What are the approaches to the treatment of venous hypertension?
- Venous hypertension is not uncommon.
- Treatment is directed to relieve symptoms and where possible the cause.
- No oral medicine has been found which can cure venous hypertension.
- Surgical or endo-venous therapy is for ulcers not responding to medical treatment.
- Graded compression stockings are the cornerstone of the modern treatment of venous hypertension.
- The main aim of treatment is to remove, if possible, major reflux pathways.
- Valvuloplasty is occasionally helpful but the incidence of post-operative DVT is high.
- A refluxing vein is no longer needed and can be ablated without side effects.
- Antibiotics are not useful in venous ulcers unless infected.
What is the role of compression stockings?
- These provide 30 – 40 mmHg or 40 – 50 mmHg compression at the ankle and reducing compression as we move upward. This helps restore venous pressure to normal and improve venous flow in patients with severe venous incompetence.
- The graded compression is vital as non-graded ones give a tourniquet effect and worsen venous reflux.
- The anti-embolic stocking is useless and neither improve venous return nor prevent venous thromboembolism.
- Leg elevation is helpful in promoting venous return due to gravity and reduces edema. On sitting legs should be above the level of the thighs and on lying above the level of the heart.
- Four layer compression dressings are the main-stay in venous ulcer cases. They contain calamine lotion, glycerine, zinc oxide, and gelatin.
What are the various treatments possible?
- The patient must be instructed that leg elevation and compression stockings are his life-line and he must not stand or sit for long at one site with legs dangling. They must walk and do calf exercises at regular intervals.
- Thrombolysis using TPA or thrombectomy have poor results with a very high recurrence rate.
- Saphenous vein bypass for iliofemoral venous occlusion shows poor results with failure rates about 30%.
- Surgery for CVI includes valvuloplasty and allografts or cadaveric vein transplants.
- Congenital absence of valves have valvuloplasty with perforator ligation but the success rate is 70% success after 5 years.
What is the latest surgical therapy available?
- The latest treatment all over the world is Radio-Frequency Ablation (RFA) or Laser therapy (EVLT) along with Foam Sclerotherapy.
- Both RFA and EVLT are endovenous ablation techniques. In both techniques, energy is delivered to the lining of the diseased vein which destroys it and causes it to fibrosis. They have provided excellent results over 10 years of study.
- Sclerotherapy uses a sclerosing agent (STD) which destroys the lining of the diseased refluxing veins which fibrosis.
- Subfascial Endoscopic Perforator Surgery (SEPS) – has been used to treat CVI. The perforating veins are ligated endoscopically. After the treatment, the average healing time for venous ulcers is 42 days with a recurrence of 3%. Ulcers with this technique heal 3 times faster.
How are bleeding veins treated?
Immediate sclerotherapy followed by compression and limb elevation is the treatment of choice.
Are there any complications of surgery?
- Sclerotherapy – allergic reaction to sclerosant; Skin necrosis after extravasation of the agent.
- RFA or EVLT – Skin burns; Thermal injury to pre-venous tissue; injury to deep tissue.
What activity is recommended?
- Regular exercise is advisable.
- Prolonged standing or sitting is not well tolerated.
- Walking, running, cycling and swimming is excellent if the muscle pump is intact.
- Patients with obstructed venous flow have increased pain and swelling on exercise.
- Patient with muscle pump failure has markedly reduced exercise tolerance due to leg fatigue.
Can venous problems be prevented?
At the first suggestion of venous disease :
- Avoid prolonged standing
- Using graded compression below knee stockings with a pressure of 30 – 40 mmHg.