLy Agree NICE UK not included EVF/UIP stronger recommendation for VAD ESVS Agree IIaA
14 Compression treatment We suggest compression therapy using moderate pressure (20-30 mm Hg) for patients with symptomatic varicose veins: 2 C We recommend against compression therapy as the primary treatment of symptomatic varicose veins in patients who are candidates for saphenous vein ablation: 1 B MoLy Agree NICE UK Agree EVF/UIP Agree ESVS Agree IB. Together with EVF/UIP recommend also IPC
15 Open venous surgery We suggest high ligation and inversion stripping of the incompetent GSV to the level of the knee: 2 B MoLy 2 B too harsh for modern open surgery NICE UK open surgery ranked after thermal ablation and foam sclero EVF/UIP Agree, old type 2A, modern type 1B ESVS Agree instead of conservative treatment IB
16 Post-intervention compression We recommend postoperative compression to reduce hematoma formation, pain and swelling. The recommended period of compression in C2 patients is one week: 1 B MoLy Agree NICE UK Agree EVF/UIP Agree ESVS Agree IA
17 Recurrent varicose veins For treatment of recurrent varicose veins, we suggest ligation of the saphenous stump, ambulatory phlebectomy, sclerotherapy, or endovenous thermal ablation, depending on the etiology, source, location, and extent of varicosity: 2 C MoLy: in practice US guided foam sclerotherapy NICE UK separate recommendations not required EVF/UIP Agree ESVS Agree IIaB, extensive redo surgery not recommended IIIB
18 Endovenous thermal ablation We recommend endovenous thermal ablations (laser and radiofrequency ablations) for treatment of saphenous incompetence, as they are safe and effective 1 B MoLy Agree NICE UK Agree as #1, Foamsclero #2, surgery #3 EVF/UIP Agree 1A ESVS Agree IA
19 Sclerotherapy We recommend liquid or foam sclerotherapy for telangiectasia, reticular veins and varicose veins 1 B MoLy: Agree for telangiectasias and reticular veins, but not varicose veins NICE UK Foam sclero second choice for varicose veins EVF/UIP Agree, US guided foam sclero 1A ESVS Agree for telangiectasia/reticular veins IIaB; not recommended for C2-6 IIIA; primary treatment in recurrence IIaB
20 Treatment of perforating veins We recommend against selective treatment of incompetent perforating veins in patients with simple varicose veins (C2) 1 B MoLy Agree NICE UK Agree EVF/UIP Agree ESVS not included
21 Conclusion Full agreement on most of SVS/AVF guidelines Minor disagreements, mainly on indications for foam sclero
22 New Kids on the block Steam ablation PI van den Bos RCT Laser vs Steam Br J Surg 2014 Mechanical Occlusion Chemically Assisted PI Alun Davies RCT RF vs MOCA Phlebology 2014 VenaSeal medical adhesive ablation PI Nick Morrison RCT RF vs VenaSeal JVS 2015
23 New kids on the block SVS/AVF 2011 not included MoLy 2012 consequently not commented upon NICE UK 2013 not included EVF/UIP 2014 described, not graded, not recommended ESVS 2015 not included
24 Surveillance to ensure that the guidelines are up to date Guidelines need to be up-dated to serve the practitioner! SVS/AVF 2011:? NICE UK 2013: regular annual check. Surveillance report 2016: no up date. Next 2017 EVF/UIP International 2014: next 2017 ESVS European 2015: next 2017
25 VIVE LA INDIFFERENCE! Joint effort between SVS/AVF, NICE UK, EVF/UIP and ESVS?
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Last Review Date: March 23, 2017 Number: MG.MM.SU.05mv2 Medical Guideline Disclaimer Property of EmblemHealth. All rights reserved. The treating physician or primary care provider must submit to EmblemHealth
LINC, Christine Teichert, MD University Medicine of Rostock, Dept. of diagnostic and interventional radiology, Germany
Comparison of the efficacy, safety, the primary and secondary technical success of the endovenous nonthermal, tumescensless mechanochemical ablation of varicose veins with the subjective outcome using
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Serious side effects of endovenous thermal or chemical ablation are rare.
For mass reproduction, content licensing and permissions contact Dowden Health Media. Jeffery P. Schoonover, MD, FAAFP, J. Theodore King, MD, FAAFP, FACPh, Captain Gray, MD, and Keith Campbell, MD Vein
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