Chronic Venous Insufficiency Treatment & Management

Nonsurgical treatments for CVI include the following:

Leg elevation

By keeping the legs elevated, venous flow is augmented by gravity, lowering venous pressures and ameliorating edema. While sitting, the legs should be above the thighs. Supine, the legs should be above the level of the heart.

Compression stockings

First described by Jobst in 1940, compression stockings produce graded pressures from the foot to the knee or thigh to decrease edema and minimize venous hypertension. For two clinical studies of compression therapy, see Vanscheidt et al.^[11]

Unna boots

First described by Unna in 1854, the Unna boot now is the mainstay of treatment for people with venous ulcers. Unna boots are rolled bandages that contain a combination of calamine lotion, glycerin, zinc oxide, and gelatin.

Injection sclerotherapy

Injection of sclerosing agent directly into veins usually is reserved for telangiectatic lesions rather than CVI.

Phlebotonics have not been proven to be beneficial for CVI.^[12]

Approximately 8% of patients require surgical intervention for CVI. Surgical treatment is reserved for those with discomfort or ulcers refractory to medical management. Below are several conditions and the surgical options considered appropriate for each.

Chronic venous insufficiency resulting from superficial vein disorders

Vein ligation is the treatment of choice for superficial vein disorders. Historically, the entire greater saphenous vein system was removed; this has been replaced by the stab evulsion technique.

Several 2- to 3-mm incisions are made overlying the greater saphenous at various levels. The vein is dissected from the underlying tissues and any perforators are ligated. A small hook or blunt needle is used to extract as much of the vein as possible.

Typically, stab evulsion is limited to areas above the knee in the greater saphenous system to avoid damage to the saphenous nerve or sural nerve. This technique is reserved for CVI in which reflux in the saphenous system occurs and causes severe symptoms. For this reason, a diagnosis (usually accomplished with photoplethysmography or duplex imaging of reflux) must be established preoperatively. Hematoma, sural or saphenous nerve damage, and infection are possible complications of vein ligation.

Chronic venous insufficiency resulting from deep vein disorders

The decision to operate on a patient with venous obstruction in the deep veins should be made only after a careful assessment of symptom severity and direct measurement of both arm and foot venous pressures. Venography alone is not sufficient because many patients with occlusive disease have extensive collateral circulation, rendering them less symptomatic. Clot lysis (eg, tissue plasminogen activator [TPA], urokinase) and thrombectomy have been tried but have largely been abandoned owing to extremely high recurrence rates.

For iliofemoral disease, the operation of choice is a saphenous vein crossover graft. In the procedure, the contralateral saphenous vein is mobilized and divided at its distal end. It then is tunneled suprapubically and anastomosed to the femoral vein on the diseased side. The result is the diversion of venous blood through the graft and into the intact contralateral venous system, as depicted in the image below.

Because of a relatively high failure rate of 20%, ringed polytetrafluoroethylene (PTFE) grafts are used. The long-term patency is unknown.

Superficial femoral vein occlusion

Described by Warren in 1954 and Husni in 1983,^[13] the Husni bypass (as it has come to be called) is used to treat occlusion of the superficial femoral vein. The ipsilateral greater saphenous vein is harvested and used as an in situ popliteal-femoral vein bypass. This surgery is performed infrequently due to the high failure rate (approximately 40%). For a minimally invasive technique using stents, see Raju and Neglén.^[14]

Deep vein incompetence

Valvuloplasty is reserved for patients with a congenital absence of functional valves. A venotomy is performed, and the valve cusps are plicated. To ensure an adequate result, plicating 20-25% of each cusp is recommended. The addition of a PTFE sleeve around the operative site is used routinely to maintain valve integrity. When combined with the ligation of perforating veins, valvuloplasty has a superior outcome in 80% of cases after 5 years.

With vein segment transposition, a vein with normal function in close proximity to the diseased vessel is identified. The incompetent vein then is dissected, mobilized, and transposed on to the normal vein distal to a functional valve.

With vein valve transplantation, a valve-containing segment of a competent axillary or brachial vein is mobilized and inserted into either the popliteal or the femoral systems. The incompetent segment of the leg vein is excised and replaced with the transplant segment. Allograft or cadaveric vein transplants are being tested, with long-term results pending.

Both invasive and noninvasive studies are conducted.

Invasive studies

Contrast venography is the criterion standard for assessing venous reflux, vein abnormalities, and the presence of valves. Ambulatory venous pressure is measured by placing a catheter in a vein on the dorsum of the foot during exercise.

Noninvasive studies

Commonly, both Doppler bidirectional-flow studies and Doppler color-flow studies are used to assess venous flow, its direction, and the presence of thrombus.

Photoplethysmography uses infrared light to assess capillary filling during exercise. Increased capillary filling is indicative of venous reflux and, consequently, incompetent veins.

Outflow plethysmography involves placing and subsequently releasing a tourniquet on the lower extremity; the veins should quickly return to baseline pressures, and failure to do so indicates reflux.

Careful monitoring of a patient's cardiac status and vital signs is extremely important. In addition, periodic monitoring of hemoglobin and hematocrit levels yields essential intraoperative data.

Anticoagulation with heparin (or low molecular weight heparin) in the immediate postoperative period and long-term prophylaxis with Coumadin are recommended.

Patients should be observed frequently for wound infection after discharge, beginning 1 week postoperatively. Sutures or staples typically stay in 2-4 weeks, depending on the health of the skin at the operative site.

For excellent patient education resources, visit eMedicine's Circulatory Problems Center. Also, see eMedicine's patient education article Varicose Veins.

Hematoma, sural or saphenous nerve damage, and infection are possible complications of lower-extremity vein ligation.

Clot lysis (eg, TPA, urokinase) and thrombectomy have been tried but generally have been abandoned due to extremely high recurrence rates.

For iliofemoral disease, the operation of choice is a saphenous vein crossover graft. Due to a relatively high failure rate of 20%, ringed PTFE grafts are being used. The long-term patency is unknown.

The Husni bypass for superficial femoral vein occlusion is performed infrequently due to the high failure rate (approximately 40%).

Surgery for CVI resulting from deep vein incompetence includes valvuloplasty and allograft or cadaveric vein transplant. Valvuloplasty for patients with congenital absence of functional valves, when combined with the ligation of perforating veins, has a superior outcome in 80% of cases after 5 years. Allograft or cadaveric vein transplants are being tested, with long-term results pending.

Tsai et al examined the National Inpatient Sample from 1988-2000 and found that mean hospital charges were $13,900 and did not change over the time period examined.^[15] They also found that deep venous thrombosis affected 1.3% of patients and amputation was necessary in 1.2%, with an overall mortality of 1.6%.

Subfascial endoscopic perforator surgery (SEPS) is gaining in popularity as a means of treating CVI. Endoscopic techniques are used to find and ligate perforating veins. Preliminary reports are encouraging. The 1997 North American Subfascial Endoscopic Perforator Surgery Registry showed that after SEPS, the average healing time for ulcers was 42 days, with a recurrence rate of 3%. Ulcers treated with SEPS heal 4 times faster than ulcers treated conventionally. In addition, morbidity of SEPS is significantly lower than traditional operations. Long-term results are pending.