What are the consequences and treatment options for untreated venous reflux?

Consequences and Treatment Options for Untreated Venous Reflux

Untreated venous reflux can lead to progressive venous disease with complications including pain, edema, skin changes, and venous ulceration, significantly impacting quality of life and requiring intervention ranging from conservative management to endovascular procedures.

Pathophysiology of Venous Reflux

• Venous reflux occurs when valvular dysfunction causes blood to flow in the reverse direction, typically due to loss of elasticity in the vein wall and failure of valve leaflets to properly close 1
• The resulting venous hypertension causes veins to become elongated and tortuous, with shear stress on venous endothelial cells and inflammation contributing to disease progression 1
• Ambulatory venous hypertension is the central mechanism in venous reflux disorders, occurring through outflow obstruction, valvular incompetence, or both 1

Clinical Manifestations and Complications

• Early symptoms include localized pain, burning, itching, and tingling at varicose vein sites, along with generalized aching, heaviness, cramping, and swelling that worsen with prolonged standing 1
• If left untreated, venous reflux can progress to more severe complications:
  • Skin changes including hyperpigmentation, eczema, and lipodermatosclerosis 1
  • Superficial thrombophlebitis and infection 1
  • Venous ulceration, which occurs in up to 5% of patients within 10 years 1
  • Rare but significant external hemorrhage from perforation of varicose veins 1
  • Venous claudication in cases with major venous confluence obstruction 1

Diagnosis of Venous Reflux

• Venous duplex ultrasonography is the modality of choice for diagnosing venous reflux, particularly when interventional therapy is being considered 1
• Reflux is defined as retrograde venous flow lasting >500 milliseconds, typically measured while standing or with provocative maneuvers 1
• The CEAP classification system provides a framework to characterize venous disease severity, with clinical classes ranging from C0 (no visible signs) to C6 (active venous ulcers) 1

Treatment Options

Conservative Management

• Compression therapy is the cornerstone of treatment for venous reflux and its complications 1, 2:
  • Compression stockings (20-30 mmHg for mild disease, 30-40 mmHg for more severe cases) 1
  • Multilayer compression bandages for venous ulcers 1
  • Intermittent pneumatic compression devices 1
• Elevation of the affected leg to reduce venous pressure and improve symptoms 1
• Lifestyle modifications including weight loss, exercise, avoiding prolonged standing, and wearing non-restrictive clothing 1

Interventional Treatments

• Endovenous thermal ablation (radiofrequency or laser) is the first-line interventional treatment for symptomatic varicose veins with documented reflux 1, 3, 4:
  • High technical success rates (91-100% at 1 year) 4
  • Can be performed under local anesthesia with same-day discharge 4
  • Lower complication rates compared to surgery 4
• Foam sclerotherapy (including Varithena) is effective for smaller veins and as an adjunct to primary treatment 3:
  • Occlusion rates of 72-89% at 1 year 3
  • Less effective than thermal ablation for long-term outcomes 3
• Surgical options (less commonly used as primary treatment):
  • Saphenopopliteal or saphenotibial bypass for occluded femoral or popliteal segments 1
  • Femoro-femoral bypass for unilateral iliac vein obstruction 1
  • Segmental vein valve transfer for correction of reflux 1

Treatment Algorithm Based on Disease Severity

• For asymptomatic or mildly symptomatic patients (CEAP C0-C1):
  • Observation and lifestyle modifications 1
• For symptomatic varicose veins without skin changes (CEAP C2-C3):
  • Trial of compression therapy and lifestyle modifications 1
  • If symptoms persist, proceed to endovenous thermal ablation for veins ≥4.5mm 3, 4
  • Foam sclerotherapy for smaller tributary veins 3
• For advanced disease with skin changes or ulceration (CEAP C4-C6):
  • Aggressive compression therapy 1
  • Endovenous thermal ablation of incompetent saphenous veins 3, 4
  • Consider surgical or endovascular procedures for venous obstruction 1
  • Multilayer compression for active ulcers 1

Important Clinical Considerations

• Early intervention for symptomatic venous reflux may prevent progression to more severe disease stages 1, 5
• Endovenous thermal ablation need not be delayed for a trial of external compression when symptoms are present 3
• Treatment of the saphenofemoral junction with thermal ablation provides better long-term outcomes than foam sclerotherapy alone 3
• Patients with postthrombotic syndrome may have both reflux and obstruction, requiring a comprehensive treatment approach 1
• Regular follow-up is essential as recurrence rates can be high (15-35% at 2 years) even after intervention 1