Venous Insufficiency Treatment & Management

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, 6]}

• 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.^[7] 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 (EVT) has been shown to have excellent results (>5 y) and a low rate of complications, which vary with the laser wavelength used. EVT 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) has been show to be effective, with a low rate of complications. It has produced excellent results that have been confirmed with up to 10 years of follow-up. RFA is performed by passing a special radiofrequency (RF) catheter from the knee to the groin and by controlled and preset heating of the targeted vessel until thermal injury causes shrinkage. The process is repeated every 7 centimeters along the course of the vein. Initial thermal injury is followed by fibrosis of the treated vessel.
• Antibiotics rarely are useful in patients with venous ulcerations.

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.^[8]

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.^{[9, 10]} 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 was the most common surgical approach in cases of superficial venous insufficiency but has been replaced by endovenous ablation techniques such as RF and laser.
• Simple ligation and division of the incompetent vessels is not an effective way to treat failed perforating vessels, because this procedure is associated with a high incidence of the early recurrence of reflux when it is applied to the great 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.

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.

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.