What is the procedure for treating venous insufficiency?

Treatment Procedures for Venous Insufficiency

For venous insufficiency, compression therapy with 20-30 mmHg graduated stockings is the first-line conservative treatment, followed by endovenous thermal ablation (radiofrequency or laser) for symptomatic varicose veins with documented reflux ≥500ms and vein diameter ≥4.5mm, with foam sclerotherapy reserved for tributary veins or as adjunctive therapy. 1, 2, 3

Initial Diagnostic Evaluation

Duplex ultrasound is the mandatory first assessment before any interventional therapy, documenting: 1, 3

• Reflux duration (pathologic if ≥500 milliseconds at saphenofemoral or saphenopopliteal junction) 2, 4
• Vein diameter at specific anatomic landmarks 2, 4
• Deep venous system patency 3
• Location and extent of refluxing segments 3

The ultrasound must be performed within 6 months of planned intervention to establish medical necessity. 2, 4

Conservative Management (First-Line)

Compression Therapy

Graduated compression stockings are the cornerstone of treatment: 1, 3

• 20-30 mmHg pressure for most patients with venous insufficiency 1, 3
• 30-40 mmHg pressure for more severe disease (C5-C6 with ulceration) 1, 3
• Inelastic compression (Velcro wraps) is superior to elastic bandaging for wound healing in venous leg ulcers 1
• Caution: Reduce compression to 20-30 mmHg if ankle-brachial index is 0.6-0.9; avoid compression if <0.6 (indicates arterial disease requiring revascularization) 1

A documented 3-month trial of properly fitted medical-grade compression stockings is required before interventional treatment, unless venous ulceration is present. 2, 3

Lifestyle Modifications

• Leg elevation above heart level 3, 5
• Regular exercise and leg strengthening (supervised program for ≥6 months shows benefit) 1, 3
• Weight loss if applicable 3
• Avoidance of prolonged standing or immobility 3

Pharmacologic Adjuncts

• Pentoxifylline 400mg three times daily improves venous ulcer healing when combined with compression (RR 1.56 for complete healing), though gastrointestinal side effects are common 1
• Horse chestnut seed extract may provide symptomatic relief, though long-term data are limited 3, 5

Interventional Treatment Algorithm

Step 1: Endovenous Thermal Ablation (First-Line for Main Truncal Veins)

Indications: 2, 4

• Great or small saphenous vein diameter ≥4.5mm 2, 4
• Documented reflux ≥500ms at saphenofemoral or saphenopopliteal junction 2, 4
• Symptomatic disease (pain, heaviness, swelling, skin changes) interfering with daily activities 2, 4
• Failed 3-month trial of compression therapy (exception: ulceration present—no delay needed) 2, 4

Procedure Options: 2, 3

• Radiofrequency ablation (RFA): 91-100% occlusion rates at 1 year 2, 4
• Endovenous laser ablation (EVLA): Similar efficacy to RFA 2, 3
• Both performed under ultrasound guidance with local anesthesia, allowing same-day discharge 4

Advantages over surgery: 4

• Similar efficacy with fewer complications 4
• Reduced rates of bleeding, hematoma, wound infection, and paresthesia 4
• Faster recovery and improved early quality of life 4

Complications: 2, 4

• Nerve damage from thermal injury: ~7% (usually temporary) 2, 4
• Deep vein thrombosis: 0.3% 2, 4
• Pulmonary embolism: 0.1% 2, 4
• Early postoperative duplex scan (2-7 days) mandatory to detect endovenous heat-induced thrombosis 2

Step 2: Foam Sclerotherapy (For Tributary Veins or Adjunctive Treatment)

Indications: 1, 2

• Tributary veins or accessory saphenous veins with diameter ≥2.5mm 2
• Residual refluxing segments after thermal ablation 2
• Veins too small or tortuous for catheter-based ablation 2

Important: Treating saphenofemoral junction reflux with thermal ablation is mandatory before tributary sclerotherapy to prevent recurrence—untreated junctional reflux causes persistent downstream pressure with 20-28% recurrence at 5 years. 2

Agents: 2, 3

• Polidocanol (Varithena) 2
• Sodium tetradecyl sulfate 3
• Hypertonic saline 3

Efficacy: 2

• 72-89% occlusion rates at 1 year for appropriately sized veins 2
• Vessels <2.0mm have only 16% patency at 3 months—avoid treating veins below 2.5mm 2

