What are the treatment options for venous insufficiency?

Treatment Options for Venous Insufficiency

First-Line Treatment: Endovenous Thermal Ablation

For symptomatic varicose veins with documented valvular reflux (≥500 milliseconds), endovenous thermal ablation—either radiofrequency ablation or endovenous laser ablation—is the first-line treatment and has largely replaced surgical stripping as the standard of care. 1, 2

Patient Selection Criteria

• Vein diameter must be ≥4.5mm for thermal ablation to be medically indicated 1
• Documented reflux duration ≥500 milliseconds at the saphenofemoral or saphenopopliteal junction is required 1, 2
• Patients must have severe and persistent pain and swelling interfering with activities of daily living despite a 3-month trial of conservative management 1, 2
• Duplex ultrasound performed within the past 6 months is mandatory before any interventional therapy 1

Treatment Efficacy

• Technical success rates range from 91-100% occlusion at 1 year post-treatment 1
• Success rate of 90% at 1 year for treating larger vessels including the great saphenous vein 2
• Improved early quality of life and reduced hospital recovery compared to surgery 1
• Fewer complications than surgery, including reduced rates of bleeding, hematoma, wound infection, and paresthesia 1

Risks and Complications

• Approximately 7% risk of surrounding nerve damage from thermal injury, though most is temporary 1, 2
• Deep vein thrombosis occurs in 0.3% of cases 1
• Pulmonary embolism occurs in 0.1% of cases 1
• Early postoperative duplex scans (2-7 days) are mandatory to detect endovenous heat-induced thrombosis 1

Second-Line Treatment: Foam Sclerotherapy

Foam sclerotherapy, including Varithena (polidocanol), is indicated as secondary treatment for tributary veins or as adjunctive therapy following thermal ablation of the main saphenous trunks. 1, 2

Indications and Patient Selection

• Appropriate for small to medium-sized veins with diameter ≥2.5mm 1, 2
• Documented reflux duration ≥500 milliseconds is required 1
• Used for residual refluxing segments, tributary veins, and accessory saphenous veins after primary treatment 1
• Vessels <2.0mm in diameter have poor outcomes with only 16% primary patency at 3 months 1

Treatment Efficacy

• Occlusion rates range from 72-89% at 1 year 1, 2
• Lower long-term success rates compared to endovenous thermal ablation, with higher rates of recurrent reflux at 1-, 5-, and 8-year follow-ups 1

Advantages Over Thermal Ablation

• Fewer potential complications, including reduced risk of thermal injury to skin, nerves, muscles, and non-target blood vessels 1
• Tumescent anesthesia is not needed 1
• Can be performed under local anesthesia with immediate walking after the procedure 2

Common Side Effects

• Phlebitis, new telangiectasias, and residual pigmentation are common 1
• Deep vein thrombosis is an exceedingly rare complication 1

Third-Line Treatment: Surgical Options

Ambulatory Phlebectomy (Stab Phlebectomy)

• Medically necessary as adjunctive procedure to address symptomatic varicose tributary veins that persist after treatment of the main saphenous trunk 1, 3
• Critical requirement: Junctional reflux must be treated concurrently (with thermal ablation or ligation) to meet medical necessity criteria and reduce recurrence rates 1, 3
• Most common complication is skin blistering from dressing abrasions, with rare sensory nerve injury 1
• The common peroneal nerve near the fibular head must be avoided during lateral calf phlebectomy to prevent foot drop 1

Surgical Ligation and Stripping

• Reserved for cases where endovenous techniques are not feasible 1
• Traditional surgical treatment has a 5-year recurrence rate of 20-28% 1
• Has been largely replaced by endovenous thermal ablation due to inferior outcomes 1, 2

Conservative Management

A minimum 3-month trial of conservative management is required before interventional treatment, except in cases of recurrent superficial thrombophlebitis or venous ulceration. 1, 2

