What are the management options for venous insufficiency?

Management of Venous Insufficiency

Initial Conservative Management (Mandatory First-Line)

Graduated compression stockings are the mandatory initial treatment for all patients with venous insufficiency before considering any interventional therapy. 1

Compression Therapy Protocol

• 20-30 mmHg compression stockings for CEAP C1-C3 disease (telangiectasias, varicose veins, edema without skin changes) 1
• 30-40 mmHg compression stockings for CEAP C4-C6 disease (skin changes, healed ulcers, active ulcers) 1
• Minimum 3-month trial required before interventional therapy is considered, except in patients with active ulceration (C6 disease) where intervention need not be delayed 1, 2
• Continue compression for 2 years post-intervention, and indefinitely if post-thrombotic syndrome develops 1

Additional Conservative Measures

• 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

Diagnostic Assessment Before Intervention

Duplex ultrasound is the diagnostic standard and must be performed within 6 months before any interventional procedure. 1, 2

Required Ultrasound Documentation

• Reflux duration ≥500 milliseconds at saphenofemoral or saphenopopliteal junction indicates pathologic reflux requiring treatment 1, 2
• Vein diameter measurements at specific anatomic landmarks (≥4.5mm for thermal ablation, ≥2.5mm for sclerotherapy) 1, 3
• Assessment of deep venous system patency to exclude deep vein thrombosis 1
• CEAP classification documentation: C0 (no visible signs), C1 (spider veins), C2 (varicose veins), C3 (edema), C4 (skin changes including pigmentation/lipodermatosclerosis), C5 (healed ulcer), C6 (active ulcer) 1

Interventional Treatment Algorithm

First-Line Intervention: Endovenous Thermal Ablation

Radiofrequency or laser ablation is the primary interventional treatment for saphenous vein reflux and has replaced surgery as standard of care. 1

Indications for Thermal Ablation

• Saphenous vein diameter ≥4.5mm 1, 3
• Reflux duration ≥500ms at saphenofemoral or saphenopopliteal junction 1, 3
• Persistent symptoms despite 3-month compression trial (except C6 disease with active ulceration where delay is not warranted) 1, 2

Efficacy and Outcomes

• Technical success rates 91-100% at 1-year follow-up, superior to all other modalities 1, 2
• Equivalent efficacy to surgery with fewer complications, faster recovery, and improved early quality of life 1, 2
• Recurrence rates 20-28% at 5 years even with appropriate treatment, necessitating long-term surveillance 1

Complications

• Nerve damage occurs in approximately 7% of cases (usually temporary) from thermal injury 1, 2
• Deep vein thrombosis in 0.3% and pulmonary embolism in 0.1% of cases 1, 2

Second-Line Intervention: Foam Sclerotherapy

Foam sclerotherapy (polidocanol/Varithena) is appropriate for tributary veins ≥2.5mm diameter after treating main saphenous trunk reflux. 1, 3

Indications and Limitations

• Occlusion rates 72-89% at 1 year, significantly lower than thermal ablation 1, 3
• Should NOT be used alone for saphenofemoral junction reflux—must address junction with thermal ablation or ligation first 1
• **Veins <2.5mm diameter have only 16% patency at 3 months** versus 76% for veins >2.5mm 1, 3

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 inferior long-term outcomes with higher recurrent reflux rates at 1,5, and 8-year follow-ups. 1

**Do not treat veins <2.5mm diameter with sclerotherapy**—patency rates are only 16% at 3 months versus 76% for veins >2.5mm. 1

Avoid delaying intervention in C4-C6 disease for prolonged compression trials—early thermal ablation prevents progression and promotes ulcer healing. 1

Ensure ultrasound documentation is <6 months old before any interventional procedure to confirm current anatomy and reflux patterns. 1

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

Special Considerations for Advanced Disease

Iliocaval Obstruction (Post-Thrombotic Syndrome)

Endovenous stenting for iliofemoral venous obstruction achieves ulcer healing in 55% of cases with significant improvement in quality of life. 4

• Procedure-related thrombosis occurs in 2.6% of cases 4
• Appropriate for patients with moderate or severe symptoms after conservative management failure 4
• IVUS is the primary modality for evaluating lesion severity and planning stent placement 4

Nonthrombotic Iliac Vein Lesions

Patient selection based on symptoms is critical, as anatomic compression occurs in up to 70% of asymptomatic patients. 4

• Stent placement in appropriately selected patients improves pain, swelling, quality of life, and promotes ulcer healing 4
• Inappropriate stent placement or sizing results in lack of symptom improvement 4

Post-Procedure Management

Post-procedure compression is mandatory to optimize outcomes and reduce complications. 1, 2

Early postoperative duplex scans (2-7 days) are mandatory to detect endovenous heat-induced thrombosis. 2