What is the treatment for chronic venous insufficiency?

Treatment for Chronic Venous Insufficiency

Compression therapy is the cornerstone of treatment for chronic venous insufficiency (CVI), with graduated compression stockings providing the most effective conservative management. 1 Additional interventions should be implemented based on disease severity, with a structured approach progressing from conservative to more invasive treatments as needed.

First-Line Treatment: Compression Therapy

• Compression stockings: 20-30 mmHg pressure is recommended as minimum effective pressure for most patients 1
  • For more severe disease, 30-40 mmHg pressure is advised 1
  • Compression is particularly effective for venous ulcers, with evidence showing faster healing compared to primary dressings alone, non-compression bandages, or usual care 1
  • Note: Despite being first-line therapy, evidence for compression stockings in the absence of active or healed ulcers is limited 1

Conservative Adjunctive Measures

• Exercise therapy: A supervised exercise training program consisting of leg strength training and aerobic activity for at least 6 months is reasonable for patients who can tolerate it (Class IIa; Level of Evidence B) 1

  • Exercise improves calf muscle pump function and dynamic calf muscle strength
  • May help with symptom relief through improved ejection of venous blood from the limb

• Leg elevation: Elevating the affected leg above heart level helps reduce edema and improve venous return

• Weight loss: For patients who are overweight or obese, weight reduction may improve symptoms 1

• Lifestyle modifications:

  • Avoid prolonged standing and straining
  • Wear non-restrictive clothing
  • Address cardiovascular risk factors 1

Pharmacological Treatment

• Pentoxifylline: 400 mg three times daily has been shown to be more effective than placebo for healing venous ulcers (RR, 1.70; 95% CI, 1.30–2.24) 1

  • Pentoxifylline plus compression is more effective than placebo plus compression (RR, 1.56; 95% CI, 1.14–2.13)
  • Common side effects include gastrointestinal symptoms (nausea, indigestion, diarrhea)

• Phlebotonics: May provide symptomatic relief, though evidence for long-term benefits is limited 2

  • Horse chestnut seed extract may ease symptoms, but long-term safety and effectiveness data are lacking 1

Interventional Treatments (for patients with persistent symptoms despite conservative therapy)

For Superficial Venous Insufficiency:

1. Endovenous thermal ablation: Recommended as first-line interventional treatment for symptomatic varicose veins with documented valvular reflux 1

   • Includes endovenous laser ablation and radiofrequency ablation
   • Can be performed under local anesthesia with same-day discharge
   • May have better outcomes and fewer complications than other treatments
   • Risk of surrounding nerve damage is approximately 7%, though most is temporary

2. Sclerotherapy: Typically used for small (1-3 mm) veins 1

   • Involves injection of a sclerosing agent that causes inflammation, fibrosis, and occlusion

3. Surgery: Includes ligation and stripping or phlebectomy 1

   • Less commonly used now due to availability of less invasive options

For Deep Venous Insufficiency:

• Endovascular procedures: For central post-thrombotic venous occlusion 1
  • Percutaneous relief of iliac vein obstruction has shown promising results
  • In one large cohort, ulcer healing occurred in 55% of patients after venoplasty and stenting

Management of Venous Ulcers

1. Compression therapy: The mainstay of treatment 1

2. Wound care principles:

   • Maintain a moist environment to optimize healing
   • Provide protective covering
   • Control dermatitis
   • Aggressively prevent and treat infection 1

3. Pentoxifylline: As adjunctive therapy to compression 1

Treatment Algorithm Based on Disease Severity

1. Mild CVI (C1-C2: telangiectasias, reticular veins, varicose veins):

   • Compression stockings (20-30 mmHg)
   • Exercise program
   • Lifestyle modifications

2. Moderate CVI (C3-C4: edema, skin changes):

   • Higher-pressure compression (30-40 mmHg)
   • Consider pentoxifylline or phlebotonics
   • Consider referral for endovenous thermal ablation if superficial reflux is documented

3. Severe CVI (C5-C6: healed or active venous ulcers):

   • Aggressive compression therapy
   • Pentoxifylline plus compression
   • Appropriate wound care
   • Consider referral to vascular specialist for potential endovascular or surgical intervention

Common Pitfalls and Caveats

• Compression therapy is often underutilized or prescribed at inadequate pressure levels
• Patients frequently have poor compliance with compression therapy due to discomfort or difficulty applying stockings
• Delaying referral for interventional treatment in appropriate candidates may lead to disease progression
• Treating only the superficial venous system when there is concomitant deep venous insufficiency may result in suboptimal outcomes
• Failing to address lifestyle factors (obesity, prolonged standing) may limit treatment effectiveness

Remember that early intervention is key to preventing progression to more severe manifestations of CVI, particularly venous ulcers, which can be costly, slow to heal, and significantly impact quality of life.