Components of Conservative Therapy

• Medical-grade gradient compression stockings with 20-30 mmHg minimum pressure 1, 2
• Daily leg elevation to control edema 2, 4
• Moderate physical activity such as walking 2, 4
• Weight loss if applicable 1
• Avoidance of prolonged standing or immobility 1

Important Limitations

• Compression stockings alone have no proven benefit in preventing post-thrombotic syndrome or treating established venous insufficiency when significant reflux is present 1
• Recent randomized trials show compression therapy does not prevent progression of venous disease 1
• Conservative measures are primarily recommended for patients who are not candidates for intervention, do not desire intervention, or are pregnant 2

Treatment Algorithm Based on Disease Severity

For CEAP C2-C3 (Varicose Veins with or without Edema)

• Begin with 3-month trial of medical-grade compression stockings (20-30 mmHg) 1, 2
• If symptoms persist despite compliance, proceed to endovenous thermal ablation for main saphenous trunks with diameter ≥4.5mm and reflux ≥500ms 1, 2
• Add foam sclerotherapy or phlebectomy for tributary veins as adjunctive treatment 1, 2

For CEAP C4 (Skin Changes Including Stasis Dermatitis)

• Patients with C4 disease require intervention to prevent progression, even when severe pain and swelling are not the primary complaint 1
• Endovenous thermal ablation for main trunks followed by sclerotherapy for tributaries is the recommended combined approach 1
• Meticulous skin care and treatment of dermatitis are essential adjuncts 4

For CEAP C5-C6 (Healed or Active Venous Ulcers)

• Endovenous thermal ablation need not be delayed for a trial of external compression when ulceration is present 1
• Compression therapy has value in C5-C6 disease for wound healing 1
• Appropriate wound care is mandatory 4
• Treating the underlying reflux with thermal ablation improves wound healing 1

Critical Pitfalls to Avoid

Treatment Sequencing Errors

• Chemical sclerotherapy or phlebectomy alone has worse outcomes at 1-, 5-, and 8-year follow-ups compared to thermal ablation of the main trunks 1, 3
• Untreated junctional reflux causes persistent downstream pressure, leading to tributary vein recurrence rates of 20-28% at 5 years even after successful sclerotherapy 1, 3
• The saphenofemoral or saphenopopliteal junction must be treated first before addressing tributary veins 1, 3

Inadequate Diagnostic Workup

• Venous duplex ultrasonography is mandatory when interventional therapy is being considered 2
• Ultrasound must document exact vein diameter at specific anatomic landmarks, reflux duration at junctions, assessment of deep venous system patency, and location/extent of refluxing segments 1
• Reflux is defined as retrograde flow duration >500 milliseconds in superficial veins 2

Inappropriate Patient Selection

• Treating veins smaller than 2.5mm results in poor outcomes with lower patency rates 1
• Proceeding to intervention without documented 3-month trial of proper compression therapy (20-30 mmHg) may result in insurance denial 1, 2
• Patients with non-visualized saphenous trunks cannot meet medical necessity criteria for phlebectomy alone 3

Pharmacologic Adjuncts

• Pentoxifylline is an effective adjunct to compression therapy in patients with large, chronic ulceration 4
• Micronized purified flavonoid fraction (phlebotropic agents) improves venous function and is an effective adjunct to compression therapy 4
• Diosmiplex, a flavonoid medical food product, is FDA-approved for management of chronic venous insufficiency 5

Special Considerations for Recurrent Disease

• Patients with recurrent varicosities from neovascular channels after prior saphenous vein ablation require repeat duplex ultrasound to identify any visualized saphenous segments that could be treated 3
• If no saphenous trunks are visualized, consider surgical exploration with saphenofemoral junction ligation, foam sclerotherapy of neovascular channels, or deep venous reflux evaluation 3
• Serial ultrasound is required to document new abnormalities in previously treated areas or identify untreated segments requiring intervention 1