Venous Insufficiency Treatment & Management

Venous insufficiency is neither uncommon nor benign. ^[22] Treatment is aimed at ameliorating the symptoms and, whenever possible, at correcting the underlying abnormality.

No oral medication has yet been proven useful for the treatment of venous disease. Graduated compression is the cornerstone of the modern treatment of venous insufficiency. Surgical or endovenous therapy is commonly reserved for those with discomfort or ulcers refractory to medical management. The primary goal of such therapy is to improve the venous circulation by correcting venous insufficiency by removing the major reflux pathways.

As yet, no treatment for deep venous insufficiency has been proved to be both safe and effective. Valvuloplasty is occasionally successful, but the incidence of postoperative deep venous thrombosis (DVT) is high. Venous bypass is successful in select patients. External vein valve banding devices and thermally induced collagen shrinkage procedures are being investigated in clinical trials. Restoration of valvular function to incompetent deep veins remains an important focus of research for vascular physicians.

Although deep system disease is often refractory to treatment, 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. Antibiotics rarely are useful in patients with venous ulcerations.

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. Guidelines have been established by the American Venous Forum and Society for Vascular Surgery, ^[23] and these guidelines are discussed in a review of modern management of venous insufficiency and varicose veins. ^[24]

The standard approach has been to use gradient compression stockings that provide 30-40 or 40-50 mm Hg of compression at the ankle, with gradually decreasing compression at more proximal levels of the leg. ^[25] This amount of graduated 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 that can exacerbate 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 1 pair of calf-high (or thigh-high with waist attachment or panty-hose style) compression hose providing a pressure gradient of 30-40 mm Hg, with refills as needed.

A different approach to graduated compression was assessed in a 2012 study of 401 ambulatory patients with CVI, in which standard “degressive” compression stockings were compared with “progressive” compression stockings that applied maximal pressure over the calf. ^[26] The investigators concluded that the progressive compressive stockings were superior with respect to improvement of pain and lower leg symptoms in patients with CVI, as well as being easier to apply.

Additional physical measures may also be helpful. Leg elevation causes venous flow to be augmented by gravity, lowering venous pressures and ameliorating edema. In a sitting position, the patient’s legs should be above the thighs; supine, they should be above the level of the heart. The Unna boot, first described in 1854, is now a 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.

Venous insufficiency is an especially common problem among postmenopausal women. In a randomized, controlled trial involving 65 postmenopausal women with venous insufficiency, the use of myofascial release therapy in combination with kinesiotherapy over a 10-week treatment period was found to yield significant improvements in basal metabolism, intracellular water, diastolic blood pressure, venous blood flow velocity, pain, and emotional role. ^[27]

Venoablation is reserved for those with discomfort or ulcers refractory to medical management. The primary goal of surgical and endovenous approaches is to correct venous insufficiency by removing the major reflux pathways. Techniques for venoablation include the following:

• Ligation with stripping

• Simple ligation and division

• Sclerotherapy (with or without ligation)

• Stab evulsion (with or without ligation)

• Radiofrequency ablation (RFA) ^[28]

• Endovenous laser therapy (EVLT) ^[28]

All methods of venoablation are effective (although there is some disagreement between the medical and the surgical literature as to the prevalence and timing of varicose recurrences). Once the overall volume of venous reflux is reduced below a critical threshold by any mechanism, venous ulcerations heal, and patient symptoms are resolved. ^{[29, 30]}

In general, vein ligation is reserved for cases of chronic venous insufficiency (CVI) involving reflux in the saphenous system that causes severe symptoms. ^[31] Thus, a diagnosis of reflux must be established preoperatively, usually with photoplethysmography or duplex imaging. [#Contraindications]In patients with symptomatic varicosities of the great saphenous vein (GSV), deep occlusion must be ruled out; it is an absolute contraindication to vein ligation. Venography of the deep venous system before superficial vein ligation is imperative.

Sclerotherapy is performed by injecting or infusing a sclerosing substance into the refluxing vessel to produce endothelial destruction and fibrosis of the treated vessel. Injection of a sclerosing agent directly into veins usually is reserved for telangiectatic lesions rather than CVI. Phlebotonics have not been proven to be beneficial for CVI. ^[32]

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. It has been shown to yield excellent long-term (>5 years) results and a low rate of complications, which vary with the laser wavelength used.

RFA is performed by passing a special radiofrequency (RF) catheter from the knee to the groin and then carrying out controlled and preset heating of the targeted vessel until thermal injury causes shrinkage. The process is repeated every 7 cm along the course of the vein. Initial thermal injury is followed by fibrosis of the treated vessel. RFA has been shown 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.

