eMedicine Specialties > Dermatology > Diseases of the Vessels
Venous Insufficiency: Treatment & Medication
Updated: Apr 14, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
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Treatment
Medical Care
Venous insufficiency is neither uncommon nor benign. Treatment is aimed at ameliorating the symptoms and, whenever possible, at correcting the underlying abnormality. Deep system disease is often refractory to treatment, but superficial system disease can usually be treated by ablating the refluxing vessels. Refluxing superficial vessels can safely be removed or ablated without sequelae; an incompetent vessel has already proved itself unnecessary because it is carrying venous blood in a retrograde direction.Graduated compression is the cornerstone of the modern treatment of venous insufficiency. Properly fitted gradient compression stockings provide 30-40 or 40-50 mm Hg of compression at the ankle, with gradually decreasing compression at more proximal levels of the leg. This amount of gradient compression is sufficient to restore normal venous flow patterns in many or most patients with superficial venous reflux and to improve venous flow, even in patients with severe deep venous incompetence.
The compression gradient is extremely important because nongradient stockings or high-stretch elastic bandages (eg, ACE wraps) may cause a tourniquet effect, with worsening of the venous insufficiency. The so-called antiembolic stockings that are commonly available in American hospitals do not provide sufficient compression to improve the venous return from the legs, and they are not particularly effective in preventing venous thromboembolism. No patient with symptoms due to venous insufficiency should be without gradient compression hose, which can be prescribed by any physician. The prescription should specify one pair of gradient compression hose with a 30-40-mm Hg gradient that is calf-high (or thigh-high with waist attachment or panty hose style), with refills as needed.
All methods of venoablation are effective. Once the overall volume of venous reflux is reduced below a critical threshold by any mechanism, venous ulcerations heal, and patient symptoms are resolved.5
- Deep vein valvular incompetence is difficult to treat. Valvuloplasty is occasionally successful, but the incidence of postoperative DVT is high. Venous bypass is successful in select patients. External vein valve banding devices (eg, Venocuff device) and thermally induced collagen shrinkage procedures (eg, Closure procedure) are being investigated in clinical trials. At this time, the restoration of valvular function to incompetent deep veins remains an important focus of research for vascular physicians.
- Patients with varicose bleeding usually present to an emergency department, where the traditional management is to oversew the involved vessel. Patients who have had significant blood loss may be admitted to the hospital, particularly if the bleeding varicosity is large and if the overlying tissue is friable. Oversewing a vessel almost always results in short-term control, but it can also cause the short-term recurrence of hemorrhage because the procedure does nothing to ablate the dilated, superficial, thin-walled vessel that has ruptured.
- Variceal hemorrhage is best managed by means of primary sclerotherapy with sodium tetradecyl sulfate (Sotradecol). Tretbar reported a series of cases that were successfully treated by means of primary compression sclerotherapy over a 3-year period.6 Sclerotherapy is performed by injecting or infusing a sclerosing substance into the refluxing vessel to produce endothelial destruction and fibrosis of the treated vessel.
- Endovenous laser therapy (EVLT) is a newer procedure with excellent early (4-y) results and an extremely low rate of complications, but the duration of follow-up is not yet long enough to provide information about mid-term and long-term results. EVLT is performed by passing a laser fiber from the knee to the groin and then delivering laser energy along the entire course of the vein. Destruction of the vascular wall is followed by fibrosis of the treated vessel.
- Radiofrequency ablation (RFA) is a relatively new procedure that has a low rate of complications. It has produced excellent results that have been confirmed after several years of follow-up. RFA is performed by passing a special radiofrequency (RF) catheter from the knee to the groin and by heating the vessel until thermal injury causes shrinkage. The process is repeated every few centimeters along the course of the vein. Initial thermal injury is followed by fibrosis of the treated vessel.
- Several reports describe that compared with more invasive surgical procedures, several newer methods (eg, radiofrequency ablation) are less invasive and are associated with fewer complications, with comparable efficacy.7,8 Similarly, others report radiofrequency ablation and these newer techniques are as safe and effective as surgery, but some caution the type of varicosity should dictate treatment as no single modality should be performed universally.9,10
- Antibiotics rarely are useful in patients with venous ulcerations.
Surgical Care
The primary goal of surgical therapy is to improve the venous circulation by correcting venous insufficiency by removing the major reflux pathways.
Traditional mechanisms of venoablation include ligation with stripping, simple ligation and division, sclerotherapy (with or without ligation), and stab avulsion (with or without ligation). These techniques offer roughly equivalent rates of technical success (although some disagreement exists between the medical and the surgical literature as to the prevalence and timing of varicose recurrences). Two newer methods of venoablation include RFA and EVLT.
