Can New Treatments Overcome Compliance Issues in CVI?

Medscape

4 days ago

President Donald Trump's recent diagnosis of chronic venous insufficiency (CVI) briefly brought a little-known but common circulatory disorder into the national spotlight. It also underscored a persistent problem that as many as 40% of US adults quietly face: the difficulty of adhering to treatment that is simple in theory but complicated in practice.
CVI occurs when veins in the legs struggle to return blood back to the heart, leading to swelling, pain, skin changes, and, in some cases, ulcers. According to the Society for Cardiovascular Angiography & Interventions, first-line treatments include compression therapy, leg elevation, exercise, and weight management.
Yet many patients abandon therapy early, either due to discomfort, physical limitations, confusion about the disease, or a frustrating cycle of delayed diagnosis and inaccessible specialty care.
Leigh Ann O'Banion, MD
'Chronic venous insufficiency is a widespread but often underrecognized condition that, when left untreated, can lead to significant morbidity,' said Leigh Ann O'Banion, MD, associate clinical professor of vascular surgery at the University of California San Francisco Fresno.
As awareness of CVI grows, experts say improving compliance may finally be possible, thanks to smarter technology, more patient-friendly devices, and greater focus on early, proactive care.
Why so Difficult?
Compression stockings are a cornerstone of CVI management. They work by reducing pressure in leg veins and help prevent blood pooling. But for many, they're also a dealbreaker — notoriously uncomfortable, difficult to put on, and hard to tolerate in hot or humid weather.
Naomi Hamburg, MD
'Adherence can be challenging, especially in people with reduced mobility including older adults and people with obesity,' said Naomi Hamburg, MD, interim director of the Whitaker Cardiovascular Institute at the Boston University Chobanian & Avedisian School of Medicine and an attending in the cardiovascular medicine section at Boston Medical Center, both in Boston. 'There are alternatives, including Velcro wraps and compression pumps, that may help, but even those require instruction and support.'
Misunderstanding the disease also plays a role in noncompliance, according to Joshua Beckman, MD, past volunteer chair of the American Heart Association's Vascular Health Advisory Committee and current chief of vascular medicine at UT Southwestern Medical Center, both in Dallas.
'I find that patients don't understand how veins work,' Beckman said. 'Once they understand why swelling occurs, it becomes easier to explain why compression garments and leg elevation overnight help combat the higher pressures in the veins.'
But even with education, many patients struggle with the fact that compression therapy doesn't cure the condition.
'Compression therapy helps reduce symptoms; it doesn't fix the underlying vein problem,' Hamburg said.
When patients give up on compression, clinicians are often hesitant to pursue the next level of care, such as referral for interventional treatment, Hamburg said.
'Lack of use of compression therapy is not a reason for interventional procedures,' Hamburg said, 'because compression is still needed after interventions to have optimal results.'
The frustrating cycle of low compliance, worsening symptoms, and reluctance to escalate care keeps many patients trapped in a state of chronic discomfort and progressive disease.
Breaking the Bottleneck
Breaking the compliance bottleneck will require more than one solution.
'I think most of what is coming are improvements in current types of therapy,' Beckman said — things like smart compression therapy devices that use miniaturized and lightweight actuators and electronics to control the applied pressure.
Beckman also cited early-stage research using artificial intelligence to detect venous obstruction or reflux and surgical innovation involving deep vein valve replacements — still in development but showing promise.
According to Hamburg, advances in fabric design could make compression garments easier to wear and tolerate, particularly in warm weather. She also highlighted studies exploring surgically implanted valves for deep veins, an option not currently available for most patients with severe CVI.
New weight-loss medications may help play a role in some cases of CVI.
Obesity is a common risk factor for CVI, Hamburg said, and new drugs for weight management may help people with obesity-related CVI. 'But we need more studies to understand this better,' she added.
Front-Line Detectors
Earlier detection is another key to breaking the compliance bottleneck, and primary care providers are often the first, and only, clinicians positioned to catch CVI early.
'Many doctors don't think about chronic venous insufficiency or don't know about the importance of it for patients,' Hamburg said. 'When I trained in internal medicine, I don't remember learning about it or how to treat it.'
When swelling or skin changes suggest CVI, she encouraged clinicians to initiate compression therapy immediately before a referral or ultrasound.
'The first step is to take off socks and shoes and examine the legs,' she said. 'We get so much information from the legs about both arterial and venous circulation.'
Beckman agreed.
'Early application of compression garments and leg elevation can reduce symptoms and slow progression,' he said. 'That first step, from a trusted provider, makes a huge difference.'
Studies also suggest CVI may be linked to broader cardiovascular problems, such as peripheral artery disease and heart failure.
'I now routinely assess cardiovascular risk factors in patients with CVI,' she said. 'We need to think about venous health not in isolation but as part of whole-body cardiovascular health.'
The path to specialty care, however, is not straightforward for all patients. Geographic isolation, sometimes referred to as 'vascular deserts,' and limited access to specialists, insurance hurdles, and transportation issues often stand in the way of early intervention. These access barriers can be particularly acute in underserved populations, said O'Banion, who also serves as the medical director for the Foundation to Advance Vascular Cures.
'Insurance coverage and out-of-pocket costs can also be prohibitive, especially for newer therapies. Systemic mistrust, lack of awareness, and logistical issues such as transportation or the inability to take time off work further complicate access,' she said.
To bridge these gaps, O'Banion and her colleagues launched CHAMPIONS — the Comprehensive Heart and Multidisciplinary Limb Preservation Outreach Network. The program brings vascular screenings and education directly to community sites such as food banks, health fairs, and local events.
'CHAMPIONS often serves as the first and only point of contact with a vascular specialist for many individuals,' she said.
When timely intervention is possible, patient outcomes improve significantly. According to O'Banion, patients who undergo endovenous ablation — especially newer, nonthermal, non-tumescent techniques — report faster recovery and higher satisfaction than those relying solely on compression.
'These newer technologies expand the number of patients eligible for outpatient care and reduce the discomfort, downtime, and risk associated with more invasive options,' she said.
In both well-resourced and rural environments, O'Banion said, patients frequently present late in the disease course, often after extended periods of conservative management or missed opportunities for earlier diagnosis.
'Late-stage referrals are common,' she said. 'But when patients understand what's happening in their bodies and feel supported in managing it, they're much more likely to stick with treatment.'
Experts said Trump's diagnosis may have temporarily brought CVI into the public eye, but the disease is likely affecting millions more silently.
'It also serves as a reminder that even individuals presumed to have the best medical care may fall through the cracks of delayed diagnosis,' O'Banion said.
And as innovation continues, the burden of early detection and patient education still falls largely on frontline providers.
'CVI is not just a quality-of-life condition,' O'Banion said. 'It's a disease with real consequences. But with better tools and earlier action, we can improve outcomes for millions.'
Beckman reported consulting for Medtronic. O'Banion reported receiving research grants and serving as a consultant for Abbott, Medtronic, Shockwave, Gore, Penumbra, and Reflow Medical. Hamburg reported having no relevant disclosures.