What are the treatment options for venous insufficiency?

Treatment Options for Venous Insufficiency

The most effective treatment approach for venous insufficiency follows a stepwise algorithm beginning with conservative management, followed by endovenous thermal ablation as first-line interventional therapy, then sclerotherapy as second-line treatment, with surgery reserved as a third-line option. 1

Diagnostic Assessment

• Venous duplex ultrasonography is the gold standard diagnostic test for venous insufficiency, evaluating the deep venous system, great saphenous vein, small saphenous vein, and accessory saphenous veins to document reflux (defined as retrograde venous flow >500 ms) 2
• Reflux is specifically defined as retrograde flow duration of >350 milliseconds in perforating veins, >500 milliseconds in superficial and deep calf veins, and >1,000 milliseconds in femoropopliteal veins 1
• Other imaging modalities such as CT, MRI, and venography are only needed when ultrasound is inconclusive or for complex surgical planning 2

Treatment Algorithm

First-Line: Conservative Management

• Compression therapy is the cornerstone of conservative management, with recommended pressure of 20-30 mm Hg for most patients and 30-40 mm Hg for more severe disease 2
• Lifestyle modifications that should be implemented include leg elevation, avoidance of prolonged standing, regular exercise, weight loss, and wearing non-restrictive clothing 2
• For venous ulcers, compression therapy remains the mainstay of treatment, with multilayer compression showing progressive benefit for ulcer management 2
• A documented trial of conservative management for at least 3 months is typically required before proceeding to interventional treatments 1

Second-Line: Endovenous Thermal Ablation

• Endovenous thermal ablation (radiofrequency or laser) is the recommended first-line interventional treatment for symptomatic varicose veins with documented valvular reflux, particularly for the great saphenous vein 3, 1
• For thermal ablation to be medically indicated, the great saphenous vein diameter should be at least 4.5mm with documented reflux 1
• This procedure has largely replaced surgical ligation and stripping due to similar efficacy with fewer complications, including reduced rates of bleeding, hematoma, wound infection, and paresthesia 3
• Technical success rates range from 91-100% at 1-year post-treatment, significantly better than other interventions 3

Third-Line: Sclerotherapy

• Foam sclerotherapy (including Varithena/polidocanol) is indicated for small to medium-sized varicose veins, as adjunctive therapy after thermal ablation, or for recurrent varicose veins 1
• For sclerotherapy to be considered medically necessary, veins should be at least 2.5mm in diameter with documented reflux 3
• Occlusion rates with foam sclerotherapy range from 72% to 89% at 1 year, which is lower than thermal ablation 3, 1
• Chemical sclerotherapy alone has worse outcomes at 1-, 5-, and 8-year follow-ups compared to thermal ablation or surgery 3

Fourth-Line: Surgical Options

• Surgical options including ligation and stripping or phlebectomy are typically limited to removal of superficial axial veins from groin to knee 2
• Modern surgical techniques use small incisions to reduce scarring, blood loss, and complications 2
• Traditional surgical treatment has a five-year recurrence rate of 20% to 28%, highlighting the importance of proper treatment sequencing 3
• Microphlebectomy is an appropriate complementary procedure to treat varicose tributary veins when other methods are insufficient 3

Special Considerations

• Patients with venous ulcers may benefit from immediate intervention without waiting for a trial of compression therapy 1
• For post-thrombotic syndrome, compression therapy should be worn for 2 years, with consideration of intermittent compression devices for severe cases 2
• Horse chestnut seed extract may provide symptomatic relief, though long-term studies are lacking 2
• The presence of recurrent superficial thrombophlebitis is a qualifying condition for immediate intervention 1

Potential Complications

• Deep vein thrombosis occurs in approximately 0.3% of cases after endovenous ablation, and pulmonary embolism in 0.1% of cases 3
• Thermal ablation carries a potential risk of approximately 7% surrounding nerve damage 1
• Common side effects of foam sclerotherapy include phlebitis, new telangiectasias, and residual pigmentation 3

By following this evidence-based treatment algorithm, clinicians can effectively manage venous insufficiency while minimizing complications and recurrence rates.