What are the differences in management and treatment between arterial and venous insufficiency?

Arterial vs Venous Insufficiency: Management and Treatment Differences

Critical Distinction in Management Priority

Arterial disease is considered more significant than venous disease and requires urgent intervention to prevent limb loss, while venous insufficiency management focuses on preventing progression and promoting ulcer healing through compression and staged interventions. 1

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Arterial Insufficiency Management

Acute Presentation

• Urgent revascularization is mandatory when neurological deficits are present—imaging should not delay intervention 1
• Immediate unfractionated heparin administration along with appropriate analgesia once clinical diagnosis is established 1
• Revascularization modalities include percutaneous catheter-directed thrombolytic therapy, mechanical thrombus extraction, or surgical thrombectomy depending on neurological deficit presence, ischemia duration, and patient comorbidities 1
• Endovascular therapy is preferred when possible due to reduced morbidity and mortality, especially in patients with severe comorbidities 1
• Four-compartment fasciotomies should be performed in patients with long-lasting ischemia to prevent post-reperfusion compartment syndrome 1

Chronic Limb-Threatening Ischemia (CLTI)

• Infra-popliteal revascularization is indicated for limb salvage (Class I recommendation, Level C evidence) 1
• Bypass using the great saphenous vein is the indicated procedure for revascularization of infra-popliteal arteries (Class I recommendation, Level A evidence) 1
• Early recognition of tissue loss and/or infection with referral to vascular team is mandatory to improve limb salvage 1
• Angiography including foot runoff should be considered prior to revascularization in CLTI patients with below-the-knee lesions 1

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Venous Insufficiency Management

Initial Conservative Management (Mandatory First-Line)

• Graduated compression stockings are mandatory initial treatment for all patients before considering any interventional therapy 2, 3
• 20-30 mmHg compression for CEAP C1-C3 disease (telangiectasias, varicose veins, edema without skin changes) 2, 3
• 30-40 mmHg compression for CEAP C4-C6 disease (skin changes, healed ulcers, active ulcers) 2, 3
• Minimum 3-month trial of compression therapy required before interventional therapy, except in patients with active ulceration (C6 disease) where delay is not warranted 2, 3
• Compression therapy should be continued for 2 years post-intervention and indefinitely if post-thrombotic syndrome develops 2, 3

Diagnostic Requirements

• Duplex ultrasound is the diagnostic standard and must be performed within 6 months before any interventional procedure 2, 3
• Reflux duration ≥500 milliseconds at the saphenofemoral or saphenopopliteal junction indicates pathologic reflux requiring treatment 2, 3
• Vein diameter measurements at specific anatomic landmarks are necessary: ≥4.5mm for thermal ablation and ≥2.5mm for sclerotherapy 2, 3
• Assessment of deep venous system patency is necessary to exclude deep vein thrombosis 2, 3

Interventional Treatment Algorithm

• Radiofrequency or laser ablation is the primary interventional treatment for saphenous vein reflux and has replaced surgery as the standard of care 2, 3
• Technical success rates for thermal ablation are 91-100% at 1-year follow-up, superior to all other modalities 2, 3
• Thermal ablation has equivalent efficacy to surgery with fewer complications, faster recovery, and improved early quality of life 2, 3
• Foam sclerotherapy is appropriate for tributary veins ≥2.5mm diameter after treating main saphenous trunk reflux 2, 3, 4
• Occlusion rates for foam sclerotherapy are 72-89% at 1 year, significantly lower than thermal ablation 2, 3, 4

Complications and Risks

• Nerve damage occurs in approximately 7% of thermal ablation cases, usually temporary, from thermal injury 2, 3
• Deep vein thrombosis occurs in 0.3% and pulmonary embolism in 0.1% of thermal ablation cases 2, 3
• Early postoperative duplex scans (2-7 days) are mandatory to detect endovenous heat-induced thrombosis 2, 3
• Recurrence rates are 20-28% at 5 years even with appropriate treatment, necessitating long-term surveillance 2, 3

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Combined Arterial and Venous Insufficiency (CAVI)

Critical Management Principles

• Ulcer healing requires correction of arterial insufficiency first—venous treatment alone will not succeed 5
• Patients with prior deep vein thrombosis (DVT) are unlikely to heal even with patent arterial bypass graft (only 15% healing rate vs 68% without DVT) 5
• Treatment includes elastic compression and leg elevation in all patients, plus arterial revascularization 5
• Greater saphenous vein stripping benefits patients with superficial venous reflux and normal deep veins (78% healing rate), but provides no benefit in patients with DVT 5
• Mean interval from bypass graft to healing is 7.9 months—this is a lengthy process requiring aggressive treatment of edema and infection 5

Diagnostic Considerations

• Peripheral arterial disease is more frequent in patients with severe forms of chronic venous insufficiency (17.3% prevalence) compared to controls 6
• In each patient with severe CVI, it is necessary to determine the ankle-brachial pressure index (ABPI) to exclude the presence of PAD 6
• Mixed arterial-venous ulcers comprise 10-18% of all leg ulcers 6

Hemodynamic Paradox

• Arterial inflow is significantly increased in extremities with chronic venous insufficiency compared to healthy controls 7
• Mean arterial inflow in severe CVI (stage III) is 6.25 ± 4.91 ml/100ml/min compared to 0.82 ± 0.48 ml/100ml/min in controls 7
• High arterial inflow, if not considered during plethysmographic evaluation, can overrepresent the true magnitude of venous reflux 7

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Common Pitfalls to Avoid

In Arterial Disease

• Never delay revascularization for imaging when neurological deficits are present—limb viability is threatened and prompt management is needed 1
• Do not use systemic thrombolysis for acute limb ischemia—it has no role in treatment 1

In Venous Disease

• Never perform sclerotherapy alone for saphenofemoral junction reflux without addressing the junction with thermal ablation or ligation—this leads to high recurrence rates 3, 4
• Do not treat veins <2.5mm diameter with sclerotherapy—patency rates are only 16% at 3 months versus 76% for veins >2.5mm 4
• Avoid delaying intervention in C4-C6 disease for prolonged compression trials—early thermal ablation prevents progression 3

In Combined Disease

• Never assume venous treatment alone will heal ulcers in CAVI—arterial insufficiency must be corrected first 5
• Do not pursue aggressive arterial or venous reconstruction in patients with prior DVT—they are unlikely to benefit 5
• Always assess ABPI in patients with severe CVI to exclude coexistent arterial disease 6