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Health Protocols

Chronic Venous Disease: Varicose Veins And Venous Insufficiency

Conventional Treatment

Conservative Management

The initial management of chronic venous disease and varicose veins relies on conservative strategies to reduce symptoms, avoid complications, and prevent disease progression (Eberhardt 2014; St. George 2012).

Compression therapy. Compression therapy is a first-line, non-invasive, conservative management option for chronic venous disease (NICE 2013; Wittens 2015). Compression can be accomplished with stockings, bandages, boots, and pneumatic devices. Of these, stockings are the most common form, though initial therapy with elastic bandages has been recommended for advanced disease and leg ulcers (Wittens 2015; Stucker 2016; Douketis 2016b).

Compression stockings provide external pressure on the superficial veins, which may shunt more blood to the deep veins. This decreases venous reflux and venous pressure; improves the efficiency of the muscle pump system; and reduces leg edema (Stucker 2016; Wittens 2015; Eberhardt 2014; Scherger 2012; NICE 2013). Compression stockings may be more effective when applied at the beginning of the day, before edema worsens (Douketis 2016b).

Shortcomings of compression therapy include low compliance due to discomfort and inconvenience, as well as an inability to address the underlying disease process (Zhan 2014).

Conventional graduated compression stockings apply high pressure at the ankles and decreasing pressure towards the knees. These are known as degressive compression stockings (Couzan 2012; Lim 2014). When used as directed, degressive stockings improve edema, discomfort, ability to remain active, and overall well-being. However, degressive stockings are often considered difficult to put on, particularly in the elderly, and estimates of non-compliance with this method of compression range from 30‒65% (Couzan 2012; St. George 2012; Wittens 2015).

Progressive compression stockings are a newer method of compression therapy directed at improving comfort, efficacy, and compliance. These stockings provide a higher pressure at the calf than at the ankle, and have been demonstrated to be superior for symptom relief, reduction of occupational edema, and improving venous pumping. In addition, progressive stockings have been found to be more comfortable and easier to put on than degressive stockings (Couzan 2012; Mosti 2012; Mosti 2013).

More studies are needed to determine the most beneficial regimen with progressive and degressive compression stockings (Wittens 2015; Douketis 2016b; Eberhardt 2014).

Periodic elevation of legs. Periodic elevation of the legs above heart level is recommended to reduce leg swelling and promote relief of symptoms. In patients with advanced venous disease, leg elevation reduces leg volume and venous blood pressure, as well as improves circulation in inflamed skin. Leg elevation improves healing of leg ulcers and reduces their recurrence rate (Fort 2017a; Wittens 2015; Scherger 2012).

Unna boot inelastic bandages. The Unna boot is a treatment for venous ulcers. Zinc oxide-infused gauze is applied to the legs, covered with inelastic compression bandages, and worn continuously for up to seven days (UWHealth 2015; Douketis 2016b; de Abreu 2015; Wittens 2015). In a 13-week randomized clinical trial, the Unna boot was found to achieve better healing of large venous ulcers than standard elastic bandages (de Abreu 2015).

Intermittent pneumatic compression devices. Pneumatic compression devices are becoming more popular as adjuvants to conventional compression stockings. A pneumatic compression device is a sleeve or cuff that fits around the leg(s), filling with air to compress the legs and enhance venous circulation. The cuffs go through cycles of compression and relaxation that push venous blood back toward the heart and allow oxygen-rich arterial blood to continue flowing into the legs. These devices also support the activity of the muscles that promote venous blood flow in the foot and calf (Hettrick 2009). Intermittent pneumatic compression devices may be recommended to people at risk of deep vein thrombosis or those who have undergone recent surgery. The devices are typically used in the hospital but may be used at home in some cases (Johns Hopkins Medicine 2017). Intermittent pneumatic compression is contraindicated in individuals with an acute wound infection, deep vein thrombosis, or decompensated congestive heart failure (Kolluri 2011).

Pharmacological Therapy

Pentoxifylline. Pentoxifylline (Trental) is a drug that enhances blood flow and is indicated for certain types of vascular disease. Pentoxifylline also inhibits the secretion of the inflammatory cytokine tumor necrosis factor-alpha (TNF-α) (McCarty 2016; Pollice 2001). Multiple randomized trials have shown that pentoxifylline, alone or in conjunction with compression bandaging, accelerates healing of chronic venous ulcers (Jull 2012; Parsa 2012). Side effects of pentoxifylline are uncommon and mild, primarily gastrointestinal distress (Hallett 2014; Jull 2012).

Interventional Management

Sclerotherapy. Venous sclerotherapy is commonly used to treat varicose veins. This procedure involves injecting a compound into the vein to damage the vessel lining, causing the vein to degrade and eventually be reabsorbed by the body. The injection can consist of material in liquid or foam form. Sclerotherapy is inexpensive, generally provides rapid results, and is suitable for use in older or frail patients (Wittens 2015; Brittenden 2014).

Compounds used in sclerotherapy procedures include detergents, osmotic agents (hypertonic saline), or chemical irritants (chromated glycerin) (Wittens 2015). Sclerotherapy may be used alone or to complement surgical procedures in the treatment of chronic venous insufficiency (Scherger 2012).

