Conservative Treatment

This involves to relieve the symptoms and prevent complications and progression of the disease.
Behavioral measures like leg elevation to reduce edema and reducing intra-abdominal pressure.
Use of compression stockings is the mainstay of the treatment.
Should conservative measures fail then further treatment is advocated based on anatomic and pathophysiologic features.
To decide the course of management color doppler study and perhaps air plethysmography help.
Specific treatment is based on CEAP classification. Classes 4 – 6 need invasive treatment. These patients if left uncorrected are at risk of ulceration, recurrent ulceration, non-healing venous ulcers, progressive infection and lymphoedema

Graded compressive stockings

This is the first line of treatment and the mainstay of therapy. It helps neutralize the hydrostatic forces of venous hypertension.
The compression provided ranges from 20 – 50 mmHg. A pressure between 30 – 40 mmHg provides a significant improvement in pain, swelling, skin pigmentation, activity and well being if compliance of 70 – 80% is achieved.
In patients with venous ulcers compression stockings and other compression, bandaging modalities are effective in healing and recurrence of ulceration.
If properly done most venous ulcers will heal in a mean time of 5.3 months.
Compression stockings reduce the residual volume fraction which is an indicator of reducing the calf muscle pump function and to reduce reflux in the veins.
The grade of compression prescribed depends on tension and length.Tension is based upon CEAP Classification – Class 2 – 3 are given stockings between 20 – 30 mmHg; class 4 – 6 are give between 30 – 40 mmHg; and for recurrent ulcers 40 – 50 mmHg.
The common length is knee length because patient compliance is best and relief of symptoms is adequate.
The use of mid-thigh or waist stocking is recommended for patients with edema above the knee but their compliance is more difficult.
Stocking should be changed every 6 – 9 months if used daily.

The compromised skin area must be kept moisturized to prevent skin breakdown and infection.
Stasis dermatitis should be treated with topical steroids creams.
Venous ulcers – control bacterial overgrowth to reduce infectious complications.
Hydrocolloid and foam dressings are needed for fluid drainage macerating the adjacent normal skin.

In infected ulcer bed, silver impregnated dressings control infection and restore tissue integrity.

Four groups of drugs have been advocated for CVI.

These drugs have veno-active properties which may improve venous tone and capillary permeability though the precise mechanism is not known.
Flavanoid (Daflon) reduces oedema related symptoms and is used as a primary treatment or in combination with surgery.
Studies show that in CVI coumarin + flavonoid with compression given for 12 weeks resulted in less oedema and pain.
Horse chestnut seed extract is as effective as compression stockings in short term to reduce oedema and pain of CVI but long term results are not available.
The use of pentoxifylline (trental) and antiplatelets like aspirin and platelet-derived growth factor helps in promoting healing and preventing recurrence of venous ulcers.

Problems in calf and foot muscle pump function play an important role in the development of CVI.
Exercise programs have been conducted to rehabilitate the muscle pump and improve the symptoms of CVI.
A study in patients with CEAP grade 4 – 6 disease underwent programs of physical training to improve muscle strength. Venous hemodynamics were assessed by color Doppler and air plethysmography and muscle strength assessed by a dynamometer. After 6 months the calf muscle strength was normalized but there was no change in the venous reflux.
Thus exercise to re-establish muscle pump function may prove beneficial as supplementary therapy to medical and surgical treatment in advanced CVI.

Content Reviewed by – Dr. Jaisom Chopra