Subfascial endoscopic perforator surgery (SEPS) has also been employed to treat CVI. Endoscopic techniques are used to find and ligate perforating veins. Preliminary reports showed that after SEPS, the average healing time for ulcers was 42 days, with a recurrence rate of 3%, and that ulcers treated with SEPS healed 4 times faster than ulcers treated conventionally. In addition, the morbidity of SEPS was significantly lower than that of traditional operations.

Overall, approximately 8% of patients require surgical intervention for CVI. Different options are suitable for different conditions (see below). 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.

Varicose bleeding

Patients with varicose bleeding usually present to an emergency department (ED), 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 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. Tretbar reported a series of cases that were successfully treated by means of primary compression sclerotherapy over a 3-year period. ^[33]

Superficial venous insufficiency

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 lower likelihood of early recurrence after surgical treatment offsets the greater risk of complications. ^{[34, 35]}

Vein stripping with ligation of the saphenofemoral junction has long been the most commonly adopted surgical approach in cases of superficial venous insufficiency. At present, it is increasingly being replaced by endovenous ablation techniques such as RFA and EVLT.

The original approach to vein ligation for superficial vein disorders involved removal of the entire GSV system; this approach has largely been supplanted by the stab evulsion technique. In stab evulsion, several 2- to 3-mm incisions are made overlying the GSV 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 GSV 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, it is mandatory to establish a diagnosis of reflux preoperatively.

Simple ligation and division of the incompetent vessels is not an effective way of treating failed perforating vessels, because this procedure is associated with a high incidence of early recurrence of reflux when it is applied to the GSV.

Skin grafts do not survive for very long unless the venous insufficiency has been treated, and after the venous insufficiency is ablated, the ulcer usually heals quickly, even without grafting.

Deep venous insufficiency

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, which renders them less symptomatic. Clot lysis (eg, with tissue plasminogen activator [TPA] or urokinase) and thrombectomy have been tried but have largely been abandoned because of extremely high recurrence rates.

For iliofemoral disease, the operation of choice is a saphenous vein crossover graft. In this procedure, the contralateral saphenous vein is mobilized and divided at its distal end, then tunneled suprapubically and anastomosed to the femoral vein on the diseased side (see the image below). The result is diversion of venous blood through the graft and into the intact contralateral venous system. Because of a relatively high failure rate (20%), ringed polytetrafluoroethylene (PTFE) grafts are used. Long-term patency has not been determined.

For occlusion of the superficial femoral vein, the Husni bypass, described by Warren in 1954 and Husni in 1983, ^[36] may be considered. In this procedure, the ipsilateral GSV is harvested and used as an in-situ popliteal-femoral vein bypass. Because of its high failure rate (approximately 40%), the Husni bypass is performed infrequently. A minimally invasive technique using stents has been described. ^[37]

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

With vein segment transposition, a normally functioning vein that is in close proximity to the diseased vessel is identified. The incompetent vein is then dissected, mobilized, and transposed onto 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 system. The incompetent segment of the leg vein is excised and replaced with the transplant segment. Allograft or cadaveric vein transplants are being evaluated, with long-term results pending.

Complications

Potential complications of surgical ablation of refluxing veins include the following:

• Infection

• Nerve injury (eg, to sural or saphenous nerves)

• Arterial injury

• Undesirable cosmetic outcomes

Potential complications of sclerotherapy include the following:

• Allergic reactions to sclerosants

• Cutaneous necrosis due to extravasation

• Inadvertent arterial injection (may cause loss of a limb)

Potential complications of RFA and EVLT include the following:

• Skin burns

• Thermal injury to adjacent tissues

• Inadvertent injury to deep veins

Postprocedural care

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

Observe patients 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.

Increased pain or swelling is an indication for repeat duplex ultrasonography to rule out DVT.

Regular activity is an important ameliorating factor in patients with early or mild venous insufficiency syndrome. Prolonged standing or sitting can aggravate the symptoms of venous insufficiency. Patients with advanced disease do not tolerate activity well.

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.

In general, patients with venous insufficiency should avoid prolonged standing or sitting. Correction of the underlying problem prevents progression of the disease.

In patients with early venous insufficiency, progression to overt signs of disease (eg, stasis dermatitis, skin breakdown, and ulceration) can virtually always be prevented with the use of compression hose that provide a pressure gradient of 30-40 mm Hg between foot and knee.

The importance of addressing CVI resides in the fact that over 2.5 million individuals have this disorder, from which around 20% percent present with venous ulcers as a complication. ^[21] Therefore, a reduction in the quality of life, exposure to financial constraints, and disability are frequently seen in this type of patient. The estimated annual expenditures dedicated to the management of venous ulcer disease exceeds $1 billion; hence, it is important to reduce the risk factors and increase the therapeutic options that could prevent disease and disability from complications of CVI.