After a sclerotherapy procedure, compression may be necessary to preserve vein closure (NIH 2014c; Alaiti 2017). Possible complications of sclerotherapy include superficial thrombophlebitis (inflammation of the vein wall), skin darkening, and blood clots (deep vein thrombosis or pulmonary embolism) (Wittens 2015; Scherger 2012).

Endovenous ablation. Endovenous ablation is a minimally invasive procedure for treating malfunctioning veins (ACP 2016; Fort 2017a). Laser ablation and radiofrequency ablation, the two most common techniques, generate heat energy to ablate (close off) diseased veins. Chemical ablation using ultrasound-guided foam sclerotherapy is also an option (Fort 2017a; Wittens 2015).

Laser and radiofrequency ablation are as effective as surgical vein stripping, but with faster recovery and less pain, and have become popular alternatives to stripping. Potential complications of endovenous ablation, though relatively rare, include burns, bruising, thrombophlebitis, deep vein thrombosis, and pulmonary embolism (Fort 2017a; Eberhardt 2014; Wittens 2015; Scherger 2012).

External laser therapy. External or transcutaneous laser therapy using long-pulsed lasers is partially effective for small spider veins and reticular (“feeder”) veins with a diameter of < 0.5 mm. In this procedure, pulses of laser light are transmitted through the skin to the targeted vein. The light energy is absorbed by hemoglobin in the vein and converted to heat energy, which closes the vein (Wittens 2015; Scherger 2012).

External laser therapy is less effective and more expensive than sclerotherapy for treating spider veins. However, external laser therapy is relatively risk-free, and can be a valuable alternative when sclerotherapy is contraindicated. These situations include allergy to sclerosing agents, fear of needles, and blood vessels too small for a fine needle (Wittens 2015; Meesters 2014; Scherger 2012). In addition, newer lasers, and combinations of laser treatment and sclerotherapy appear promising (Wittens 2015).

Conventional Surgery

Surgery is reserved for more advanced cases of venous disease that do not fully respond to less invasive procedures (Eberhardt 2014). However, not all randomized trials have found that surgery leads to better results than less invasive methods (Rasmussen 2011; Shadid 2012; Brittenden 2014; Wittens 2015; Scherger 2012). Varicose veins recur in 20‒60% of patients within five years of surgery (Gad 2012). Complications of surgical intervention for venous disease include bruising, infection, scarring, nerve injury, and injury to arteries (Zhan 2014; Scherger 2012; Weiss 2016; Gad 2012).

Vein ligation and stripping. Vein ligation and stripping is reserved for chronic venous insufficiency, to treat symptomatic disease involving reflux in the saphenous vein system (Weiss 2016).

Vein ligation and stripping is usually performed on an outpatient basis and under general anesthesia. Small incisions are made in the skin, and the damaged vein is tied off and removed. Recovery time is approximately one to four weeks. Good cosmetic results, symptom relief, and avoidance of long-term risks related to varicose veins are benefits of this procedure. Vein stripping does not, however, prevent the formation of new varicose veins (Wittens 2015; NIH 2014c; Scherger 2012).

Ambulatory phlebectomy. Similar to vein stripping, ambulatory phlebectomy involves the removal of varicose veins through small incisions in the skin. This procedure is generally performed for varicose veins close to the skin surface. Ambulatory phlebectomy is often used in conjunction with endovenous ablation (Fort 2017a; NIH 2014c; Wittens 2015).

Unlike vein stripping, ambulatory phlebectomy is a minor procedure performed under local anesthesia in a physician’s office. It is safe and provides immediate symptom relief along with excellent cosmetic results (Fort 2017a; Wittens 2015).

Subfascial endoscopic perforator vein surgery. Perforator vein surgery is a newer, minimally invasive procedure indicated for advanced venous insufficiency. With this procedure, the incision site can be further away from the affected area, which can be advantageous in cases where local tissue damage prevents surgical access. This approach is indicated in patients who have compromised perforator veins, and is associated with a high rate of ulcer healing and a low rate of ulcer recurrence (Eberhardt 2014; Scherger 2012).

VenaSeal Closure System

The VenaSeal closure system is an in-office procedure that uses a liquid adhesive (a specially formulated cyanoacrylate) injected through a catheter ins vein. The VenaSeal system was approved by the Food and Drug Administration (FDA) in 2015 for treating symptomatic superficial varicose veins of the legs, and allows patients to quickly resume normal activities (FDA 2015). Multiple clinical trials have shown VenaSeal to be safe and effective for treating refluxing and malfunctioning great saphenous veins and relieving symptoms (Gibson 2017; Almeida 2015; Morrison, Gibson, McEnroe 2015; Morrison, Gibson, Vasquez 2017; Proebstle 2015).

Patients who are hypersensitive to the VenaSeal adhesive; have venous blood clots with acute inflammation; or have systemic infections should not undergo the VenaSeal procedure. Potential side effects from VenaSeal are typical of treatments for chronic venous disease and include phlebitis (vein inflammation) and paresthesia (burning or tingling) in the treatment region (FDA 2015).