What is the treatment for chronic venous insufficiency?

Treatment of Chronic Venous Insufficiency

Compression therapy is the first-line treatment for chronic venous insufficiency (CVI), with a minimum pressure of 20-30 mmHg recommended for most patients and 30-40 mmHg for more severe disease. 1, 2

Diagnostic Approach

• Duplex ultrasound should be the first assessment for evaluating the venous system, documenting presence, location, and extent of reflux (defined as retrograde venous flow >500 ms) 1, 2
• The CEAP (Clinical, Etiologic, Anatomic, Pathophysiologic) classification system helps categorize disease severity from C0 (no visible signs) to C6 (active venous ulcers) 1

Treatment Algorithm

Conservative Management

• Compression Therapy:

  • Use 20-30 mmHg pressure for mild to moderate disease 1, 2
  • Increase to 30-40 mmHg for more severe disease 1, 2
  • Negative graduated compression bandages (higher pressure at calf than ankle) show improved ejection fraction in refluxing vessels 1
  • For venous ulcers (C5-C6), compression therapy has proven value in healing ulcers and preventing recurrence 1

• Lifestyle Modifications:

  • Leg elevation to reduce venous stasis 2, 3
  • Regular exercise and weight loss to improve venous return 2, 3
  • Avoiding prolonged standing or sitting 2, 3
  • Wearing non-restrictive clothing 2, 3

• Pharmacological Options:

  • Horse chestnut seed extract containing aescin may provide symptomatic relief 2, 4
  • Pentoxifylline (400 mg three times daily) may improve ulcer healing when added to compression therapy 3

Interventional Treatments

• Endovenous Thermal Ablation:

  • Preferred first-line treatment for saphenous vein incompetence 2, 3
  • Includes laser or radiofrequency ablation techniques 2, 3
  • Shows fewer adverse effects compared to traditional surgery 2

• Sclerotherapy:

  • Effective for smaller varicosities and telangiectasias 2, 5
  • Uses agents such as hypertonic saline, sodium tetradecyl, or polidocanol 2, 5

• Surgical Options:

  • No longer considered first-line treatment 3, 5
  • Limited to removal of superficial axial veins from groin to knee 2
  • Modern techniques use small incisions to reduce scarring and complications 2

• Endovascular Stenting:

  • Beneficial for iliocaval obstruction or post-thrombotic syndrome 1, 3
  • Improves symptomatology and quality of life compared to medical treatment alone 1

Special Considerations

Post-Thrombotic Syndrome

• Compression therapy should be worn for 2 years 2
• Supervised exercise training with leg strength training and aerobic activity for at least 6 months 3
• For severe cases, endovascular stenting may be beneficial 1, 3

Venous Ulcers (C5-C6)

• Multilayer compression is the mainstay of treatment 2, 1
• 30-40 mmHg inelastic compression is better than elastic bandaging for wound healing 1
• For ankle-brachial indices between 0.9 to 0.6, reduced compression to 20-30 mmHg is safe and effective 1, 6

Coexisting Peripheral Arterial Disease

• Special compression stockings (German compression class 1 with high stiffness) may be safe for patients with ankle-brachial index ≥0.5 6
• Caution is advised when ankle-brachial index is <0.6, as arterial revascularization may be needed 1

Treatment Pitfalls to Avoid

• Relying solely on compression therapy without addressing underlying venous reflux 3, 5
• Overlooking the need for regular follow-up, as recurrence rates 2 years post-intervention can be 15-35% 1, 3
• Failing to evaluate for iliac vein compression in patients with left-sided symptoms 3
• Using traditional surgical approaches as first-line when less invasive endovenous techniques would be more appropriate 3, 5