Chronic Venous Insufficiency (CVI)

What is chronic venous insufficiency?

Chronic venous insufficiency (CVI) is a form of venous disease that occurs when veins in your legs are damaged. As a result, these veins can’t manage blood flow as well as they should, and it’s harder for blood in your legs to return to your heart. CVI causes blood to pool in your leg veins, leading to high pressure in those veins.

CVI can happen due to damage in any of your leg veins. These include your:

• Deep veins, which are large veins deep in your body that run through your muscle.
• Superficial veins, which are close to your skin’s surface.
• Perforating veins, which connect your deep and superficial veins.

CVI may cause mild symptoms at first. But over time, this condition may interfere with your quality of life and lead to serious complications.

Chronic venous insufficiency vs. post-thrombotic syndrome

Both terms refer to the same problem of damaged leg veins. Post-thrombotic syndrome is chronic venous insufficiency caused by deep vein thrombosis (DVT). DVT is a blood clot in a deep vein in your leg. “Post-thrombotic” means after a blood clot (which is also called a “thrombus”). After the blood clot is gone, it can leave scar tissue that damages your vein.

About 20% to 50% of people who’ve had DVT develop post-thrombotic syndrome, usually within one to two years.

How common is chronic venous insufficiency?

Venous disease in general is very common. For example, varicose veins affect about 1 in 3 adults. Each year, about 1 in 50 adults with varicose veins go on to develop chronic venous insufficiency.

Chronic venous insufficiency usually affects people over age 50. The risk goes up the older you get.

Overall, chronic venous insufficiency affects about 1 in 20 adults.

How does chronic venous insufficiency affect my body?

Chronic venous insufficiency slows down blood flow from your legs back up to your heart. Without treatment, CVI raises the pressure in your leg veins so much that your tiniest blood vessels (capillaries) burst. When this happens, the skin in that area takes on a reddish-brown color and can easily break open if bumped or scratched.

These burst capillaries can cause:

• Tissue inflammation in that area.
• Tissue damage.
• Venous stasis ulcers. These are open sores on your skin’s surface.

Venous stasis ulcers don’t heal easily, and they can become infected. The infection could spread to nearby tissue. This condition is known as cellulitis, which is dangerous if not treated right away.

What are the signs and symptoms of chronic venous insufficiency?

Chronic venous insufficiency signs and symptoms include:

• Achy or tired legs.
• Burning, tingling or “pins and needles” sensation in your legs.
• Cramping in your legs at night.
• Discolored skin that looks reddish-brown.
• Edema (swelling) in your lower legs and ankles, especially after standing a while or at the end of the day.
• Flaking or itching skin on your legs or feet.
• Full or heavy feeling in your legs.
• Leathery-looking skin on your legs.
• Ulcers (open sores), usually near your ankles. If they’re very painful, they may be infected.
• Varicose veins.

Severe edema in your lower leg can cause scar tissue to develop. This scar tissue traps fluid in your tissues. Your calf may feel large and hard to the touch. When this happens, your skin is more vulnerable to persistent ulcers.

You may not have all of these issues at once. Instead, you may only have one or two. Your signs and symptoms depend on how far your condition has progressed.

What are the stages of chronic venous insufficiency?

The stages of venous disorders range from 0 to 6. “Venous disorders” is a general category for many possible issues with your veins, including CVI. The stages are based on clinical signs, which are things your provider can see or feel when they examine your legs.

Venous disorder stages include:

• Stage 0: No signs that can be seen or felt. You may feel symptoms like achy or tired legs.
• Stage 1: Visible blood vessels, including spider veins.
• Stage 2: Varicose veins at least 3 millimeters wide.
• Stage 3: Edema (swelling) but no skin changes.
• Stage 4: Changes to your skin’s color and/or texture.
• Stage 5: Healed ulcer.
• Stage 6: Acute (active) ulcer.

You’ll be diagnosed with chronic venous insufficiency if you’re at stage 3 or above. In other words, having varicose veins doesn’t mean you have CVI. But varicose veins are a sign of blood flow problems that could get worse over time. So, it’s important to tell your provider about any new varicose veins you notice.

What causes chronic venous insufficiency?

Chronic venous insufficiency happens when the valves in your leg veins don’t work properly. Your leg veins contain valves that help your blood flow in the correct direction (toward your heart). If a valve becomes damaged, it can’t close properly. Gravity takes over, and blood struggles to flow upward toward your heart. It instead flows backward, a situation known as venous reflux.

Causes of valve malfunction may be congenital, primary or secondary.

