How Do You Treat Chronic Venous Insufficiency?

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Chronic venous insufficiency is a frequently underdiagnosed venous disease that affects approximately 25 million people in the United States, with elderly individuals (>65 years) more vulnerable to developing this disease. An estimated cost of USD 3 billion per year is being spent in addressing this venous disorder, providing the perspective that CVI is an important burden both for individuals and healthcare systems.

So how do you treat chronic venous insufficiency? Treatment of chronic venous insufficiency first requires a proper diagnosis that may be done through a physical exam or non-invasive or invasive testing. Upon diagnosis, management plans that may depend on the preference of the patient or the healthcare provider may be provided, namely conservative management, interventional management, and surgical procedures.

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Signs And Symptoms Of Chronic Venous Insufficiency

Chronic venous insufficiency doesn’t just appear one day: due to a plethora of factors, it adds up through time, and eventually gets worse if untreated. If you’re looking for signs and symptoms, the most common manifestations of chronic venous insufficiency (CVI) include enlargement of leg veins, edema, pain in the legs, and changes in the appearance and quality of the skin. 

  • Dilated leg veins - Dilated leg veins are called differently based on their sizes. The types of enlargement of leg veins include varicose veins, reticular veins, and telangiectasias. The table below shows the summary of the differences between these dilated veins.
Type Of Dilated VeinLocationSize
Varicose Veinalso known as varix, varices, and varicositiessuperficial thrombophlebitis, a condition characterized by pain and inflammation in the surrounding area, may also arise with varicose veinsSubcutaneous> 3 mm
Reticular Veinalso known as blue veins, subdermal varices, and venulectasiasSubdermal1 mm to 3 mm
Telangiectasiaalso known as spider veins, hyphen webs, and thread veinsIntradermal< 1 mm
  • Edema - Edema is the characteristic swelling that starts from the perimalleolar region and extends up to the legs. This is due to fluid buildup in the legs.
  • Leg discomfort - Leg discomfort is pain or heaviness after prolonged standing that may be relieved by raising the legs up to above the level of the heart. An increase in blood pressure and volume in the venous system may be the reason behind this symptom.
  • Hyperpigmentation - Darkening of the skin may be exhibited by patients with CVI because of deposition of hemosiderin (a result of the entrapment and build-up of iron in tissues) and pronounced eczematous dermatitis (a condition characterized by redness and itchiness).
  • Lipodermatosclerosis - This is an associated condition with chronic venous insufficiency found deep in the lower extremities above the ankle. It’s brought by the inflammation of the dermis and subcutaneous tissue.

Other conditions may also arise directly via ulcer formation or even indirectly, like in cases of patient anxiety due to CVI. It’s important to reach out to healthcare professionals as soon as you can so as to prevent further complications from arising.

  • Ulcer formation - CVI may become so severe that it may lead to occlusion of blood vessels supplying the skin, causing its poor oxygenation and nourishment. Venous leg ulcers arise as a result of this pathological process. Ulcer healing entails treatment of its underlying cause, including CVI.
  • Malignancy - characterized by skin breakdown
  • Depression and anxiety - Depression and anxiety are psychiatric conditions that patients with CVI may experience due to loss of confidence attributed to aesthetic changes of the skin brought by CVI.

How Chronic Venous Insufficiency Is Diagnosed

The establishment of a diagnosis is important to provide the proper treatment strategies to every disease entity and chronic venous insufficiency (CVI) is no exception to this. An accurate diagnosis of CVI may be arrived at through careful history-taking and physical examination, complemented with non-invasive and invasive testing procedures.

1) Medical History And Physical Examination

Medical history is important to determine possible risk factors associated with CVI that the patient exhibits. Risk factors of CVI include advanced age, sedentary lifestyle, increased body mass index (i.e., overweight or obesity), being female, and a family history of varicose veins or other cardiovascular disorders.

On the other hand, conducting a physical exam is important to look at the signs and symptoms that may help in increasing the certainty of the diagnosis of CVI. This involves examining the patient in an upright position to observe the maximum distention of veins.

