Treatment of chronic venous disease

While many dermatologists have gradually lost interest in them over the second half of the 20th century, chronic venous disease (or chronic venous disorders, CVD) are nonetheless an essential part of their specialist field, as much for their clinical impact as for their potential complications [1-3].

There are many different stages of CVDs, ranging from simple telangiectasias to leg ulcers. For reasons of homogeneity, a common language was established using Clinical, Etiological, Anatomical and Pathophysiological (CEAP) criteria [4]. The focus in this article will be on the clinical aspects of chronic venous disease (C₀ to C₆, Table I) (Figure 1), since the other features can only be explored using duplex ultrasound. 

The term chronic venous insufficiency (CVI) should only be used when skin changes ranging from oedema (C₃) to ulcers (C₆), are present. Simple varicose veins are an indication of CVD and not CVI.

Varicose veins are veins that have become enlarged and tortuous. Varicose veins can be primary or secondary, the latter being most common after thrombosis [1]. Several forms are possible (Table II) and healthcare providers must be able to distinguish amongst them, since the treatments required by each vary.

Varicose veins cause a variety of problems:

– functional: venous pooling and reflux, overloading of neighbouring veins or the deep venous system;

– symptomatic: pain, heaviness, itching and a swollen feeling. Some patients may also experience other, less specific symptoms such as cramp, restless legs and paresthesias;

– aesthetic, particularly in women. .

The importance of treatment must not be underestimated, since varicose veins can have a major impact on quality of life [5].

Complications include superficial phlebitis, deep venous thrombosis and other conditions related to inadequate blood supply to the tissues including stasis dermatitis (C_4A), lipodermatosclerosis (C_4B) and leg ulcers (C₆), the latter arising after superficial venous disease in almost 50% of cases [1, 6]. In addition, severe superficial reflux overloads the deep vein system and may cause secondary failure, a serious and delayed complication that is too often overlooked or underestimated [1-3].

A detailed vascular workup must be carried out before treatment is started. If undetected, saphenous junction incompetence or an incompetent perforator vein will inevitably result in varicose vein recurrence, which tends to reinforce the widely held belief that varicose vein treatments are ineffective. Simple telangiectasias can be a sign of underlying deep venous insufficiency. The vascular work up must include a detailed investigation of the patient’s history, an in-depth clinical examination and, if duplex ultrasound is not possible, a Doppler examination of the veins.

Once the varicose veins have been identified and explored (type, origin, length, communication with superficial and deep venous systems, etc.), there are several possible treatment options (see below). The aim of treatment is to provide relief for patients, limit disease progression and prevent its complications whilst providing an acceptable cosmetic outcome, an aspect that has been much neglected in the past, especially by surgeons.