What are the management options for venous insufficiency?

Management of Venous Insufficiency

The management of venous insufficiency should prioritize minimally invasive endovenous techniques over traditional surgery, with compression therapy used primarily as an adjunctive treatment rather than first-line therapy. 1

Diagnostic Approach

• Duplex ultrasonography is the gold standard for diagnosis of venous insufficiency, allowing assessment of incompetent saphenous junctions, reflux extent, perforator vein incompetence, and evaluation for deep vein thrombosis 1
• Reflux is defined as retrograde flow duration >350 milliseconds in perforating veins, >500 milliseconds in superficial and deep calf veins, and >1,000 milliseconds in femoropopliteal veins 1
• The CEAP (Clinical, Etiologic, Anatomic, Pathophysiologic) classification system should be used to categorize disease severity, though it does not provide guidance for treatment decisions 1

Conservative Management

Compression Therapy

• Compression is no longer recommended as initial therapy for varicose veins except in pregnant women or when interventional treatments are ineffective 1
• When used, compression stockings should provide 20-30 mmHg pressure with gradient decreasing from distal to proximal extremity 1
• Progressive compression stockings (maximal pressure at calf rather than ankle) may be more effective than traditional degressive stockings for symptom improvement 2

Lifestyle Modifications

• Recommend avoidance of prolonged standing/straining, regular exercise, wearing non-restrictive clothing, and weight loss 1
• Elevating the affected leg can help reduce symptoms 1
• These measures are particularly important for patients who are not candidates for interventional management, do not desire intervention, or are pregnant 1

Interventional Management

Thermal Ablation

• Endovenous thermal ablation (laser or radiofrequency) is preferred for larger vessels including the greater saphenous vein 1
• External laser thermal ablation works best for telangiectasias (spider veins) 1
• These techniques have largely replaced traditional surgical approaches due to better outcomes and fewer complications 1

Sclerotherapy

• Endovenous sclerotherapy uses agents like hypertonic saline, sodium tetradecyl (Sotradecol), or polidocanol (Varithena) to treat varicose veins 1
• Particularly useful for smaller veins and as adjunctive therapy after other interventions 1

Surgical Options

• Traditional surgery (ligation and stripping or phlebectomy) is no longer considered first-line treatment 1
• Modern surgical techniques use small incisions to reduce scarring and blood loss, limiting removal to superficial axial veins from groin to knee 1
• Surgery may be considered when endovenous techniques are not feasible or have failed 1

Special Considerations

Venous Ulcers

• Compression therapy remains the mainstay of treatment for venous ulcers 1
• Pentoxifylline (400 mg three times daily) may improve ulcer healing when added to compression therapy 1
• Maintain moist wound environment, provide protective covering, control dermatitis, and aggressively prevent/treat infection 1

Post-Thrombotic Syndrome (PTS)

• Supervised exercise training program with leg strength training and aerobic activity for at least 6 months is recommended for patients with PTS 1
• For severe PTS with iliac vein obstruction, endovascular intervention with stenting may be beneficial 1

Iliac Vein Compression (May-Thurner Syndrome)

• Nonthrombotic iliac vein lesions may require stent placement in appropriately selected patients with moderate to severe symptoms 1
• Intravascular ultrasound (IVUS) is the primary modality for evaluating lesion severity and guiding intervention 1

Treatment Algorithm

1. Initial Assessment: Duplex ultrasound to determine pattern and extent of venous insufficiency
2. Mild Symptoms (CEAP C1-C2):
   • Trial of lifestyle modifications
   • Consider compression stockings (20-30 mmHg) if symptomatic relief needed
3. Moderate Symptoms (CEAP C3-C4):
   • Endovenous thermal ablation for saphenous vein incompetence
   • Sclerotherapy for tributary varicosities
   • Adjunctive compression therapy
4. Severe Symptoms (CEAP C5-C6):
   • Aggressive compression therapy for ulcer management
   • Endovenous ablation of incompetent veins
   • Consider iliac vein stenting if obstruction present
   • Pentoxifylline for venous ulcers

Treatment Pitfalls to Avoid

• Relying solely on compression therapy for primary treatment of varicose veins without addressing underlying venous reflux 1
• Failing to evaluate for iliac vein compression in patients with left-sided symptoms, especially in young, otherwise healthy patients 1
• Overlooking the need for regular follow-up as recurrence rates 2 years post-intervention can be 15-35% 1
• Using traditional surgical approaches as first-line when less invasive endovenous techniques would be more appropriate 1