For superficial vein treatment, primary surgery offers a lower rate of early recurrence, whereas sclerotherapy produces fewer complications and offers higher rates of patient satisfaction both early and at follow-up. The relatively higher incidence of complications associated with surgery is offset by the relatively lower likelihood of early recurrence. As yet, no treatment for deep venous insufficiency has been proven both safe and effective. All current surgical procedures are experimental, or they have a low success rate and a high complication rate.
- Vein stripping with ligation of the saphenofemoral junction is the most common surgical approach in cases of superficial venous insufficiency.
- Saphenofemoral ligation may be performed in combination with sclerotherapy or with microincision phlebectomy.
- Simple ligation and division of the incompetent vessels is an effective way to treat failed perforating vessels, but this procedure is associated with a high incidence of the early recurrence of reflux when it is applied to the greater saphenous vein.
- Skin grafts do not survive long unless the venous insufficiency has been treated, and after the venous insufficiency is ablated, the ulcer usually heals quickly, even without grafting.
Consultations
Consultation with a phlebologist (a physician or vascular surgeon specializing in venous diseases) often yields new options for patients with chronic and seemingly refractory disease. Venous insufficiency syndromes can be diagnosed and treated by means of a variety of specialized techniques with which a generalist may not be familiar.
Activity
Regular activity is an important ameliorating factor in patients with early or mild venous insufficiency syndrome. Patients with advanced disease do not tolerate activity well.
- Prolonged standing or sitting can aggravate the symptoms of venous insufficiency.
- Walking or running, bicycling, and swimming are excellent activities for patients with an intact and functioning calf muscle pump.
- Patients with obstructed venous outflow usually experience increased pain and swelling with activity.
- Patients with muscle pump failure usually have a markedly reduced exercise tolerance because of early leg fatigue.
Medication
No oral medication has yet been proven useful for the treatment of venous disease. Findings of prospective studies have not supported some manufacturers' claims about the effectiveness of their herbal products and nutritional supplements.
Sclerosing agents that are used to ablate refluxing veins and other anatomic structures can be grouped into several categories, including fatty alcohols (detergents), osmotic agents, and caustic agents. The safest and most widely used sclerosing agents are detergents.
Sclerosing agents
These agents are used for the primary sclerosis of reflux pathways and for the ablation of friable thin-walled veins judged to be at high risk for rupture and hemorrhage.
Sodium tetradecyl sulfate (Sotradecol, STS, STD)
Primary sclerotherapy is the treatment of choice for ablation of refluxing superficial venous circuits in the absence of saphenofemoral junctional reflux. Also, treatment of choice for ablation of venous bleeding sites and friable thin-walled varices. In general, 1% most useful; may use 3% in larger varicosities.
Adult
Variceal bleeding: Inject 0.5-2 mL of 1% solution into varicosity, slightly proximal and distal to site of hemorrhage; apply firm pressure above and below area for several min to increase contact time with vascular endothelium; 1 mL maximum is preferred; not to exceed 10 mL in a single treatment
Pediatric
Not established
None reported
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
After injection, apply firm local compression bandage to ruptured varix; avoid a tourniquet effect that could cause distal venous stasis; extravasation may cause local soft-tissue necrosis; patients with variceal rupture should be referred to phlebologist (specialist in venous disease) for definitive care of other associated varices and failed high-pressure perforators that are invariably present
More on Venous Insufficiency |
| Overview: Venous Insufficiency |
| Differential Diagnoses & Workup: Venous Insufficiency |
 Treatment & Medication: Venous Insufficiency |
| Follow-up: Venous Insufficiency |
| Multimedia: Venous Insufficiency |
| References |
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References
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Sadick NS. Advances in the treatment of varicose veins: ambulatory phlebectomy, foam sclerotherapy, endovascular laser, and radiofrequency closure. Dermatol Clin. Jul 2005;23(3):443-55, vi. [Medline].
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Feied CF. Peripheral venous disease. In: Rosen and Barkin, eds. Emergency Medicine Principles and Practice. Vol 3. 4th ed. St. Louis, Mo: Mosby-Year Book; 1998:Chapter 107.
Goldman MP. Sclerotherapy: Treatment of Varicose and Telangiectatic Leg Veins. 2nd ed. St. Louis, Mo: Mosby-Year Book; 1995:1-519.
Weiss RA, Feied CF, Weiss MA. Vein Diagnosis & Treatment: A Comprehensive Approach. New York, NY: McGraw-Hill; 2001:1-304.
Further Reading
Keywords
venous insufficiency, venous stasis, postphlebitic syndrome, venous reflux, stasis dermatitis, stasis ulcer, venous ulcer, valvular incompetence, DVT, deep vein thrombosis, deep venous thrombosis, superficial venous incompetence, superficial venous insufficiency, varicose veins, junctional high-pressure disease, perforator high-pressure disease, venous hypertension