Advantages: 2

• Fewer complications than thermal ablation (no thermal injury risk) 2
• No tumescent anesthesia required 2
• Ultrasound guidance mandatory for safety 2

Limitations: 2

• Lower long-term success rates compared to thermal ablation 2
• Higher rates of recurrent reflux at 1-, 5-, and 8-year follow-up 2

Common side effects: 2

• Phlebitis, new telangiectasias, residual pigmentation 2
• Deep vein thrombosis is exceedingly rare 2

Step 3: Microphlebectomy/Stab Phlebectomy (For Bulging Tributary Veins)

Indications: 2

• Symptomatic varicose tributary veins >4mm diameter 2
• Performed concurrently with treatment of saphenofemoral junction reflux 2
• Addresses veins that persist after main trunk ablation 2

Technique: 2

• Small incisions with updated techniques reducing scarring and blood loss 2
• Critical: Avoid common peroneal nerve near fibular head during lateral calf phlebectomy to prevent foot drop 2

Common complication: Skin blistering from dressing abrasions 2

Step 4: Endovascular Stenting (For Post-Thrombotic Syndrome)

Indications: 1

• Iliac vein obstruction from chronic post-thrombotic changes 1
• Moderate to severe post-thrombotic syndrome with lifestyle-limiting symptoms 1

Evidence: Iliac vein stenting improves symptomatology and quality of life compared to medical treatment alone in randomized trials. 1

Approach: 1

• Angioplasty is typically first-line for femoral and popliteal vein recanalization 1
• Stenting below the lesser trochanter has poor outcomes and should be avoided 1

Step 5: Surgical Options (Reserved for Complex Cases)

Indications: 3

• Failure of endovascular options 3
• Complex venous anatomy not amenable to minimally invasive techniques 3

Procedures: 1, 3

• Ligation and stripping (largely replaced by endovenous techniques) 3
• Neovalve reconstruction for refractory venous ulcers 1
• Venous bypass (poor patency rates, significant morbidity—last resort) 1

Special Considerations for Venous Ulcers (C5-C6 Disease)

Compression therapy remains the mainstay: 1

• Multilayer compression with 30-40 mmHg pressure 1
• Chronic venous ulcers heal more quickly with compression versus primary dressings alone 1

Adjunctive measures: 1

• Maintain moist wound environment 1
• Protective covering 1
• Control dermatitis 1
• Aggressive infection prevention and treatment 1

Pentoxifylline 400mg three times daily plus compression is more effective than placebo plus compression (RR 1.56 for healing). 1

Endovenous ablation should not be delayed for compression trials when ulceration is present—treat underlying reflux to promote healing. 2, 4

Exercise Training for Post-Thrombotic Syndrome

A supervised exercise program consisting of leg strength training and aerobic activity for ≥6 months is reasonable for patients with post-thrombotic syndrome who can tolerate it (Class IIa recommendation). 1

• Exercise does not aggravate symptoms or increase PTS risk 1
• Improves calf muscle pump function and venous blood ejection 1
• Many patients report symptom improvement with exercise 1

Treatment Sequence Summary

1. Duplex ultrasound to document reflux and vein diameter 1, 3
2. 3-month trial of compression therapy (20-30 mmHg) unless ulceration present 2, 3
3. Endovenous thermal ablation for main saphenous trunks with diameter ≥4.5mm and reflux ≥500ms 2, 4
4. Foam sclerotherapy for tributary veins ≥2.5mm diameter 2
5. Microphlebectomy for bulging tributaries >4mm 2
6. Stenting for iliac vein obstruction in post-thrombotic syndrome 1
7. Surgery only when minimally invasive options fail 3

Common Pitfalls to Avoid

• Never perform sclerotherapy alone for saphenofemoral junction reflux—this leads to high recurrence rates; thermal ablation must address the junction first 2
• Do not treat veins <2.5mm diameter—poor outcomes with only 16% patency at 3 months 2
• Avoid compression if ankle-brachial index <0.6—indicates arterial disease requiring revascularization first 1
• Do not delay treatment for compression trials when venous ulceration is present—endovenous ablation promotes healing 2, 4
• Ensure ultrasound is within 6 months of planned intervention for medical necessity 2, 4
• Document exact reflux duration and vein diameter at specific anatomic landmarks—vague measurements lead to inappropriate treatment selection 2, 4