What are the treatment options for chronic venous insufficiency?

Treatment Options for Chronic Venous Insufficiency

A stepwise approach to treating chronic venous insufficiency should begin with a 3-month trial of compression therapy (20-30 mmHg) before proceeding to interventional treatments for patients with persistent symptoms. 1

Conservative Management

Compression Therapy

• First-line treatment for all patients with CVI
  • 20-30 mmHg gradient compression stockings for most patients
  • 30-40 mmHg for more severe disease 1
  • Must be worn consistently for effectiveness
  • Minimum 3-month trial before considering interventional options

Elevation and Lifestyle Modifications

• Leg elevation to reduce edema and improve symptoms 2
• Exercise program with leg strength training and aerobic activity 1
• Weight loss for obese patients 2
• Avoiding prolonged standing and restrictive clothing 2

Pharmacological Options

• Pentoxifylline 400 mg three times daily for venous ulcers (RR 1.70; 95% CI 1.30-2.24) 1
• Phlebotonics (horse chestnut seed extract) may provide symptomatic relief 2
• Rutosides for symptom management 1
• Oral antihistamines for itching relief 1

Interventional Treatments

Consider when conservative management fails after 3 months and specific criteria are met

Endovenous Thermal Ablation

• First-line interventional treatment for saphenous vein incompetence 1
• Indications:
  • Vein diameter >4.5 mm
  • Documented junctional reflux duration ≥500 ms
  • Failed conservative management
  • Significant symptoms affecting quality of life 1
• Types:
  • Radiofrequency ablation
  • Endovenous laser ablation
• High success rates: 91-100% at 1 year 1

Sclerotherapy

• Indicated for:
  • Spider veins (≤1 mm)
  • Reticular veins (1-3 mm) 1
  • Telangiectasias 2
• Agents include:
  • Polidocanol (Varithena)
  • Sodium tetradecyl (Sotradecol)
  • Hypertonic saline 2

Surgical Options

• Microphlebectomy/stab phlebectomy for tributary veins >2.5 mm 1
• Traditional ligation and stripping (less commonly used now) 2
• Lower recurrence rates compared to sclerotherapy for large varicosities 1

Treatment Algorithm Based on CEAP Classification

1. C1-C2 (Telangiectasias, reticular veins, varicose veins)

   • Compression therapy (20-30 mmHg)
   • If persistent: Sclerotherapy or external laser for telangiectasias; endovenous thermal ablation for larger varicose veins

2. C3-C4 (Edema, skin changes)

   • Compression therapy (30-40 mmHg)
   • Leg elevation and lifestyle modifications
   • Pharmacological management
   • If persistent: Endovenous thermal ablation or surgical intervention

3. C5-C6 (Healed or active ulceration)

   • Compression therapy (30-40 mmHg)
   • Wound care for ulcers
   • Pentoxifylline
   • Prompt referral to vascular specialist for interventional treatment

Post-Procedure Care

• Compression therapy (20-30 mmHg) to promote vein closure 1
• Walking for 15-20 minutes immediately after procedure to reduce DVT risk 1
• Follow-up ultrasound to confirm successful vein closure 1

Common Pitfalls to Avoid

• Inadequate compression pressure (minimum 20-30 mmHg required) 1
• Poor patient compliance with compression therapy 1
• Delaying referral for symptomatic patients with documented reflux 1
• Focusing only on cosmetic concerns without addressing underlying pathology 1
• Failing to obtain venous duplex ultrasound before deciding on treatment approach 1

Potential Complications

• Phlebitis
• Residual pigmentation
• New telangiectasias
• Nerve damage from thermal injury (approximately 7%)
• DVT risk (0.3-0.7%) 1

With appropriate treatment, patients can expect reduction in pain and discomfort, decreased swelling, improved daily activities and quality of life, and reduced risk of complications such as ulceration or recurrent thrombophlebitis 1.