Varicose Veins and Chronic Venous Insufficiency

How are varicose veins and chronic venous insufficiency managed?

Treatment depends on patient choice, severity and fitness. Options include:

• No treatment – not a life-threatening condition especially for varicose veins
• Conservative – trial of compression stockings
  

Compression treatment

In patients who are considering or unsure about surgery, a trial of compression treatment can be employed. Recommendations include:

• (20-30mmHg) for C2- C4 disease of the CEAP classification
• (30-40mmHg) compression therapy with garment for C6 ulcer disease

Most chronic discomfort and skin changes can be ameliorated by judicious use of compression garments, skin care, lifestyle changes and topical dressings.

Surgery

Surgery may be:

• Open – ligation and stripping of saphenous vein with multiple stab avulsions of varicose tributaries.
• Endo-venous – with or without multiple stab avulsions of varicose tributaries including energy devices such as Laser, Radiofrequency ablation, Microwave ablation and Chemical ablation or sealant with or without mechanical destruction such as Veneseal or Clarivein.
• Injection Sclerotherapy is — for small reticular “spider veins” (Aesthetic procedure).
  • Reticular veins are the thin walled blue vennules lying within the superficial compartments. They have diameter ranging from 1- 3mm.
    
  • Telangiectasia are dilated venule/ capillaries or arterioles measuring 0.1 to 1mm in diameter. Their color depends on the origin of the vessel.
    

When considering surgery, anatomy and general medical status are key. Endo-venous therapies are standard of care today. The obvious advantages include no incisions, no need for general anaesthesia, earlier return to work and higher likelihood of being performed as a day procedure. 

Nevertheless, there are instances where open surgery still proves advantageous. These include:

• Superficial saphenous tributaries
  When a superficial saphenous vein or tributary is closely adherent to the skin; be it an extra-fascial continuation of the main GSV, superficial branch or a separate anterior accessory or a true duplicate, the inability to provide a 1cm buffer zone between skin and vein with tumescent anaesthesia risk skin burns.
  Similarly, non-thermal techniques can result in inflammation and pigmentation issues when the vein is very superficial
• GSV dilatation or aneurysm greater than 2.5 – 3cm or along the GSV course are relative indications for open
• Chronic thrombophlebitis with formation of synechiae can prevent advancement of RFA catheter, laser sheath or glue catheter
• Excessive tortuosity likewise
• Acute clot with extension to the femoral junction

Treatment selection

Speak with your vascular surgeon to discuss treatment options.