What is the recommended management for chronic venous insufficiency (CVI)?

Management of Chronic Venous Insufficiency

Graduated compression stockings (20-30 mmHg for mild disease, 30-40 mmHg for severe disease) are the mandatory first-line treatment for all patients with chronic venous insufficiency, and radiofrequency or laser ablation has replaced surgery as the standard interventional treatment when conservative therapy fails after 3 months. 1, 2

Initial Diagnostic Workup

Before initiating any treatment, obtain the following:

• Duplex ultrasound is the diagnostic standard to document reflux location, duration, and vein diameter—pathologic reflux is defined as ≥500 milliseconds at the saphenofemoral or saphenopopliteal junction 1, 2
• Measure ankle-brachial index (ABI) before applying compression—compression is absolutely contraindicated when ABI <0.5, and approximately 16% of venous insufficiency patients have concurrent arterial disease 1, 3
• Document CEAP classification to categorize severity: C0 (no visible signs), C1 (spider veins), C2 (varicose veins), C3 (edema), C4 (skin changes/pigmentation), C5 (healed ulcer), C6 (active ulcer) 1, 4
• Ensure ultrasound is <6 months old before any interventional procedure to confirm current anatomy 1

Conservative Management (Mandatory Initial Therapy)

All patients must begin with conservative measures before considering intervention:

• 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 1, 2, 3
• Require a minimum 3-month compression trial before considering interventional therapy, except in patients with active ulceration (C6) where delay is not warranted 1, 2
• Continue compression for 2 years post-intervention, and indefinitely if post-thrombotic syndrome develops 1, 2
• Elevate legs above heart level regularly throughout the day to reduce venous hypertension 1, 2
• Avoid prolonged standing or sitting >30 minutes without movement to prevent venous pooling 1, 2
• Implement regular calf muscle pump exercises (ankle flexion/extension, walking) to improve venous return 1, 2
• Recommend weight loss if BMI >25 to reduce intra-abdominal pressure 1, 2
• Avoid restrictive clothing around waist, groin, or legs 1, 2

Critical evidence note: Negative-gradient compression (higher pressure at calf than ankle) provides superior venous ejection fraction compared to traditional graduated compression 1, 3. However, the 2013 National Institute for Health and Care Excellence guidelines note insufficient evidence for compression effectiveness in varicose veins without active or healed ulcers 5, though this conflicts with American guidelines that mandate compression as first-line therapy 1, 2.

Interventional Treatment Algorithm

Proceed to thermal ablation when all of the following criteria are met:

• Persistent symptoms despite 3-month compression trial (except C6 disease where immediate intervention is appropriate) 1, 2
• Duplex ultrasound shows reflux ≥500 milliseconds at saphenofemoral or saphenopopliteal junction 1, 2
• Saphenous vein diameter ≥4.5 mm 1, 2
• Deep venous system is patent 2

Primary Intervention: Endovenous Thermal Ablation

• Radiofrequency or laser ablation is the primary interventional treatment and has replaced surgery as standard of care due to equivalent efficacy with fewer complications, faster recovery, and improved early quality of life 1, 2, 4
• Technical success rates are 91-100% at 1-year follow-up, superior to all other modalities 1, 2, 3
• Nerve damage occurs in approximately 7% of cases (usually temporary) from thermal injury 1, 2
• Deep vein thrombosis occurs in 0.3% and pulmonary embolism in 0.1% of cases 1, 3
• Mandatory early postoperative duplex scan (2-7 days) to detect endovenous heat-induced thrombosis 2

Secondary Intervention: Foam Sclerotherapy

• Foam sclerotherapy (polidocanol/Varithena) is appropriate only for tributary veins ≥2.5mm diameter after treating main saphenous trunk reflux 1, 2
• Occlusion rates are 72-89% at 1 year, significantly lower than thermal ablation 1, 2
• Sclerotherapy alone has inferior long-term outcomes with higher recurrent reflux rates at 1,5, and 8-year follow-ups 1

Critical Treatment Pitfalls to Avoid

• Never perform sclerotherapy alone for saphenofemoral junction reflux—the junction must be addressed with thermal ablation or ligation first 1
• **Do not treat veins <2.5mm diameter with sclerotherapy**—patency rates are only 16% at 3 months versus 76% for veins >2.5mm 1
• Avoid delaying intervention in C4-C6 disease for prolonged compression trials—early thermal ablation prevents progression 1
• Never apply compression when ABI <0.5—this can cause critical limb ischemia 1, 3
• Refer to experienced vascular specialists when local expertise is unavailable—outcomes are highly operator-dependent 1

Special Considerations for Venous Ulcers

• Compression therapy (30-40 mmHg) is the primary treatment to aid ulcer healing 4
• Add micronized purified flavonoid fraction (e.g., pentoxifylline) to compression therapy to improve venous tone—this yields a relative risk of healing of 1.56 versus compression alone, though gastrointestinal side effects (nausea, indigestion, diarrhea) are more frequent 3
• To decrease ulcer recurrence, perform ablation of incompetent superficial veins in addition to compression therapy 4
• Maintain a moist wound environment with protective covering to promote granulation 3
• Control periwound dermatitis and aggressively prevent/treat infection 3

Long-Term Surveillance

• Recurrence rates are 20-28% at 5 years even with appropriate treatment, necessitating lifelong surveillance 1, 2, 3
• If ulcer recurs, repeat duplex ultrasound to evaluate for recanalization of previously treated veins or new reflux pathways (e.g., Giacomini vein transmission to short saphenous vein) 1, 3
• Patient adherence to compression therapy is the single most critical factor for preventing ulcer recurrence—proper fitting, education, and detailed written instructions are essential 1, 3
• Post-procedure compression is mandatory to optimize outcomes and reduce complications 1, 2