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Chronic venous insufficiency

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of chronic venous insufficiency are prepared by our editorial team based on guidelines from the European Society for Vascular Surgery (ESVS 2022), the Society for Vascular Medicine (SVM/SVS/ACP/AVF/IUP 2019), and the American Academy of Family Physicians (AAFP 2013).
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Classification and risk stratification

Severity assessment
As per ESVS 2022 guidelines:
Use the CEAP classification for clinical audit and research in patients with chronic venous disease.
B
Consider using the r-VCSS and the Villalta scale for post-thrombotic syndrome for grading clinical severity and assessing treatment success in patients with chronic venous disease.
C
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Diagnostic investigations

Ankle-brachial index: as per AAFP 2013 guidelines, obtain ankle-brachial index measurement in patients with chronic venous insufficiency and cardiovascular risk factors before initiating compression therapy, which is contraindicated in PAD.
B
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  • Diagnostic imaging

  • Plethysmography

Medical management

Topical therapies: as per AAFP 2013 guidelines, advise daily hydration with emollients and prescribe short courses of topical corticosteroid creams for severely inflamed skin to treat eczematous (stasis) dermatitis associated with chronic venous insufficiency.
B
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  • Venoactive agents

Nonpharmacologic interventions

Exercise: as per ESVS 2022 guidelines, advise exercising to reduce venous symptoms in patients with symptomatic chronic venous disease.
B
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  • Compression stockings (medically managed)

  • Compression stockings (after interventional treatment)

  • Compression stockings (post-thrombotic syndrome)

Therapeutic procedures

Indications for interventional treatment: as per ESVS 2022 guidelines, offer interventional treatment in patients with superficial venous incompetence presenting with symptomatic varicose veins (CEAP clinical class C2S).
B
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  • Considerations for interventional treatment (setting)

  • Considerations for interventional treatment (anesthesia)

  • Considerations for interventional treatment (thromboprophylaxis)

  • Choice of interventional treatment (thermal ablation)

  • Choice of interventional treatment (non-thermal ablation)

  • Interventions for varicose tributaries

  • Interventions for incompetent perforating veins

  • Interventions for reticular veins and telangiectasias

  • Interventions for foot and ankle veins

Surgical interventions

Vein ligation and stripping
As per ESVS 2022 guidelines:
Consider performing high ligation and stripping in patients with great saphenous vein incompetence requiring treatment if endovenous thermal ablation is not available.
B
Consider administering ultrasound-guided tumescent anesthesia as an alternative to general or regional anesthesia in patients with superficial venous incompetence undergoing high ligation/stripping.
C
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  • Ambulatory conservative hemodynamic treatment

  • Ambulatory selective variceal ablation

Specific circumstances

Pregnant patients: as per ESVS 2022 guidelines, offer elastic compression hosiery in pregnant patients presenting with symptoms and/or signs of chronic venous disease.
B
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  • Patients on anticoagulants

  • Patients with obesity

  • Patients with iliac vein outflow obstruction

  • Patients with deep venous incompetence

  • Patients with popliteal vein aneurysm

Follow-up and surveillance

Post-procedural monitoring: as per ESVS 2022 guidelines, consider obtaining duplex ultrasound surveillance 1-4 weeks after treatment of the saphenous trunk.
C
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  • Management of recurrent varicose veins