What are the treatment options for chronic venous insufficiency?

Treatment Options for Chronic Venous Insufficiency

Compression therapy is the mainstay of treatment for chronic venous insufficiency, with a minimum pressure of 20-30 mm Hg recommended for most patients and 30-40 mm Hg advised for more severe disease. 1, 2

Diagnostic Approach

• Duplex ultrasound should be the first assessment for venous insufficiency, evaluating the deep venous system, great saphenous vein (GSV), small saphenous vein (SSV), and accessory saphenous veins 1, 2
• Ultrasound evaluation should document presence, absence, and location of reflux (defined as retrograde venous flow >500 ms) 1, 2
• The CEAP classification system (Clinical, Etiologic, Anatomic, Pathophysiologic) helps characterize the severity of venous disease, ranging from C0 (no visible signs) to C6 (active venous ulcers) 1, 3

Treatment Algorithm

First-Line: Conservative Management

• Compression Therapy:

  • Minimum pressure of 20-30 mm Hg for most patients; 30-40 mm Hg for more severe disease 1, 2
  • Negative graduated compression bandages (higher pressure at calf over distal ankle) show improved ejection fraction in refluxing vessels 1
  • Compression therapy reduces venous stasis by containing edema, increasing venous blood flow velocity, reducing pooling, and improving venous pumping function 1, 4

• Lifestyle Modifications:

  • Regular leg elevation to reduce edema 2, 5
  • Avoidance of prolonged standing or sitting 2, 5
  • Regular exercise to improve calf muscle pump function 1, 6
  • Weight loss for obese patients 2, 5

• Pharmacological Treatment:

  • Horse chestnut seed extract containing aescin has shown short-term improvement in signs and symptoms 2, 5
  • Pentoxifylline (400 mg three times daily) can be effective for venous ulcer healing, though it may cause gastrointestinal side effects 1

Second-Line: Interventional Treatments

• Endovenous Thermal Ablation:

  • First-line interventional treatment for saphenous vein reflux 2, 7
  • Includes radiofrequency ablation (RFA) and endovenous laser treatment (EVLT) 2, 7
  • High technical success rates (91-100% occlusion at 1 year) 2, 7
  • Fewer complications compared to surgery, including reduced rates of bleeding, hematoma, wound infection, and paresthesia 7

• Sclerotherapy:

  • Appropriate for smaller varicosities and telangiectasias 2, 8
  • Foam sclerotherapy has occlusion rates of 72-89% at 1 year 2, 8
  • Ultrasound-guided foam sclerotherapy (UGFS) is effective for treating saphenous insufficiency 9

• Surgical Options:

  • High ligation and stripping (HL/S) for saphenous insufficiency 9
  • Phlebectomy for removal of superficial varicose veins 1, 2
  • Neovalve reconstruction may be considered for refractory venous ulcers 1

Special Considerations

Venous Ulcer Management

• Compression therapy is the mainstay of treatment for venous ulcers 1, 2
• Maintain a moist environment to optimize wound healing 1
• Provide protective covering and control dermatitis 1
• Aggressively prevent and treat infection 1
• Consider pentoxifylline as adjunctive therapy for ulcer healing 1

Exercise for CVI

• Supervised exercise training program consisting of leg strength training and aerobic activity for at least 6 months is reasonable for patients who can tolerate it 1, 6
• Exercise may improve calf muscle function and ejection of venous blood from the limb 1, 6
• Exercise does not appear to aggravate leg symptoms after DVT or increase the risk of post-thrombotic syndrome 1

Common Pitfalls and Caveats

• Treatment failure with compression therapy often results from non-compliance 1
• Deep vein thrombosis occurs in approximately 0.3% of cases after endovenous ablation, and pulmonary embolism in 0.1% of cases 7
• Recurrence rates after intervention can be high (15-35% at 2 years post-intervention) 1
• Interventional treatment of co-existing incompetent perforator veins is not supported by contemporary evidence 9
• When using pharmacological treatments like pentoxifylline, monitor for gastrointestinal side effects 1

Treatment Based on Disease Severity

• Mild CVI (CEAP C1-C2): Compression therapy (20-30 mm Hg), lifestyle modifications, and consider pharmacological treatment 1, 2
• Moderate CVI (CEAP C3-C4): Compression therapy (30-40 mm Hg), consider endovenous thermal ablation or sclerotherapy for persistent symptoms 1, 2
• Severe CVI (CEAP C5-C6): Aggressive compression therapy, consider endovenous thermal ablation, and specialized wound care for ulcers 1, 2