A procedure used in the physical examination called the classic tourniquet (the Brodie-Trendelenburg) test may also be performed to differentiate deep from superficial venous reflux. In this procedure, the rapid dilation of the varicose veins is indicative of deep venous reflux, while >20 seconds of dilation is indicative of superficial venous reflux.

Upon history-taking and physical examination, a classification scheme may be used to further evaluate CVI and the associated valvular reflux, namely CEAP Classification and Venous Clinical Severity Score. 

2) Non-invasive Testing

Diagnostic techniques under non-invasive testing involve the use of sound waves, air displacement, or other imaging modalities to ascertain the involvement and extent of the venous disease. These techniques include the following: 

  • Venous duplex imaging (the most common technique for the diagnosis of CVI and is recommended by clinical practice guidelines)
  • Air plethysmography 
  • Computed tomography venography or magnetic resonance venography

3) Invasive Testing

Invasive procedures for diagnosis of CVI involve the injection of contrast medium (contrast venography), use of a catheter-based ultrasound probe (intravascular ultrasound), and injection of a needle in the dorsal foot which is then connected to a transducer (ambulatory venous pressure, the gold standard in determining the mechanisms of blood in CVI).

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Conservative Management

Conservative therapy entails the use of non-invasive and non-surgical options to address a disease. In the case of CVI, it's used with the primary goal of reducing symptoms, preventing complications, and delaying disease progression for the overall improvement of the quality of life of patients with CVI. Treatment strategies under conservative management include wound and skincare, pharmacologic therapy, and exercise therapy.

1) Wound And Skin Care

Venous obstruction caused by CVI may lead to the formation of breaks in the skin, which predisposes the skin to infection and other skin conditions associated with CVI such as stasis dermatitis and venous ulcer. 

Skin health must be maintained with the use of topical moisturizers to avoid the fissuring and breakdown of dry skin. Aggressive wound care using hydrocolloids and foam dressings must be done if a venous stasis ulcer occurs.

2) Pharmacologic Therapy

Drugs and other substances with venoactive properties (i.e., those that can decrease vascular permeability, modulate the inflammatory response, stabilize the vascular tone, and regulate platelet aggregation) are being evaluated for their use in addressing CVI (it's widely used in Europe but not in the United States). These venoactive substances include:

  • coumarins (α-benzopyrenes)
  • flavonoids (γ-benzopyrenes)
  • saponosides (horse chestnut extracts)

Other drugs that are considered useful in managing the symptomatology of CVI include:

  • Acetylsalicylic acid - Also known as aspirin, this is a blood thinner that can decrease the viscosity of blood and prevent a blood clot from forming.
  • Diuretics - This class of drug can reduce excess fluid from the body associated with CVI and other cardiovascular disorders and thus reduce swelling associated with fluid build-up
  • Pentoxifylline - This drug can help reduce the effects of the inflammatory response and can help improve blood flow.

3) Exercise Therapy

Graded or structured exercise programs can help rehabilitate the calf muscle pump functions which are impaired in CVI. Physical activity may also help an individual to lose weight and thus reduce an aggravating factor for CVI.

Surgical Procedures

Surgical intervention is a treatment strategy employed in patients who aren't responsive to conservative management (i.e., those with recurring symptomatology, especially non-healing venous leg ulceration). Surgical treatment of patients with these problems must already be considered to prevent the occurrence of severe complications associated with CVI. Conventional surgery procedures currently available include:

  • Surgery for truncal vein or venous tributaries
  • Perforator vein surgery,
  • Venous valve reconstruction.

Vein Center Doctor: Offering The Best Outpatient Vein Treatments

sclerotherapy treatment performed by professional vein doctor

At Vein Center Doctor, healthy patients are our top priority. We're committed to helping our patients address their vascular disease through a combination of patient-centered medical care and expertise in the use of the latest technologies or standards of care recommended by clinical practice guidelines. We offer the best outpatient vein treatments like radiofrequency ablation, endovenous laser treatment, sclerotherapy, VenaSeal, and compression therapy.

