What are the management options for Chronic Venous Insufficiency (CVI)?

Management of Chronic Venous Insufficiency

Compression therapy with graduated compression stockings (20-30 mmHg for mild disease, 30-40 mmHg for moderate-to-severe disease) is the cornerstone of CVI management and must be attempted for at least 3 months before considering any interventional procedures. 1

Initial Diagnostic Assessment

• Duplex ultrasound is the diagnostic standard for evaluating the deep venous system, greater saphenous vein, small saphenous vein, and accessory saphenous veins, documenting presence, absence, and location of reflux (reflux duration ≥500 milliseconds indicates pathologic reflux). 1, 2

• Document CEAP classification to categorize severity: C0 (no visible signs), C1 (telangiectasias/spider veins), C2 (varicose veins), C3 (edema), C4 (skin changes including pigmentation and lipodermatosclerosis), C5 (healed ulcer), C6 (active ulcer). 1

• Assess specific symptoms including pain, burning, itching, heaviness, cramping, throbbing, and swelling that typically worsen at day's end or after prolonged standing. 1

Conservative Management (First-Line for All Patients)

Compression Therapy

• Graduated compression stockings are mandatory initial treatment: 20-30 mmHg for CEAP C1-C3 disease, 30-40 mmHg for C4-C6 disease, worn daily for minimum 3 months before interventional therapy is considered. 1

• Compression should be continued for 2 years post-intervention, and beyond if post-thrombotic syndrome develops and patients find stockings helpful. 3

Lifestyle Modifications

• Elevate legs above heart level regularly throughout the day to reduce venous hypertension. 1

• Avoid prolonged standing or sitting (>30 minutes without movement) to prevent venous pooling. 1

• Regular calf muscle pump exercises (ankle flexion/extension, walking) to improve venous return. 1

• Weight loss if BMI >25 to reduce intra-abdominal pressure and venous hypertension. 1

• Avoid restrictive clothing around waist, groin, or legs that impedes venous return. 1

Pharmacologic Adjuncts

• Horse chestnut seed extract (containing aescin) may provide symptomatic relief, though long-term studies are limited and FDA approval is lacking. 1, 4

• Venoactive medications (rutosides, daflon, hidrosmin) are NOT recommended as primary therapy due to insufficient evidence. 3

Interventional Treatment Algorithm

For CEAP C2-C3 (Varicose Veins ± Edema)

Step 1: Endovenous Thermal Ablation (First-Line Intervention)

• Radiofrequency or laser ablation is the primary interventional treatment for saphenous vein reflux when vein diameter ≥4.5mm and reflux duration ≥500ms at saphenofemoral or saphenopopliteal junction. 1, 5, 2

• Technical success rates are 91-100% at 1-year follow-up, superior to all other modalities. 1, 2

• Thermal ablation has replaced surgery as standard of care due to equivalent efficacy with fewer complications (reduced bleeding, hematoma, wound infection, paresthesia), faster recovery, and improved early quality of life. 1, 2

• Nerve damage occurs in approximately 7% of cases (usually temporary) from thermal injury. 1, 2

• Deep vein thrombosis occurs in 0.3% and pulmonary embolism in 0.1% of cases. 2

Step 2: Sclerotherapy for Tributary Veins (Adjunctive Treatment)

• Foam sclerotherapy (polidocanol/Varithena) is appropriate for tributary veins ≥2.5mm diameter after treating main saphenous trunk reflux. 1, 5

• Occlusion rates are 72-89% at 1 year, significantly lower than thermal ablation. 1, 5

• Sclerotherapy alone has inferior long-term outcomes with higher recurrent reflux rates at 1,5, and 8-year follow-ups compared to thermal ablation. 1, 5

• Common side effects include phlebitis, new telangiectasias, and residual pigmentation; deep vein thrombosis is exceedingly rare. 1

Step 3: Surgical Options (Third-Line)

• Ligation and stripping or ambulatory phlebectomy are reserved for very large varicosities, failed thermal ablation, or when other methods are unavailable. 1

For CEAP C4-C6 (Skin Changes, Healed or Active Ulcers)

• More aggressive early intervention is warranted to prevent progression and promote ulcer healing. 1, 5

• Thermal ablation should NOT be delayed for compression trial in presence of ulceration (C5-C6), as evidence supports immediate definitive treatment. 5, 2

• Compression therapy remains essential alongside interventional treatment for wound healing. 1

• Appropriate wound care protocols must be implemented for active ulcers (C6). 6

For Severe Post-Thrombotic Syndrome

• Venoplastia and stent placement may be offered for central venous obstruction with severe symptoms, showing 55% ulcer healing rates but 2.6% procedure-related thrombosis risk. 1

• Surgical venous valve reconstruction can be considered for severe infrainguinal valve incompetence refractory to other treatments, though requires specialized expertise. 1

Critical Treatment Pitfalls to Avoid

• Never perform sclerotherapy alone for saphenofemoral junction reflux without addressing the junction with thermal ablation or ligation—this leads to high recurrence rates. 1, 5

• **Do not treat veins <2.5mm diameter** with sclerotherapy—patency rates are only 16% at 3 months versus 76% for veins >2.5mm. 5

• Avoid delaying intervention in C4-C6 disease for prolonged compression trials—early thermal ablation prevents progression. 1, 5

• Ensure ultrasound documentation is <6 months old before any interventional procedure to confirm current anatomy and reflux patterns. 5

• Refer to experienced vascular specialists when local expertise is unavailable—outcomes are highly operator-dependent. 1

Special Considerations

• Recurrence rates are 20-28% at 5 years even with appropriate treatment, necessitating long-term surveillance. 5

• Post-procedure compression is mandatory to optimize outcomes and reduce complications. 2

• Patient selection must account for surgical risk, clinical severity, specific venous anatomy, and life expectancy. 1