What is the treatment for venous insufficiency?

Treatment of Venous Insufficiency

Endovenous thermal ablation (radiofrequency or laser) is the recommended first-line treatment for saphenous vein reflux due to its higher efficacy, lower complication rates, faster recovery times, and better patient outcomes. 1

Diagnosis

Before initiating treatment, proper diagnosis is essential:

• Duplex ultrasound is the gold standard for evaluating venous reflux, with diagnostic criteria including valve closure times exceeding 500 milliseconds 1
• Complete duplex ultrasound (CDUS) should include compression of deep veins from the inguinal ligament to the ankle 1
• For suspected pelvic origin varicose veins, pelvic duplex ultrasound is necessary (diagnostic criteria: dilated tortuous pelvic vein >4 mm, slow/reversed blood flow) 1

Treatment Algorithm

First-line Treatments

1. Compression Therapy

   • Graduated compression stockings (30-40 mmHg) are the foundation of medical management 1, 2
   • Progressive compression stockings (10 mmHg at ankle, 23 mmHg at upper calf) have shown superior efficacy compared to traditional degressive stockings (70.0% vs 59.6% success rate) and are easier to apply 3
   • Should be continued even after procedural interventions 1

2. Lifestyle Modifications

   • Weight management
   • Regular exercise
   • Leg elevation
   • Avoiding restrictive clothing 1

Interventional Treatments (for symptomatic or drug-resistant cases)

1. Endovenous Thermal Ablation

   • First-line procedural treatment with 87-95% success rates 1
   • Options include radiofrequency ablation (RFA) or laser ablation
   • Indicated for symptomatic varicose veins that are drug-resistant or drug-intolerant 1

2. Adjunctive Treatments

   • Ultrasound-guided foam sclerotherapy for tributary veins and varicosities 1
   • Microphlebectomy or phlebectomy for visible varicosities 1
   • These can be performed in combination with endovenous ablation for comprehensive treatment

Medical Therapy

• Pharmacologic agents (diuretics, topical steroids) may provide short-term symptom relief but offer no long-term advantage 4
• Herbal supplements like horse chestnut seed extract containing aescin have shown short-term improvement in signs and symptoms 4
• For patients with concurrent DVT, anticoagulation therapy should be initiated based on the extent and location of thrombosis 1

Special Considerations

Wound Care for Venous Ulcers

• Surgical debridement to convert chronic wounds to acute wounds
• Topical dressings to maintain a moist, warm wound environment 1
• Compression therapy is essential for ulcer healing

Follow-up Protocol

• Early follow-up ultrasound within 1-2 weeks after interventional procedures to confirm successful closure and rule out complications like endovenous heat-induced thrombosis (EHIT) 1
• Regular follow-up to monitor disease progression and adjust treatment plans

Potential Complications and Pitfalls

• Deep vein thrombosis is a potential complication of radiofrequency ablation, reported in up to 16% of cases 1

• Risk factors for more rapid progression include:

  • Positive D-dimer
  • Extensive thrombosis (>5 cm in length)
  • Multiple vein involvement
  • Larger vein diameter (>7 mm)
  • Active cancer
  • History of venous thromboembolism 1

• Common pitfall: Inadequate compression therapy due to poor patient compliance or improper stocking fit. Ensure proper sizing and consider progressive compression stockings which are easier to apply 3

• Caution: Don't focus solely on visible varicosities while missing underlying saphenous reflux, which requires treatment to prevent recurrence 1, 5