To whom should I refer a patient with chronic venous insufficiency (CVI) for evaluation and treatment?

Referral Options for Chronic Venous Insufficiency

Patients with chronic venous insufficiency should be referred to a vascular specialist, specifically a vascular surgeon or interventional radiologist who specializes in endovenous procedures, as these specialists can provide the recommended first-line treatments such as endovenous thermal ablation. 1

Appropriate Specialists for CVI Referral

• Vascular Surgeons: These specialists are trained to perform both endovenous procedures and traditional surgical interventions for CVI
• Interventional Radiologists: Experts in image-guided endovenous procedures such as radiofrequency ablation and ultrasound-guided foam sclerotherapy
• Phlebologists: Physicians specifically focused on venous disorders who may have backgrounds in various specialties but with additional training in venous disease management

When to Refer

Referral is appropriate when patients present with:

1. Symptomatic venous reflux confirmed by duplex ultrasound (retrograde flow >500 milliseconds) 1
2. Progressive symptoms despite conservative management
3. Advanced CEAP classification (C3-C6) including:
   • Edema
   • Skin changes
   • Active or healed venous ulcers
4. Significant impact on quality of life

Pre-Referral Workup

Before referral, consider obtaining:

• Duplex ultrasound to document venous reflux (the gold standard diagnostic test) 1
• Ankle-brachial index (ABI) for patients with suspected concurrent arterial disease 1
• Documentation of failed conservative measures (compression therapy, leg elevation)

Treatment Options Available Through Specialists

The vascular specialist can offer:

1. Endovenous thermal ablation (radiofrequency or laser) - recommended first-line treatment for saphenous vein reflux due to higher efficacy, lower complication rates, and faster recovery 1, 2

2. Ultrasound-guided foam sclerotherapy - effective for tributary veins and as adjunctive therapy 1

3. Microphlebectomy/Phlebectomy - for visible varicosities 1

4. Venous stenting - for deep venous insufficiency with femoroiliocaval occlusive disease 2

Important Considerations

• Patients with concomitant arterial disease require careful risk assessment before endovenous procedures 1
• Early follow-up ultrasound within 1-2 weeks post-procedure is recommended to confirm successful closure and rule out complications 1
• Compression therapy (30-40 mmHg) should be continued after procedures 1

Potential Pitfalls

• Failure to identify pelvic-origin varices can lead to incorrect treatment 1
• Overlooking underlying cardiac conditions may result in recurrent varices 1
• Deep vein thrombosis is a potential complication of radiofrequency ablation, reported in up to 16% of cases 1
• Combined procedures (RFA with stab phlebectomy) may increase risk of endovenous heat-induced thrombosis 1

By referring to the appropriate specialist, patients with CVI can access evidence-based treatments that have been shown to improve venous hemodynamics, promote healing of venous ulcers, and improve quality of life 3.