With the advent of minimally invasive therapies and new anesthesia techniques, chronic venous disease can now be treated cost-effectively in an office setting.
Options for managing chronic venous disease have expanded in recent years. With the advent of minimally invasive therapies and new anesthesia techniques, most patients can now be treated cost-effectively in an office setting.
Here I detail the latest treatment options, as well as the traditional approaches. In a second article, I describe the workup of chronic venous disease.
TELANGIECTASES AND RETICULAR VEINS
Injection sclerotherapy. For telangiectases that are not associated with varicosities and underlying pathology, sclerotherapy using a fine 30-gauge needle can be at least temporarily effective. The desired effect of a sclerosant is fibrosis without excessive thrombosis. Sodium tetra-decyl sulfate, sodium morrhuate, and polidocanol-sclerosants known as detergents-can provoke epithelial damage and change the surface tension of the plasma membrane. Hypertonic solutions, such as hypertonic dextrose and hypertonic saline, also may be used.
Sodium morrhuate and sodium tetradecyl sulfate are the only sclerosants approved by the FDA. Sodium morrhuate is not frequently used because it can cause anaphylactic reactions. Sodium tetradecyl sulfate is associated with allergic reactions and postsclerotherapy hyperpigmentation. A widely used sclerosant, polidocanol, is not approved by the FDA but is currently undergoing trials. Polidocanol is well tolerated, does not cause burning (such as that seen with hypertonic solutions), and is associated with a low incidence of allergic reactions and postsclerotherapy hyperpigmentation.1
Laser therapy. The laser has been used to manage telangiectases. However, this treatment is more painful than injection sclerotherapy, and many phlebologists feel it has no cosmetic advantage in the legs.
For patients who have primary varicose veins without advanced sequelae of chronic venous disease, a number of treatment options are available.
Compression therapy. The most conservative method for managing varicose veins of the lower legs is the use of graduated compression stockings. These stockings can alleviate symptoms; however, they do not eliminate the underlying, unsightly veins.
Surgical ligation and stripping. This procedure involves removal, or stripping, of the great saphenous vein. If the saphenofemoral valve at the groin is incompetent, the vein can be tied off and transected. Because stripping or removing the great saphenous vein from the groin to the ankle can lead to saphenous nerve neuralgia and numbness along the medial aspect of the calf to the foot, most surgeons strip the saphenous vein from the groin to the knee.
Saphenous vein removal with an inversion technique-inverting the vein into itself-causes less surrounding tissue trauma and pain than conventional techniques. With the use of tumescent anesthesia-in which a local anesthetic is mixed with saline and injected around the vein-saphenous vein removal can be performed in an office setting without sedation in certain patients.
Stab phlebectomy. Secondary varicosities can be managed with stab phlebectomy. This is performed with local or tumescent anesthesia, a No. 11 scalpel or 18-gauge needle to make the tiny incisions, and small hooks to avulse the affected vein segments. Phlebectomy has been shown to be highly effective in eliminating large varicosities. The procedure is followed by compression and can be performed alone or in conjunction with ligation and stripping.
Nonsurgical ablation. Internal occlusion of the great or small saphenous vein using foam sclerotherapy, radiofrequency energy, or laser closure is increasing in popularity.
Echo-guided foam sclerotherapy. In the past, sclerotherapy of the great or small saphenous vein was associated with a relatively high incidence of recurrence of varicose veins in the first few years. Part of the problem was that varicosities were injected, rather than the axial saphenous vein. Because the source of pressure was not treated, recanalization was frequently seen. When sclerotherapy was combined with ligation at the saphenofemoral junction, recurrence was less frequent but was still significant.
Studies performed by the Spanish phlebologist Cabrera2 in 1997 showed excellent and enduring results using a foam solution of polidocanol. These results have been reproduced in other studies using polidocanol or sodium tetradecyl sulfate, even when injecting the axial great and small saphenous veins. Foam sclerotherapy concentrates the sclerosant and allows it to remain in contact with the vein wall longer when the feet are elevated.
Guidance with ultrasonography allows adequate treatment of the saphenous vein and occasionally of the perforator vein. Ultrasonography has also resulted in a much lower incidence of extravasation of the sclerosant because it allows the physi-cian to see veins not apparent when the patient is lying down, facilitates the safe placement of the needle, and is a means of visualizing the injected material.
In British studies of liquid sclerotherapy, excellent results were achieved when researchers placed needles sequentially in varicosities along the saphenous vein, elevated the leg to exsanguinate the extremity, injected the solution, and immediately wrapped the leg with a firm elastic dressing (which was left in place for several weeks).3 In the United States, patients have been less tolerant of the degree and duration of compression. It has been repeatedly shown, however, that those patients who wear compressive dressings-either a wrap or elastic stockings-for several days after treatment experience less phlebitis and postsclerotherapy hyperpigmentation.
Endovenous laser or radiofrequency ablation. This relatively new mode of therapy is used predominantly for occlusion of the great saphenous vein; however, it may be used for the small saphenous vein. Endovenous laser or radiofrequency ablation can be performed as an outpatient office procedure with the use of tumescent anesthesia. A catheter is threaded through the saphenous vein from a distal site to a point just below the saphenofemoral junction. Activation of the laser or radiofrequency energy through the catheter causes transmural injury and vein occlusion (Figure).
