What are the treatment options for chronic venous insufficiency?

Treatment Options for Chronic Venous Insufficiency

The first-line treatment for chronic venous insufficiency is compression therapy, with medical-grade compression stockings (20-30 mmHg for mild to moderate disease and 30-40 mmHg for severe disease) being the cornerstone of management. 1

Diagnostic Evaluation

• Duplex Doppler ultrasound is essential for:

  • Evaluating venous reflux (abnormal = retrograde flow >500 milliseconds)
  • Assessing deep venous system patency
  • Documenting affected vein diameters (varicosities typically >4mm)
  • Mapping refluxing superficial venous pathways 1

• Patient evaluation should include:

  • Assessment in both supine and semi-standing positions
  • Valsalva maneuver to assess valve competency
  • Documentation of reflux severity based on duration 1

Treatment Algorithm

1. Conservative Management

• Compression Therapy:

  • Medical-grade compression stockings: 20-30 mmHg for mild to moderate disease, 30-40 mmHg for severe disease 1
  • Continue compression therapy for at least 2 years, longer if symptoms persist 1
  • Avoid compression when ankle-brachial index is <0.6 due to risk of arterial compromise 1
  • Meta-analysis evidence shows that 10-20 mmHg compression is effective, with no additional benefit from higher pressures 2

• Lifestyle Modifications:

  • Avoid prolonged sitting; take regular breaks to walk
  • Elevate legs when possible to reduce venous pressure
  • Wear non-restrictive clothing
  • Maintain healthy weight and reduce sodium intake
  • Regular exercise, particularly ankle movements to activate calf muscle pumps 1

• Pharmacologic Therapy:

  • Flavonoid medications (e.g., horse chestnut seed extract) for symptom management 1, 3
  • Diuretics and topical steroid creams may provide short-term relief of swelling and pain 3

2. Interventional Treatments

For patients with persistent symptoms despite conservative management:

• Superficial Venous Insufficiency:

  • Endovenous Thermal Ablation (first-line for veins >4.5mm) 1:

    • Radiofrequency ablation (RFA)
    • Endovenous laser treatment

  • Sclerotherapy:

    • Recommended for smaller veins (<4.5mm), spider veins (≤1 mm), reticular veins (1-3 mm) 1
    • Agents include polidocanol, sodium tetradecyl, and hypertonic saline

  • Surgical Options:

    • High ligation and stripping (HL/S) 4
    • Non-thermal non-tumescent ablation systems 4

• Deep Venous Insufficiency:

  • Endovascular Procedures for Iliocaval Obstruction:

    • Venoplasty and stenting for iliac vein obstruction 5
    • Technical success rates are high with significant improvement in quality of life 5

  • Hybrid Surgical and Endovenous Reconstruction:

    • For patients with common femoral vein and iliac vein segment obstruction
    • Combines surgical endophlebectomy with endoluminal balloon venoplasty and stenting 5

  • Segmental Vein Valve Transfer:

    • Transplanting competent valve segments or transposing incompetent veins 5
    • Long-term outcomes show 37% of patients with PTS had good to excellent results 5

3. Post-Intervention Follow-up

• Schedule follow-up ultrasound within 1-2 weeks after intervention to:

  • Confirm successful vein closure
  • Rule out deep venous thrombosis complications
  • Assess for residual reflux requiring additional treatment 1

• Regular follow-up to assess treatment effectiveness and disease progression 1

Special Considerations

• Potential Complications:

  • Procedure-related thrombosis (2.6% with venoplasty and stenting) 5
  • Bleeding, acute lymphedema, and wound complications (5-10%) with open surgical procedures 5
  • Risk of compartment syndrome requiring fasciotomy 1

• Treatment Efficacy:

  • Ulcer healing occurs in 55% of patients after venoplasty and stenting 5
  • Quality of life significantly improves after venous interventions 5
  • Physical exercise may improve symptoms, but evidence is currently insufficient to make strong recommendations 6

Pitfalls to Avoid

• Failing to evaluate the deep venous system before treating superficial veins
• Overlooking pelvic origin for varicosities in posterior thigh, vulva, or inguinal regions 1
• Using compression therapy in patients with severe arterial disease (ABI <0.6) 1
• Relying solely on pharmacologic agents without addressing underlying venous hypertension 3
• Neglecting long-term compression therapy after interventional procedures 1

The management of chronic venous insufficiency requires a systematic approach starting with conservative measures and progressing to interventional treatments when necessary. Compression therapy remains the cornerstone of management, with endovenous procedures offering significant benefits for patients with persistent symptoms.