• Congenital causes are malformations in your leg veins that you’re born with. For example, some people are born without valves in their leg veins.
• Primary causes are any changes to your leg veins that prevent them from working as they should. For example, your vein may get too wide, preventing its valve from closing all the way.
• Secondary causes are other medical issues that damage your leg veins. Deep vein thrombosis (DVT) is usually the culprit. The thrombus (blood clot) leaves behind scar tissue that damages your valve.

What is the most common cause of chronic venous insufficiency?

Deep vein thrombosis (DVT) is the most common cause of chronic venous insufficiency. The blood clot damages the valve in your leg vein. People with a history of DVT face a higher risk of developing CVI.

How is chronic venous insufficiency diagnosed?

Chronic venous insufficiency is diagnosed through a physical exam and ultrasound imaging. During the physical exam, your provider will:

• Carefully examine your legs. Your provider will look for clinical signs of CVI, like ulcers or changes in skin color.
• Perform a vascular ultrasound. This painless test uses sound waves to create an image of your veins. It shows which parts of your veins are damaged.

Your provider will also rule out other medical conditions that could be causing your symptoms. This may involve other tests like an MRI.

Many people with CVI also have peripheral artery disease (PAD). So, your provider may ask questions or run tests to check you for PAD. If you have both CVI and PAD, your provider will advise you on treatment methods and precautions you need to take with compression therapy.

What are the treatments for chronic venous insufficiency?

Treatment for chronic venous sufficiency involves lifestyle changes and compression therapy. If these measures aren’t enough, your provider may recommend a procedure or surgery. The best treatment for you depends on how far your condition has progressed and other medical conditions you have. Your provider will tailor treatment to your individual needs.

The goals of treatment are to:

• Help your blood flow better in your veins.
• Help ulcers heal and limit their chances of coming back.
• Improve your skin’s appearance.
• Reduce pain and swelling.

Lifestyle changes

Usually, providers recommend lifestyle changes as the first method of treatment for CVI. These include:

• Leg elevation: Lifting your legs above the level of your heart can help reduce pressure in your leg veins. Your provider may suggest you do this for 30 minutes or longer at least three times per day.
• Exercise: Walking and other forms of exercise can help blood flow better in your leg veins. Each time you take a step, your calf muscle squeezes and helps your veins pump blood back up to your heart. This “calf muscle pump” is known as your “second heart.” It helps blood in your legs defy gravity, and it’s vital for your circulation. So, making your calf muscles stronger can help improve your blood flow. Your provider may also recommend foot and ankle flexing exercises.
• Weight management: Extra weight can put pressure on your veins and damage the valves. Ask your provider what a healthy weight is for you. Work with your provider to come up with a healthy and manageable plan for achieving that weight.

Compression therapy

Providers commonly recommend compression therapy for treating CVI. Compression therapy helps ease swelling and discomfort in your legs.

There are many types of compression bandages and stockings. Some offer more compression than others. Very tight stockings require a prescription.

Some stockings are “graduated,” meaning they’re tighter down by your ankles and less tight further up your leg. It’s essential that you follow your provider’s guidance on the type of compression you need and when to use it.

Many people with CVI struggle to wear compression stockings over the long term. But compression therapy is very important to help your veins work better and ease your symptoms. If you struggle with compression therapy, talk with your provider. You may need a different type of stocking. Or, your provider may offer advice to make the treatment plan more doable for you.

If stockings don’t help, your provider may suggest intermittent pneumatic compression (IPC). IPC devices are inflatable sleeves you wear on your legs that help blood flow through your veins.

People who have peripheral artery disease (PAD) need to be careful with compression therapy. Your provider may caution you not to use it at all depending on the extent of your PAD. Closely follow your provider’s instructions.

Medications

Medications used to treat CVI include:

• Antibiotics to clear skin infections or ulcers caused by CVI. These medications don’t treat the underlying disease.
• Anticoagulants, or “blood thinners,” to treat blood clots and prevent future blood clots from forming.
• Medicated wrap known as an Unna boot. This wrap combines multilayer compression with a zinc oxide gel-based wound cover that forms a semi-rigid bandage.

Nonsurgical treatment

Nonsurgical treatments for CVI include:

• Sclerotherapy: Your provider injects a foam or liquid solution into your spider vein or varicose vein. This causes the vein to collapse or disappear.
• Endovenous thermal ablation: This technique targets large veins. It uses a laser or high-frequency radio waves to create intense heat. This heat closes up the diseased vein but leaves it in place so there’s minimal bleeding or bruising.

