What are the treatment options for venous insufficiency?

Treatment Options for Venous Insufficiency

Compression therapy is the first-line treatment for venous insufficiency, with a minimum pressure of 20-30 mm Hg recommended for most patients and 30-40 mm Hg for more severe disease. 1

Diagnostic Approach

• Duplex ultrasound is the recommended initial assessment for venous insufficiency, evaluating the deep venous system, great saphenous vein (GSV), small saphenous vein (SSV), and accessory saphenous veins 1
• Ultrasound should document presence, absence, and location of reflux, with reflux defined as retrograde venous flow >500 ms 1
• Other imaging modalities (CT, MRI, venography) are reserved for cases where ultrasound is inconclusive or for complex surgical planning 1

Treatment Algorithm

Conservative Management

• Compression therapy:

  • 20-30 mm Hg pressure for mild to moderate disease 1
  • 30-40 mm Hg pressure for severe disease 1
  • Negative graduated compression bandages (higher pressure at calf than ankle) show improved ejection fraction in refluxing vessels 1
  • Should be worn for 2 years in patients with post-thrombotic syndrome 1
  • Despite recommendations, patient compliance with compression therapy is often poor (only 21% of patients use them daily) 2

• Lifestyle modifications:

  • Leg elevation to reduce venous stasis 1
  • Avoidance of prolonged standing and straining 1
  • Regular exercise to improve calf muscle pump function 1
  • Weight loss in patients who are obese 1
  • Wearing non-restrictive clothing 1

• Pharmacologic options:

  • Horse chestnut seed extract may provide symptomatic relief, though long-term studies are lacking 1
  • Venoactive medications (rutosides, defibrotide, hidrosmin) are not recommended for post-thrombotic syndrome 1

Interventional Treatments

When conservative measures fail to provide adequate symptom relief, the following interventional options should be considered:

• Thermal ablation:

  • External laser thermal ablation for telangiectasias (spider veins) 1
  • Endovenous thermal ablation (using laser or radiofrequency) for larger vessels including the greater saphenous vein 1
  • May be better tolerated than sclerotherapy and surgery, with fewer adverse effects 1

• Endovenous sclerotherapy:

  • Uses agents such as hypertonic saline, sodium tetradecyl, or polidocanol 1
  • Effective for smaller varicosities and telangiectasias 1

• Surgical options:

  • Ligation and stripping or phlebectomy with multiple small incisions 1
  • Updated surgical techniques use small incisions to reduce scarring, blood loss, and complications 1
  • Typically limited to removal of superficial axial veins from groin to knee 1
  • For severe cases with venous ulcers refractory to other treatments, neovalve reconstruction may be considered 1

• Novel therapies:

  • Bioprosthetic venous valves (VenoValve) show promise for severe chronic venous insufficiency with significant improvements in reflux times (61%), disease severity (56%), and pain (87%) at 2-year follow-up 3

Special Considerations

• For venous ulcers:

  • Compression therapy remains the mainstay of treatment 1
  • Multilayer compression has shown progressive benefit for ulcer management 1
  • A supervised exercise training program consisting of leg strength training and aerobic activity for at least 6 months is reasonable for patients with post-thrombotic syndrome who can tolerate it 1

• For post-thrombotic syndrome:

  • Compression stockings are recommended for acute symptomatic DVT of the leg 1
  • For severe post-thrombotic syndrome not adequately relieved by compression stockings, a trial of an intermittent compression device is suggested 1

Common Pitfalls and Caveats

• Despite being widely recommended, there is insufficient evidence to determine if compression stockings are effective in the treatment of varicose veins without active or healed venous ulcers 1
• Patient compliance with compression therapy is a major challenge, with only about one-third of patients using stockings as prescribed 2
• Referral for interventional treatment should not be delayed for a trial of external compression if valvular reflux is documented, though insurance companies may require it 1
• Symptoms may persist in about one-third of patients despite apparent compliance with prescribed stockings 2
• Endovascular and surgical treatments should be considered for patients with moderate to severe post-thrombotic syndrome, particularly when there is iliac vein obstruction 1