1) Radiofrequency Ablation

Radiofrequency ablation is a kind of thermal ablation that uses heat energy delivered by radiofrequency catheters with a heating element at its tip to destroy the inner lining of the vein. It's FDA-approved, minimally invasive, and only requires local anesthesia, making it an outpatient procedure where patients can resume their normal activities as soon as possible.

Patients are placed in a supine position and the affected leg is sterilized prior to the procedure. At the end of the procedure, the site of entry of the catheter will be manually compressed followed by the use of compression bandages or stockings for 1 to 3 days to avoid side effects such as bruising and tenderness.

Despite the benefits of this procedure, individuals with a superficial vein diameter of less than 2 mm, medical history of deep vein thrombosis and malignancy, or pregnant women must not undergo this procedure.

2) Endovenous Laser Treatment

Endovenous laser ablation is a type of interventional management. Like radiofrequency ablation, it uses local anesthesia to make the patient more comfortable by preventing skin burns and the sensation of pain. It's a a kind of procedure where heat energy delivered closes an incompetent vein through scar tissue formation, resulting to the redirection of blood flow to healthy veins.

However, unlike radiofrequency ablation, it's a laser therapy which uses a catheter where laser fiber of 810-nm or 940-nm diode is passed through to prevent reflux of saphenous vein, superficial vein, and perforator vein. This procedure has no downtime and provides immediate relief although side effects may occur such as infection, bruising, and nerve damage. 

3) Sclerotherapy

This interventional management entails the use of sclerosing agents such as a hypertonic solution of sodium chloride (23.4%), detergents such as sodium tetradecyl sulfate, and sodium iodide. It's used as a primary treatment and an adjunctive therapy for surgery in a variety of conditions such as dilated veins, bleeding varicosities, and small cavernous hemangiomas.

This procedure may be classified into 2 types, the liquid sclerotherapy and ultrasound-guided foam sclerotherapy. When compared, ultrasound-guided foam sclerotherapy showed a better efficacy but more painful treatment. Side effects of the 2 types of sclerotherapy also don't vary, and include local inflammation, thrombophlebitis, and hyperpigmentation.

4) VenaSeal

The VenaSeal closure system is an innovative, minimally-invasive procedure. Before proceeding with this procedure, ultrasound examination is performed first to locate the target vein at its most distal point which will serve as the access site. 

Guided by ultrasound imaging, flushing is then done using saline solution then the medical grade VenaSeal adhesive is delivered using a delivery catheter. This procedure follows a delivery sequence where 3 cm of adhesive is delivered every 3 seconds until the entire length of the target vein is covered. 

Compression of the area will then be done followed by placing a bandage over the insertion site. 

5) Compression Therapy

Compression therapy is the standard of care for chronic venous insufficiency, with the primary goal of compressing the leg and preventing the fluid build-up that may result due to venous hypertension. Compliant patients are provided the benefits of improved pain, swelling, skin pigmentation, and activity. It's also shown to be a good venous ulcer treatment strategy as it's capable of healing and preventing the recurrence of venous ulcer.

There are numerous compression garments and types of compression systems available. Different types of compression garments include:

  • graded elastic compression stockings
  • paste gauze boots
  • layered bandaging
  • adjustable layered compression garments

Meanwhile, some types of compression systems include:

  • inelastic compression therapy
  • elastic compression therapy
  • single component systems
  • multicomponent systems

The Best Outpatient Vein Treatments At Vein Center Doctor

Proper diagnosis is the first step in the treatment of chronic venous insufficiency. Upon diagnosis, medical management of this vascular disease may be done through conservative management, interventional management, or surgical management that depends on patient and physician preference.

At Vein Center Doctor, our team of healthcare professionals headed by Dr. Rahul Sood provides excellent, patient-centered care to effectively address vascular diseases and prevent potential complications associated with them. Say goodbye to your varicose veins and other leg vein issues by contacting us today at 862-227-1143 (NJ) or 862-227-1054 (NY) for your free consultation.

Your First Step To Being Vein Pain Free

Find exactly what you need to get rid of your vein-related problems. Dr. Sood and the rest of our team at Vein Center Doctor are ready to help: schedule your free consultation today.

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