Lifestyle modifications including weight loss, leg elevation, elastic compression therapy, and exercise are generally recommended for patients with venous insufficiency, but compliance and effectiveness are difficult. Venoactive medications have also been used for the treatment of chronic venous insufficiency. While many medications have been tried, most success has been noted with horse chestnut seed extract (aescin), micronized purified flavonoid fraction (rutosides, diosmin, hesperidin), pine bark extract, and pentoxifylline. While most of these medications have been shown to improve venous tone and decrease capillary permeability leading to diminished symptoms from varicose veins, decreased inflammation and swelling, and improved ulcer healing, overall effectiveness has been variable. However, a recent Cochrane meta-analysis failed to show sufficient evidence to support global use of the venoactive medications in the treatment of chronic venous insufficiency. Compression is standard treatment for all patients with chronic venous insufficiency ranging from spider veins, varicose veins, venous edema, skin changes, and venous ulcerations, with most effectiveness seen in the later more advanced clinical classes. The goal of compression is to decrease venous reflux and improve calf muscle pump function, which has the net effect of decreasing ambulatory venous hypertension. Methods of compression include elastic graduated compression stockings for most patients with C1–3 disease, reserving paste gauze boots (Unna’s boot), multilayered compression dressings, elastic and nonelastic bandages, and pneumatic compression devices for advanced C4–6 venous disease that is not controlled with standard compression stockings. While implementation of these nonoperative measures prior to surgical intervention for superficial venous disease is important, the requirement of failure of these measures by third-party payers is not supported by scientific evidence. Unfortunately, most insurance plans require a trial of nonoperative measures, including compression therapy, prior to providing coverage for superficial venous operations, and providers should work with patients and insurance carriers to most accurately represent medical justification for operative planning.

Based on clinical severity, there are several considerations that should be factored into the decision to perform superficial venous operations: (1) Patients with more symptoms, higher clinical CEAP (C4/5/6), or higher VCSS will have a higher potential symptomatic benefit; (2) larger varicose vein size and extensive varicose vein burden are less likely to resolve with isolated treatment of superficial axial venous reflux and may need additional therapy with either phlebectomy or sclerotherapy depending on the size, number, and distribution of residual varicosities; (3) patients with recurrent varicose veins after prior venous intervention may represent a more severe group in which more extensive treatment is required; (4) based on venous duplex ultrasound and additional plethysmography testing, patients who have more severe documented physiologic venous impairment would have expected higher margin of benefit and improvement in objective parameters; (5) stratifying patients with isolated superficial venous reflux vs. multilevel disease including deep and/or perforator venous insufficiency may have bearing on outcome, with extended venous treatment more often needed in the latter group; (6) patients with symptoms out of proportion to visualized infra-inguinal reflux, or obstruction, varicosities in the inguinal or peroneal areas, presence of venous stasis ulcer, or history of deep venous thrombosis extending to iliac veins may merit evaluation of the supra-inguinal system.