What is the appropriate management for peripheral venous insufficiency?

Management of Peripheral Venous Insufficiency

Begin with graduated compression stockings (20–30 mmHg for mild-to-moderate disease, 30–40 mmHg for severe disease) as mandatory first-line therapy for a minimum of 3 months before considering any interventional procedures. 1

Initial Diagnostic Workup

• Obtain duplex ultrasound as the diagnostic standard to document presence, location, and duration of reflux (pathologic reflux defined as ≥500 milliseconds), assess deep venous system patency, evaluate saphenous vein diameter, and identify perforating vein location. 2, 1

• Measure ankle-brachial index (ABI) before applying compression therapy—compression is contraindicated when ABI <0.5, as approximately 16% of venous insufficiency patients have concomitant arterial disease. 2, 3

• Document CEAP classification to categorize severity: 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

• Assess specific symptoms including pain, burning, itching, heaviness, cramping, throbbing, and swelling that typically worsen at day's end or after prolonged standing. 1

Conservative Management (Mandatory First-Line for 3 Months)

• Prescribe medical-grade graduated compression stockings: 20–30 mmHg for CEAP C1–C3 disease, 30–40 mmHg for C4–C6 disease, worn daily from toes to knee. 2, 1

• Apply negative graduated compression (higher pressure at calf than ankle) over the calf region, which provides superior venous ejection fraction and higher extrinsic pressures compared to traditional graduated compression. 2, 3

• Elevate legs above heart level regularly throughout the day to reduce venous hypertension. 1, 3

• Avoid prolonged standing or sitting (>30 minutes without movement) to prevent venous pooling. 1

• Implement regular calf muscle pump exercises (ankle flexion/extension, walking) to improve venous return. 1

• Recommend 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

Adjunctive Pharmacotherapy

• Add micronized purified flavonoid fraction (diosmin) to compression therapy to improve venous tone and reduce inflammation—this yields a relative risk of healing of 1.56 versus compression alone, though gastrointestinal side effects (nausea, indigestion, diarrhea) are more frequent. 3, 4

• Diosmin demonstrates 30–60% superiority to placebo in clinical endpoints of patient-reported symptoms, edema, and quality of life across more than 40 clinical trials comprising >15,000 patients. 4

• For patients with CEAP class 0–4 disease, diosmin produces significant reduction in CEAP class, edema, and quality-of-life scores (p=0.0001) after 6 months, with 79% of subjects and 83% of investigators rating effectiveness as good or excellent. 4

Wound Care for Active Ulceration (C6 Disease)

• Maintain a moist wound environment with protective covering to promote granulation tissue formation. 3

• Control periwound dermatitis and aggressively prevent and treat infection as part of routine ulcer care. 3

• Combine pentoxifylline with compression therapy for venous leg ulcers, which improves healing rates compared to compression alone. 3

• Implement a supervised exercise program lasting at least 6 months, incorporating leg-strength training and aerobic activity, to improve calf-muscle pump function and accelerate ulcer healing. 3

Indications for Endovenous Thermal Ablation

Proceed to radiofrequency or laser ablation when ALL of the following criteria are met: 1, 3

• Ulcer persists after ≥3 months of appropriate compression therapy (or symptoms remain lifestyle-limiting for C2–C4 disease despite 3-month compression trial)

• Duplex ultrasound shows reflux ≥500 ms at saphenofemoral or saphenopopliteal junction

• Target vein diameter ≥4.5 mm

• Deep venous system is patent

• Thermal ablation achieves technical success rates of 91–100% at 1-year follow-up, superior to all other modalities, and has replaced surgery as standard of care due to equivalent efficacy with fewer complications, faster recovery, and improved early quality of life. 1, 3

• Do not delay intervention in C4–C6 disease for prolonged compression trials—early thermal ablation prevents progression when reflux criteria are met. 1

Foam Sclerotherapy (Secondary/Adjunctive Treatment)

• Use foam sclerotherapy (polidocanol/Varithena) for tributary veins ≥2.5 mm diameter after treating main saphenous trunk reflux, achieving occlusion rates of 72–89% at 1 year. 1, 3

• Never perform sclerotherapy alone for saphenofemoral junction reflux without addressing the junction with thermal ablation or ligation—sclerotherapy alone has inferior long-term outcomes with higher recurrent reflux rates at 1-, 5-, and 8-year follow-ups. 1

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

Complications of Interventional Treatment

• Nerve damage occurs in approximately 7% of thermal ablation cases (usually temporary) from thermal injury. 1

• Deep vein thrombosis occurs in 0.3% and pulmonary embolism in 0.1% of cases. 1

• Common sclerotherapy side effects include phlebitis, new telangiectasias, residual pigmentation, and transient colic-like pain resolving within 5 minutes. 1

Long-Term Management and Surveillance

• Continue compression therapy indefinitely after ulcer healing or intervention—venous insufficiency is a chronic condition requiring lifelong management. 1, 3

• Recurrence rates are 20–28% at 5 years even with appropriate treatment, necessitating long-term surveillance. 1

• If an ulcer recurs, repeat duplex ultrasound to assess for recanalization of treated veins or new reflux (e.g., Giacomini vein transmitting to short saphenous vein). 2, 3

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

Critical Pitfalls to Avoid

• Patient adherence to compression is the most critical factor in preventing ulcer recurrence—proper fitting, education, and detailed instructions are essential. 2, 3

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

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

• Patient selection must account for surgical risk, clinical severity, specific venous anatomy, and life expectancy. 1