What are the symptoms and treatment options for venous insufficiency?

Symptoms and Treatment Options for Venous Insufficiency

Venous insufficiency presents with a spectrum of symptoms including pain, burning, itching, aching, heaviness, cramping, throbbing, restlessness, and swelling in the legs, which typically worsen at the end of the day after prolonged standing and improve with leg elevation. 1

Symptoms of Venous Insufficiency

Localized Symptoms

• Pain, burning, itching, and tingling at the site of varicose veins, which may be unilateral or bilateral 1
• Symptoms are often worse after prolonged standing and typically resolve with sitting and leg elevation 1
• Women report lower limb symptoms significantly more often than men 1

Generalized Symptoms

• Aching, heaviness, cramping, throbbing, restlessness, and swelling in the legs 1
• Symptom severity typically increases with advancing CEAP clinical class (clinical classification of venous disease) 1
• Symptoms may progress to more serious signs including skin pigmentation changes, eczema, infection, and venous ulceration 1

Advanced Signs of Venous Insufficiency

• Changes in skin pigmentation due to hemosiderin deposition 1
• Stasis dermatitis and eczema 1
• Superficial thrombophlebitis 1
• Venous ulceration, particularly around the ankle 1
• Lipodermatosclerosis (hardening of skin and subcutaneous tissues) 1

Risk Factors

• Family history of venous disease 1
• Female sex 1
• Older age 1
• Chronically increased intra-abdominal pressure (obesity, pregnancy, chronic constipation) 1
• Prolonged standing 1
• Previous deep venous thrombosis 1
• Arteriovenous shunting 1

Diagnosis

• Venous duplex ultrasonography is the diagnostic modality of choice when venous disease is severe or interventional therapy is being considered 1
• Ultrasound assesses both anatomy and physiology of the venous system, identifying incompetent valves and reflux 1
• The CEAP classification system provides a framework to characterize venous disease severity 1

Treatment Options

Conservative Management

• Compression therapy (bandages, support stockings, intermittent pneumatic compression devices) is the first-line treatment 1
• Compression stockings can provide symptomatic relief, though evidence for their effectiveness is limited 1
• Leg elevation helps reduce symptoms in many patients 1
• Lifestyle modifications:
  • Avoiding prolonged standing and straining 1
  • Regular exercise 1
  • Wearing non-restrictive clothing 1
  • Weight loss for obese patients 1

Pharmacological Options

• Phlebotonics (available as dietary supplements) may provide symptomatic relief 1
• Horse chestnut seed extract may help relieve symptoms, though long-term studies are lacking 1
• Diosmiplex, a flavonoid medical food product derived from oranges, is FDA-approved for management of CVI 2
• Pentoxifylline is indicated for intermittent claudication but not specifically for venous insufficiency 3

Interventional Treatments

• Endovenous thermal ablation (laser or radiofrequency) is the first-line interventional treatment for larger vessels with reflux 1

  • Occlusion rates range from 91-100% at 1-year post-treatment 4
  • Better tolerated than sclerotherapy and surgery, with fewer adverse effects 1

• Sclerotherapy:

  • Foam sclerotherapy shows occlusion rates of 72-89% at 1 year 4
  • Appropriate for tributary veins after main saphenous trunks have been addressed 4
  • Common side effects include phlebitis, new telangiectasias, and residual pigmentation 4

• External laser thermal ablation works best for telangiectasias (spider veins) 1

• Surgical options (less commonly used now):

  • Traditional surgical treatment has a five-year recurrence rate of 20-28% 5
  • Has largely been replaced by endovenous procedures 1

Treatment Algorithm

1. Begin with conservative measures (compression, elevation, lifestyle modifications) for all patients 1
2. For persistent symptoms with documented reflux:
   • For main saphenous trunks with reflux: endovenous thermal ablation 1
   • For tributary veins: sclerotherapy or ambulatory phlebectomy 5
   • For telangiectasias: external laser treatment 1

Important Considerations

• Treating only tributary veins without addressing saphenofemoral junction reflux can lead to higher recurrence rates 4
• Interventional treatment should be offered if valvular reflux is documented 1
• Patients with more severe manifestations should be referred to a vascular subspecialist 2
• Chronic venous insufficiency requires "chronic management" with ongoing compression therapy even after interventional procedures 6