During the workup of CVI, the physician gathers a patient’s full history and physical and weighs the risk and benefits of any therapeutic interventions. An important consideration in the process of weighing operative therapy is the optimal type of anesthesia for the procedure. Common modes of anesthesia for venous procedures include local tumescent anesthesia (LA), regional anesthesia (RA) , and general anesthesia. While no dedicated studies exist on the type of optimal anesthesia for CVI procedures in the elderly—indeed, optimal anesthesia is largely patient-specific—one may extrapolate from studies in the elderly population as a whole. In general, anesthesia-associated risks depend on American Society of Anesthesiologists classification (ASA score), comorbidities, the type of surgery, and the emergent nature of the surgery. A recent Cochrane review of LA, RA, and GA in noncardiac surgery for patients >65 years reviewed morbidity and mortality in mostly orthopedic and various surgical disciplines (not vascular-specific) [17]. The review found that in elderly orthopedic patients, RA showed a lower early-term mortality rate, reduced fatal pulmonary embolisms rates, and lessened postoperative confusion compared to GA. However, GA is associated with a lower incidence of hypotension. Nausea and vomiting was observed in a lesser extent with LA compared to RA and GA in elderly patients undergoing hernia surgery. Overall, the authors note that the occurrence of true anesthesia-related complications is rare and that the postoperative complications are often related to the procedure itself, not the anesthetic of choice. While difficult to generalize these findings to vascular patients undergoing procedures for CVI, physicians must work closely with the anesthesia team to optimize the patient’s individual anesthetic choice.

As previously discussed (Table 5.1), the CEAP classification presents a standardized system by which to catalog the clinical findings of chronic venous insufficiency. As the severity of CVI increases, the patient’s concerns typically shift from cosmetic to impaired functional status and discomfort. In the early stage with telangiectasias and reticular veins (C1), however, cosmetic concerns typically drive the request for physician evaluation and potential invasive intervention. In addition to discussing surgical risks and benefits as with all patients, providers must make aware to patients whose clinical severity is C1 that the insurance coverage may not extend to procedures performed for cosmetic indications.

Patients with C1 disease with cosmetic concerns or minimal symptoms may benefit from local ablative therapies [18]. These include chemical-based therapies such as sclerotherapy and heat-based therapies such as thermocoagulation and laser treatments. Sclerotherapy is often used for smaller affected veins, and common sclerosing agents are classified as detergents, hypertonic solutions, or chemical irritants. While the agents act through different mechanisms, the ultimate result is sclerosis through endothelial cell injury. Heat-based therapies also produce endothelial injury, resulting in thrombosis and eventual fibrosis of the treated vein. Regardless of the modality used to treat telangiectasias or reticular veins, posttreatment compression of the lower extremity is recommended for more effective sclerosis and improved cosmetic results. Postoperative bruising and hyper-pigmentation of the treated areas are potential outcomes, which must be discussed specially with patients who are undergoing the procedure for cosmetic purposes. Both bruising and the hyper-pigmentation, caused by deposition of dermal hemosiderin, fade over time.

As CVI continues to progress from reticular veins and telangiectasias, varicose veins develop, marking C2 disease in the CEAP classification. This chronic condition is estimated in more than 20% of adults in the United States [3], and risk factors include older age, female gender, multiparity, family history, obesity, history of thrombophlebitis, or history of thrombosis. As previously discussed in the “Venous Insufficiency” section, the underlying etiology of the development and progression of CVI is from valvular insufficiency leading to reflux, obstruction, calf muscle pump malfunction, or a combination of these factors. While some patients with varicosities may not present with symptoms, those with more advanced disease may complain of heaviness of the legs, tingling, achiness, prutitis, pain, and fatigue. These symptoms are often exacerbated by prolonged dependency or heat and relieved by leg elevation or compression elastic bandages or stockings. The presence of varicosities is often more than a nuisance or a cosmetic concern—they are a frequent cause of discomfort, disability, and decreased quality of life.

Following a dedicated history and physical and imaging (duplex scanning as the most common noninvasive modality) confirming varicose veins from underlying CVI, treatment options are considered on a patient-specific basis. The clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum [19] provide recommendations to enhance consistent evidence-based approaches to care for patients with varicose veins and associated chronic venous diseases, and they encompass medical therapy, compression, and surgical interventions.

Medical treatment incorporates venoactive drugs for the treatment of symptoms of varicose veins, though they do not address the underlying etiology. While the exact mechanism of action for most of these agents is unknown and they are unavailable in the United States, their use is intended to improve venous tone and capillary permeability. A recent Cochrane review by Martinez and colleagues analyzed 44 studies and found diosmin, hesperidin, and MPFF were the most effective venoactive drugs [20]. Diosmin and hesperidin also helped with the healing of trophic skin changes and treated cramps and swelling. Cramps and restless legs were also reduced by calcium dobesilate. Rutosides reduced venous edema. Overall, the meta-analysis concluded that evidence was insufficient to support the global use of these agents in the treatment of chronic venous disease.

Compression therapy is the most often used treatment of varicose veins and comes in various forms including elastic compression stockings, multilayer elastic wraps, bandages, and Unna boots. The use of compression is recommended in order to decrease venous hypertension in the lower extremities. While randomized control trials have not suggested definitive compressive pressures for addressing C2 disease, currently, the SVS/AVF Guideline Committee suggests graded prescriptions stockings with an ankle pressure of 20–30 mm Hg (Grade 2C). The use of compression therapy prior to consideration for surgical therapy may be a requirement for some practitioners due to insurance company policies for coverage. The REACTIV trial (Randomized Clinical Trial, Observational Study and assessment of Cost-Effectiveness of the Treatment of Varicose Veins), which randomized 246 patients with C2 disease to conservative management or surgery, demonstrated a significant quality of life benefit for surgery in the first 2 years after treatment, with substantial improvements in symptomatic and anatomic measures [21]. As noted in the SVS/AVF guidelines , there is virtually no scientific evidence to support requiring a trial of compression prior to more aggressive intervention, even though third-party payers often require it. Indeed, the REACTIV trial as described above has demonstrated that surgical treatment to treat superficial reflux is more efficacious and more cost-effective.