What are the therapies for chronic venous insufficiency?

Therapies for Chronic Venous Insufficiency

Compression therapy is the mainstay of treatment for chronic venous insufficiency, with a minimum pressure of 20-30 mmHg recommended for most patients and 30-40 mmHg advised for more severe disease. 1

Conservative Management

First-Line Therapy

• Compression therapy:
  • 20-30 mmHg gradient compression stockings for most patients 1, 2
  • 30-40 mmHg for more severe disease 1
  • Negative graduated compression bandages (higher pressure at calf than ankle) show improved ejection fraction 1

Additional Conservative Measures

• Leg elevation: Enhances microcirculatory flow velocity in liposclerotic skin (45% median increase in flux) 3
• Exercise: Supervised exercise training program with leg strength training and aerobic activity for at least 6 months (Class IIa; Level of Evidence B) 1
• Lifestyle modifications:
  • Regular physical activity
  • Weight management
  • Avoiding prolonged standing 2

Pharmacological Treatment

• Pentoxifylline: 400 mg three times daily - more effective than placebo for ulcer healing (RR, 1.70; 95% CI, 1.30-2.24), though with increased gastrointestinal side effects 1
• Rutosides: May provide symptomatic relief 1

Venous Ulcer Management

• Compression therapy: Primary treatment for venous ulcers 1
• Wound care:
  • Maintain moist environment
  • Provide protective covering
  • Control dermatitis
  • Aggressively prevent and treat infection 1
• Pentoxifylline: Adjunctive to compression for ulcer healing 1

Interventional Treatments

Indications for referral:

• Persistent symptoms despite compression therapy
• Documented reflux on venous duplex ultrasound
• Significant impact on quality of life
• Active venous ulceration or history of venous ulcer
• Lipodermatosclerosis or atrophie blanche
• History of superficial thrombophlebitis
• External hemorrhage from varicose vein 2

Interventional Options

1. Endovenous thermal ablation:

   • First-line treatment for saphenous vein incompetence
   • 91-100% success rate at 1 year
   • Radiofrequency ablation recommended for veins >4.5mm diameter 2

2. Sclerotherapy:

   • Indicated for smaller veins (spider veins ≤1 mm, reticular veins 1-3 mm)
   • Uses polidocanol or sodium tetradecyl sulfate 2
   • Ultrasound-guided foam sclerotherapy (UGFS) effective for saphenous insufficiency 4

3. Surgical options:

   • Microphlebectomy/stab phlebectomy for tributary veins >2.5 mm 2
   • High ligation and stripping (HL/S) for saphenous insufficiency 4

4. Non-thermal non-tumescent ablation systems:

   • Safe and efficacious for saphenous insufficiency 4

5. Endovascular procedures:

   • Iliac vein stenting for chronic venous obstruction 5
   • Percutaneous transluminal venoplasty stenting for symptomatic femoroiliocaval occlusive disease 4

Post-Procedure Care

• Compression therapy (20-30 mmHg) post-procedure
• Walking for 15-20 minutes immediately after procedure
• Follow-up ultrasound to confirm successful vein closure 2

Potential Complications

• Phlebitis
• New telangiectasias
• Residual pigmentations
• Surrounding nerve damage from thermal injury (~7%)
• Deep vein thrombosis (0.3-0.7%) 2

Common Pitfalls

• Delaying referral for symptomatic patients with documented reflux
• Prolonging conservative management without offering interventional treatment
• Failing to obtain venous duplex ultrasound before deciding on treatment approach 2
• Inadequate compression pressure (minimum 20-30 mmHg required) 1
• Not addressing patient compliance with compression therapy 1

By following this algorithmic approach to chronic venous insufficiency management, clinicians can effectively improve symptoms, prevent complications, and enhance patients' quality of life.