Once endovenous laser or radiofrequency ablation is complete, the leg is wrapped with an elastic bandage, which is kept in place for several days. After the axial (great or small saphenous) vein is closed, the varicose branches are treated with stab avulsions or sclerotherapy. The results are comparable to those of stripping procedures; patients experience much less pain and a shorter recovery. Some investigators be- lieve that neovascularization, which may lead to recurrence, occurs less frequently around the saphenous stump.4
CHRONIC VENOUS INSUFFICIENCY
The management of advanced venous disease is similar to that of varicose veins; however, there are additional treatment options.
Treatment of deep vein incompetence. In patients with widely incompetent deep veins, some investigators have performed transplantation or transposition of a competent valve to the system or repair of 1 or more of the valves.5 These are very specialized procedures that are performed only in a few centers with mixed results. In most clinical settings, deep vein incompetence is treated with elastic compression or is "partially" treated by addressing the superficial and perforator veins.
Treatment of perforator vein incompetence. Although severe isolated incompetence of the superficial system may lead to the development of ulcers, the evidence suggests that at least 2 venous systems are involved in the majority of patients with venous ulcers.6,7 Perforator incompetence is present in most of these patients.
Subfascial endoscopic perforator surgery. This technique for ablation of perforator veins through an endoscope placed subfascially at a site proximal to skin changes and ulcerations was developed in 1985.8 Subfascial endoscopic perforator surgery (SEPS) has since been refined using laparoscopic instrumentation with balloon dissection and carbon dioxide insufflation.9
SEPS is usually performed on the medial aspect of the leg. The procedure requires general anesthesia and can be challenging when advanced skin and subcutaneous changes to the distal leg are present; this makes it difficult to deal with the Cockett perforators. Nevertheless, the results can be gratifying. SEPS is often combined with ligation, stripping, and avulsion of superficial veins, which addresses 2 of the 3 venous systems. Because of advances in less invasive techniques, perforator surgery has been performed less frequently in recent years.
Nonsurgical methods.Perforator veins can be eliminated using echo-guided sclerotherapy or radiofrequency ablation with cannulation of individual perforator veins via a small probe. Both techniques are relatively new for the management of perforator vein incompetence, and the preliminary results need to be validated over time.
Treatment of cutaneous manifestations. Traditional management of advanced chronic venous insufficiency has been mechanical compression with elastic stockings, various types of dressings for venous ulcers, and elevation. Liberal lubrication of the skin several times a day, with occasional use of corticosteroid cream for eczema exacerbations, is recommended.
Pharmacologic therapy has had limited success. Diuretics have shown no long-term benefit, but they may be used for brief periods in patients with severe edema. Caution is advised because while many of these patients are fluid-overloaded, they can be relatively hypovolemic intravascularly, and aggressive diuresis can lead to prerenal azotemia and metabolic derangements.
Phlebotrophic agents (those that supposedly stabilize capillary and lymphatic dynamics) are not beneficial. Hemorheologic agents have shown positive, reproducible results. Pentoxifylline, when used to treat ulcers in conjunction with compression, leads to a much higher healing rate than placebo.10
Horse-chestnut seed extract stimulates prostaglandin release and causes vasoconstriction. These effects reduce edema. The extract was superior to placebo in several trials.11
Topical therapies have had mixed results. Application of antiseptic agents can adversely affect wounds. In addition, povidone-iodine, peroxide, and acetic acid are cytotoxic to fibroblasts.
Iodine that contains hydrophilic starch powder, flexible hydroactive dressings, and dextranomer paste, when used on ulcers along with elastic compression, have shown good results. Ketanserin (a serotonin-2 antagonist) improves fibroblast collagen synthesis, and when used with compression has shown far superior results compared with compression alone.12 Skin substitutes have shown promise, especially with chronic (longer than 12 months) and large (greater than 6 cm) ulcers.13
The results of conservative treatment alone, without treatment of the underlying venous problem, have been generally disappointing; recovery is prolonged, and the incidence of at least partial disability and ulcer recurrence is high. Closure of perforator veins with SEPS, radiofrequency closure, or foam sclerotherapy can accelerate ulcer healing and delay progression of stasis dermatitis.
None of these treatments is a permanent cure. Therefore, I recommend monitoring patients who have chronic venous insufficiency with duplex ultrasonography semiannually to detect recurrences at an early stage, when they may be treated less invasively. With surveillance and follow-up treatment, long-term palliation is possible.
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Raju S, Fredericks R. Valve reconstruction procedures for nonobstructive venous insufficiency: rationale, techniques, and results in 107 procedures with two- to eight-year follow-up.
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Taheri SA, Lazar L, Elias SM, Marchand P. Vein valve transplant.
Lees TA, Lambert D. Patterns of venous reflux in limbs with skin changes associated with chronic venous insufficiency.
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Hauer G. Endoscopic subfascial discussion of perforating veins--preliminary report [in German].
Gloviczki P, Cambria RA, Rhee RY, et al. Surgical technique and preliminary results of endoscopic subfascial division of perforating veins.
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Jull A, Waters J, Arroll B. Pentoxifylline for treatment of venous leg ulcers: a systematic review.
Diehm C, Trampisch HJ, Lange S, Schmidt C. Comparison of leg compression stocking and oral horse-chestnut seed extract therapy in patients with chronic venous insufficiency.
Roelens P. Double-blind placebo-controlled study with topical 2% ketanserin ointment in the treatment of venous ulcers.
Falanga V, Margolis D, Alvarez O, et al. Rapid healing of venous ulcers and lack of clinical rejections with an allogenic cultured human skin equivalent. Human Skin Equivalent Investigators Group.