What is the recommended management of chronic venous insufficiency?

Management of Chronic Venous Insufficiency

Graduated compression stockings (20–30 mmHg for CEAP C1–C3; 30–40 mmHg for C4–C6) are mandatory first-line therapy and must be worn daily for a minimum of 3 months before any interventional procedure is considered. 1

Initial Diagnostic Workup

• Duplex ultrasound is the diagnostic standard to document presence, location, and duration of venous reflux; pathologic reflux is defined as ≥500 milliseconds at the saphenofemoral or saphenopopliteal junction. 1
• Measure ankle-brachial index (ABI) before initiating compression therapy—compression is absolutely contraindicated when ABI <0.5, and approximately 16% of venous insufficiency patients have concurrent arterial disease. 1, 2
• Document CEAP classification: 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—pain, burning, itching, heaviness, cramping, throbbing, swelling—that typically worsen at day's end or after prolonged standing. 1

Conservative Management Algorithm

Compression Therapy (Mandatory First-Line)

• Prescribe 20–30 mmHg graduated compression stockings for C1–C3 disease worn daily from toes to knee for minimum 3 months. 1
• Escalate to 30–40 mmHg stockings for C4–C6 disease (active skin changes or ulceration). 1, 2
• Negative-gradient graduated compression (higher pressure at calf than ankle) provides superior venous ejection fraction compared to traditional graduated compression. 1
• Continue compression for 2 years post-intervention; extend indefinitely if post-thrombotic syndrome develops. 1
• Compression pressures below 20 mmHg are ineffective—minimum 20 mmHg is required for therapeutic benefit. 2

Lifestyle Modifications

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

Pharmacologic Adjuncts

• Add micronized purified flavonoid fraction (MPFF) or pentoxifylline to compression therapy to improve venous tone and reduce inflammation. 2, 3
• Pentoxifylline 400 mg three times daily combined with compression yields relative risk of healing 1.56 versus compression alone, though gastrointestinal side effects (nausea, indigestion, diarrhea) are more frequent. 4, 2
• Diosmin (Vasculera) 1 tablet daily is FDA-approved for dietary management of chronic venous insufficiency manifested as varicose/spider veins, edema, stasis dermatitis, or venous ulcers; results may not appear for 4–8 weeks (several months for venous ulcers). 5
• MPFF-based conservative therapy was associated with the greatest reduction in symptom and sign intensity in a prospective real-world study of 6,084 patients, with 89% showing global symptom improvement at 2 weeks and 96% at 4 weeks. 3

Interventional Treatment Algorithm

Indications for Endovenous Thermal Ablation

Proceed to radiofrequency or laser ablation when all of the following criteria are met: 1, 2

• Documented reflux ≥500 milliseconds at saphenofemoral or saphenopopliteal junction
• Target vein diameter ≥4.5 mm
• Deep venous system is patent
• Symptoms persist after ≥3 months of appropriate compression therapy (or immediate referral for C4–C6 disease)

Primary Interventional Treatment

• Radiofrequency or laser ablation is first-line interventional treatment for saphenous vein reflux meeting above criteria, with technical success rates of 91–100% at 1-year follow-up. 1, 6
• Thermal ablation has replaced surgery as standard of care due to equivalent efficacy with fewer complications (reduced bleeding, hematoma, wound infection, paresthesia), faster recovery, and improved early quality of life. 1, 6
• Do not delay intervention in C4–C6 disease for prolonged compression trials—early thermal ablation prevents progression. 1

Adjunctive Sclerotherapy

• Foam sclerotherapy (polidocanol/Varithena) is appropriate for tributary veins ≥2.5 mm diameter after treating main saphenous trunk reflux. 1, 6
• Occlusion rates are 72–89% at 1 year, significantly lower than thermal ablation. 1, 6
• Never perform sclerotherapy alone for saphenofemoral junction reflux—untreated junctional reflux causes persistent downstream pressure leading to tributary vein recurrence rates of 20–28% at 5 years. 1, 6
• **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, 6

Venous Ulcer Management

• Compression therapy is the mainstay of treatment for venous ulcers—chronic venous ulcers heal more quickly with compression compared to primary dressings alone, noncompression bandages, or usual care without compression. 4
• Maintain a moist wound environment with protective covering to optimize wound healing. 4
• Control periwound dermatitis and aggressively prevent and treat infection. 4
• For patients with venous ulcers, do not delay endovenous ablation for compression trials—existing evidence suggests immediate referral for thermal ablation is appropriate when reflux is documented. 1, 6

Exercise Training Component

• A supervised exercise training program lasting at least 6 months, incorporating leg-strength training and aerobic activity, improves calf-muscle pump function and may accelerate ulcer healing. 4
• Exercise does not aggravate leg symptoms after DVT or increase risk of post-thrombotic syndrome; many patients report symptom improvement with exercise. 4

Critical Treatment Pitfalls to Avoid

• Ensure ultrasound documentation is <6 months old before any interventional procedure to confirm current anatomy and reflux patterns. 1, 6
• Refer to experienced vascular specialists when local expertise is unavailable—outcomes are highly operator-dependent. 1
• Patient adherence to compression therapy is the single most critical factor for preventing ulcer recurrence; proper fitting, education, and detailed instructions are essential. 1, 2

Complications of Interventional Treatment

• Nerve damage occurs in approximately 7% of cases (usually temporary) from thermal injury. 1, 6
• Deep vein thrombosis occurs in 0.3% and pulmonary embolism in 0.1% of cases. 1, 6
• Common side effects of foam sclerotherapy include phlebitis, new telangiectasias, residual pigmentation, and transient colic-like pain resolving within 5 minutes. 6

Long-Term Surveillance

• Recurrence rates are 20–28% at 5 years even with appropriate treatment, necessitating long-term surveillance. 1, 6
• Post-procedure compression is mandatory to optimize outcomes and reduce complications. 1
• If a venous 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
• Indefinite continuation of compression therapy after ulcer healing is essential because venous insufficiency is a chronic condition. 2