What is the management of venous insufficiency (Chronic Venous Insufficiency, CVI)?

Management of Venous Insufficiency

Initial Treatment Approach

Endovenous thermal ablation (radiofrequency or laser) is now the first-line treatment for symptomatic venous insufficiency with documented saphenous vein reflux, replacing compression therapy as initial management except in pregnant women or when interventional treatments are ineffective. 1

Diagnostic Requirements Before Treatment

• Duplex ultrasonography is mandatory as the gold standard for diagnosis, measuring reflux duration (>500 milliseconds in superficial/deep calf veins, >1,000 milliseconds in femoropopliteal veins, >350 milliseconds in perforating veins) and vein diameter at specific anatomic landmarks 1
• Use the CEAP classification system to categorize disease severity: C1 (telangiectasias), C2 (varicose veins), C3 (edema), C4 (skin changes), C5 (healed ulcer), C6 (active ulcer) 1
• Assess for deep vein thrombosis and iliac vein obstruction, particularly in young patients with left-sided symptoms 1

Treatment Algorithm by Disease Severity

Mild Symptoms (CEAP C1-C2)

• Avoid prolonged standing/straining, perform regular exercise, wear non-restrictive clothing, pursue weight loss, and elevate the affected leg 1
• Compression stockings (20-30 mmHg) are no longer recommended as initial therapy for varicose veins, though they may be used when interventional treatments fail 1
• Consider endovenous thermal ablation without delay when symptoms are present and reflux is documented—compression trials need not postpone intervention 1, 2

Moderate Symptoms (CEAP C3-C4)

• Endovenous thermal ablation (laser or radiofrequency) for saphenous vein incompetence with diameter ≥4.5mm and reflux ≥500ms 1, 3
• Technical success rates are 91-100% at 1 year with fewer complications than traditional surgery (reduced bleeding, hematoma, wound infection, and paresthesia) 1, 3
• Foam sclerotherapy using hypertonic saline, sodium tetradecyl (Sotradecol), or polidocanol (Varithena) for tributary veins ≥2.5mm diameter after treating main saphenous trunk reflux 1, 3
• External laser thermal ablation works best for telangiectasias (spider veins) 1

Severe Symptoms (CEAP C5-C6 with Ulceration)

• Compression therapy (30-40 mmHg) remains the mainstay for venous ulcer management 1, 2
• Endovenous ablation of incompetent veins should be performed to address underlying reflux contributing to poor wound healing 1
• Add pentoxifylline 400mg three times daily to compression therapy to improve ulcer healing 1
• For venous leg ulcers ≤10cm diameter, micronized purified flavonoid fraction (MPFF) 500mg twice daily plus standard management significantly increases complete healing rates over 2-6 months 2

Specific Interventional Techniques

Treatment Selection Based on Vessel Size

• Vessels ≥4.5mm diameter with reflux ≥500ms: Endovenous thermal ablation (radiofrequency or laser) 1, 3
• Vessels 2.5-4.5mm diameter: Foam sclerotherapy 3
• Vessels <2.5mm diameter: External laser or liquid sclerotherapy 1, 3
• Vessels <2.0mm have only 16% primary patency at 3 months with sclerotherapy compared to 76% for veins >2.0mm 3

Combined Treatment Approach

• Treat saphenofemoral junction reflux first with thermal ablation or ligation—chemical sclerotherapy alone has worse outcomes at 1-, 5-, and 8-year follow-ups 3
• Foam sclerotherapy achieves 72-89% occlusion rates at 1 year for tributary veins when used as adjunctive therapy after treating main trunk reflux 1, 3
• Stab phlebectomy is appropriate for symptomatic varicose tributary veins when performed concurrently with treatment of junctional reflux 3

Special Clinical Situations

Post-Thrombotic Syndrome

• Supervised exercise training program with leg strength training and aerobic activity for at least 6 months 1
• For severe PTS with iliac vein obstruction, endovascular intervention with stenting may be beneficial 1
• Compression stockings alone have no proven benefit in preventing post-thrombotic syndrome in recent randomized trials 2

Nonthrombotic Iliac Vein Lesions

• Stent placement may be required in appropriately selected patients with moderate to severe symptoms 1
• Evaluate for iliac vein compression in patients with left-sided symptoms, especially young, otherwise healthy patients 1

Adjunctive Pharmacotherapy

• Micronized purified flavonoid fraction (MPFF) serves as adjunctive medical therapy to compression and thermal ablation, not as replacement 2
• MPFF should be initiated particularly in patients with moderate-to-severe symptoms (CEAP C4-C6) 2
• Compression therapy (20-30 mmHg for CEAP C1-C3, 30-40 mmHg for C4-C6) remains mandatory and must be continued for minimum 3 months before interventional therapy is considered 2

Critical Treatment Pitfalls to Avoid

• Do not rely solely on compression therapy for primary treatment of varicose veins without addressing underlying venous reflux—this leads to higher recurrence rates 1, 3
• Do not perform tributary sclerotherapy without first treating saphenofemoral junction reflux—untreated junctional reflux causes persistent downstream pressure leading to recurrence rates of 20-28% at 5 years 1, 3
• Do not use traditional surgical approaches (ligation and stripping) as first-line when endovenous thermal ablation is more appropriate 1, 3
• Do not overlook the need for regular follow-up—recurrence rates 2 years post-intervention can be 15-35% 1
• Avoid the common peroneal nerve near the fibular head during lateral calf procedures to prevent foot drop 3

Expected Complications and Monitoring

• Deep vein thrombosis occurs in 0.3% of cases after endovenous ablation, pulmonary embolism in 0.1% 1, 3
• Approximately 7% risk of temporary nerve damage from thermal injury 1, 3
• Early postoperative duplex scans (2-7 days) are mandatory to detect endovenous heat-induced thrombosis 3
• Common side effects of foam sclerotherapy include phlebitis, new telangiectasias, and residual pigmentation 3