What is the treatment for chronic venous insufficiency (CVI)?

Treatment for Chronic Venous Insufficiency

The first-line treatment for chronic venous insufficiency (CVI) is compression therapy with graduated compression stockings (30-40 mmHg), combined with endovenous thermal ablation (radiofrequency or laser) for patients with saphenous vein reflux. 1

Diagnostic Approach

Before initiating treatment, proper diagnosis is essential:

• Gold standard diagnostic test: Duplex ultrasound to evaluate venous reflux

  • Diagnostic criteria: Valve closure times exceeding 500 milliseconds 1
  • Retrograde venous flow exceeding 500 milliseconds 1

• Additional evaluation:

  • Document ankle-brachial index (ABI) prior to intervention, especially in patients with suspected arterial disease 1
  • Pelvic duplex ultrasound for suspected pelvic origin varicose veins 1

Treatment Algorithm

1. Conservative Management

• Compression therapy:

  • Graduated compression stockings (30-40 mmHg) 1, 2
  • Compression therapy has been shown to effectively reduce venous hypertension and retard the development of inflammation and pathologic skin changes 3
  • Studies show that even 10-20 mmHg compression is effective compared to no treatment, with no additional benefit from higher pressure in many cases 2

• Lifestyle modifications:

  • Weight management
  • Regular exercise
  • Leg elevation
  • Avoiding restrictive clothing 1
  • These modifications help reduce symptoms and slow disease progression

2. Interventional Treatment for Saphenous Vein Reflux

• First-line interventional treatment: Endovenous thermal ablation (radiofrequency or laser)

  • Higher efficacy, lower complication rates, faster recovery times, and better patient outcomes compared to traditional surgical approaches 1
  • Target segments with documented reflux exceeding 500ms during treatment 1

• Adjunctive treatments:

  • Ultrasound-guided foam sclerotherapy for tributary veins and varicosities 1
  • Microphlebectomy or phlebectomy for visible varicosities 1
  • These can be performed during the same procedure as endovenous ablation

3. Deep Venous Insufficiency Management

• For symptomatic femoroiliocaval occlusive venous disease refractory to conservative treatment, percutaneous transluminal venoplasty stenting has shown encouraging results 4

4. Post-Procedure Care

• Early follow-up ultrasound within 1-2 weeks to confirm successful closure and rule out complications 1
• Continue compression therapy with 30-40 mmHg thigh-high compression stockings 1
• Regular follow-up to monitor disease progression and adjust treatment plans 1

Pharmacological Options

• Pharmacological agents can provide symptomatic relief and should be considered as part of conservative treatment 4
• Herbal supplements like horse chestnut seed extract containing aescin have shown short-term improvement in signs and symptoms of CVI in several randomized controlled trials 3
• Diuretics and topical steroid creams may reduce swelling and pain short-term but offer no long-term treatment advantage 3

Potential Complications and Pitfalls

• Deep vein thrombosis is a potential complication of radiofrequency ablation, reported in up to 16% of cases in some studies 1
• Combined radiofrequency ablation with stab phlebectomy may increase the risk of endovenous heat-induced thrombosis (EHIT) 1
• Misdiagnosis of pelvic-origin varices can lead to incorrect treatment 1
• Failure to identify underlying causes such as undiagnosed cardiac conditions can result in recurrent varices 1
• Inappropriate stent placement or inadequate stent sizing can lead to undesirable outcomes 1

Special Considerations

• Chronic venous disease is the leading etiology of leg ulcers, which are associated with poor quality of life 5
• Risk factors include age, female gender, positive family history, pregnancy, obesity, prolonged standing, and history of deep vein thrombosis 5
• CVI affects up to 45% of the general population, with clinical manifestations ranging from telangiectasias to venous leg ulcers 4