What is the treatment and work-up for chronic venous insufficiency (CVI)?

Treatment and Work-up for Chronic Venous Insufficiency (CVI)

The gold standard for diagnosing chronic venous insufficiency is duplex ultrasound, and endovenous thermal ablation (radiofrequency or laser) is the recommended first-line treatment for saphenous vein reflux due to its higher efficacy and better patient outcomes. 1

Diagnostic Work-up

Initial Assessment

• Evaluate for clinical manifestations according to CEAP classification:
  • C0: No visible signs
  • C1: Telangiectasias or reticular veins
  • C2: Varicose veins
  • C3: Edema
  • C4: Skin changes (pigmentation, eczema)
  • C5: Healed ulcer
  • C6: Active ulcer

Diagnostic Testing

1. Duplex Ultrasound (gold standard) 1, 2

   • Diagnostic criteria: valve closure times >500 milliseconds
   • Evaluates venous reflux, vein dilation, and obstruction
   • Examines both superficial and deep venous systems

2. Pelvic Duplex Ultrasound (when pelvic origin suspected) 1

   • Diagnostic criteria:
     • Dilated tortuous pelvic vein >4 mm
     • Slow/reversed blood flow
     • Dilated arcuate vein in myometrium communicating with pelvic varicosities

3. Advanced Imaging (in selected cases) 3

   • CT scan or MR Venography for:
     • Complex cases
     • Suspected iliac vein compression
     • Planning for invasive interventions

Treatment Algorithm

1. Conservative Management

• Compression Therapy (first-line treatment) 1

  • Graduated compression stockings (30-40 mmHg)
  • Should be worn daily during waking hours
  • Particularly important after acute DVT has resolved

• Lifestyle Modifications 1

  • Weight management
  • Regular exercise
  • Leg elevation when sitting or lying
  • Avoiding restrictive clothing
  • Regular walking to activate calf muscle pump

2. Pharmacologic Therapy

• Micronized Purified Flavonoid Fraction (MPFF) 3
  • Helps relieve symptoms and prevent morbidity
  • Reduces inflammatory response to venous hypertension

3. Interventional Procedures (for persistent symptoms or complications)

• Endovenous Thermal Ablation (first-line for saphenous reflux) 1

  • Radiofrequency or laser ablation
  • Higher efficacy, lower complication rates, faster recovery compared to surgery

• Ultrasound-Guided Foam Sclerotherapy 1

  • Adjunctive treatment for tributary veins and varicosities
  • Can be combined with thermal ablation for better outcomes

• Microphlebectomy 1

  • For visible varicosities
  • Often performed in conjunction with other procedures

• Reconstructive Deep Venous Surgery 4

  • Reserved for severe cases where conservative measures have failed
  • Reported ulcer healing in 60-78% of cases
  • Clinical improvement in up to 90% of patients

4. Post-Procedure Care

• Early Follow-up Ultrasound (within 1-2 weeks) 1

  • Confirms successful closure
  • Rules out complications like endovenous heat-induced thrombosis (EHIT)

• Continued Compression Therapy 1

  • 30-40 mmHg thigh-high compression stockings
  • Maintains treatment benefits and prevents recurrence

Important Considerations and Pitfalls

Potential Complications

• Deep Vein Thrombosis 1

  • Reported in up to 16% of radiofrequency ablation cases
  • Risk factors: positive D-dimer, extensive thrombosis >5 cm, multiple vein involvement, larger vein diameter >7 mm

• Endovenous Heat-Induced Thrombosis (EHIT) 1

  • Higher risk when combining RFA with stab phlebectomy
  • Requires early post-procedure ultrasound for detection

Treatment Selection Considerations

• Primary (congenital, familial) CVI may have better long-term outcomes after surgery than secondary (post-thrombotic) CVI 4
• Patients with deep venous insufficiency are more challenging to treat than those with only superficial venous insufficiency 5
• Regular follow-up is essential to monitor disease progression and adjust treatment plans 1

Common Pitfalls

• Focusing only on visible varicosities without addressing underlying venous reflux
• Inadequate compression therapy (incorrect pressure gradient or inconsistent use)
• Failure to identify and address pelvic sources of venous reflux
• Not providing adequate post-procedure follow-up to detect complications