Surgical treatment

Surgical treatments for CVI include:

• Ligation and stripping: These two procedures are often performed together. For vein ligation, your provider cuts and ties off the problem veins. Stripping is the surgical removal of larger veins through two small incisions.
• Microincision/ambulatory phlebectomy: This is a minimally invasive procedure. It targets varicose veins near your skin’s surface. Your provider makes small incisions or needle punctures over your veins. Then, they use a phlebectomy hook to remove the problem veins.
• Subfascial Endoscopic Perforator Surgery (SEPS): This is a minimally invasive procedure. It targets your perforating veins above your ankle. Your provider uses a clip to block off damaged veins so blood doesn’t flow through them. SEPS helps ulcers heal and also helps prevent them from coming back.
• Vein bypass: This is similar to heart bypass surgery, just in a different location. Your provider takes part of a healthy vein from somewhere else in your body and uses it to reroute blood around your damaged vein. Providers only use this method in severe cases when no other treatment is effective.

What are the risk factors for chronic venous insufficiency?

If you have risk factors for CVI, you’re more likely than other people to develop the disease. Risk factors include:

• History of deep vein thrombosis (most important).
• Varicose veins or a family history of varicose veins.
• Obesity.
• Pregnancy.
• Not getting enough physical activity.
• Smoking and tobacco use.
• Sitting or standing for long periods of time.
• Sleeping in a chair or recliner.
• May-Thurner syndrome.
• Being female or designated female at birth (DFAB).
• Being over age 50.

How can I prevent chronic venous insufficiency?

Sometimes, CVI can’t be prevented. But you can lower your risk of CVI and other vein problems by making some lifestyle changes. These include:

• Avoid smoking and tobacco use.
• Avoid wearing restrictive clothing like tight girdles or belts.
• Don’t sit or stand for too long at a time. Get up and move around as often as you can.
• Eat a heart-healthy diet. This includes reducing your sodium (salt) intake.
• Exercise regularly.
• Keep a healthy weight.

If you’ve had DVT, your provider may recommend anticoagulants.

What can I expect if I have chronic venous insufficiency?

CVI usually isn’t life-threatening and doesn’t result in amputation. But it’s a progressive disease that can cause discomfort, pain and reduced quality of life. Treatment can help manage your symptoms and give you a better quality of life.

Venous ulcers are difficult to treat, and they may return even after treatment. It’s important to keep all your medical appointments and closely follow your provider’s guidance.

Can chronic venous insufficiency be reversed?

Treatment can’t reverse the damage to your vein valves. But it can reverse your symptoms so that you feel better and have a better quality of life. Some procedures and surgeries can target and remove the damaged veins so that blood doesn’t flow through them anymore.

Similarly, chronic venous insufficiency can’t be cured. But you can manage the condition with lifestyle changes and other treatments your provider recommends.

How do I take care of myself with chronic venous insufficiency?

Your provider will tell you how to manage CVI at home. Some general tips include:

• Avoid long periods of standing or sitting. On long car or plane rides, flex and extend your legs, feet and ankles about 10 times every 30 minutes. This helps your blood flow through your leg veins. If you have to stand for a while, take breaks often to sit down and elevate your feet.
• Check your skin. Each time you shower, check your skin. If you notice any changes, like new ulcers, call your provider.
• Elevate your legs. When sitting or lying down, elevate your legs above the level of your heart.
• Exercise on a regular basis. Walking is especially helpful for your leg veins.
• Manage your weight. Keep a weight that’s healthy for you. Talk with your provider about what that weight is.
• Practice good skin hygiene. Wash and moisturize your skin every day. Ask your provider what kind of moisturizer is best for your skin. Keeping your skin moisturized will help prevent flaking and cracks, which could become infected. Your provider may also recommend creams to reduce itching, protect your skin or prevent fungal infections.
• Wear compression stockings if your provider recommends them. This is one of the best ways to manage CVI. There are many different types, so follow your provider’s guidance on which type is best for you. Also, ask your provider how best to wash and care for your stockings.

When should I see my healthcare provider?

See your provider if you have any risk factors for chronic venous insufficiency. Your provider can assess your risk factors and help you lower them.

If you have CVI, keep all your medical appointments, and follow your provider’s guidance on when to return.

Call your provider if:

• You have any questions about your condition.
• You have new or changing symptoms.
• Your compression stockings don’t fit right. There shouldn’t be any bunching. Elastic stockings that don’t fit right can make your condition worse by blocking blood flow in the area where they’re bunched up.

When should I go to the ER?

Call your local emergency number right away if you have symptoms of a pulmonary embolism. This is a life-threatening complication of deep vein thrombosis. It needs immediate medical attention.

What questions should I ask my healthcare provider?

There’s a lot to learn about chronic venous insufficiency. Don’t hesitate to ask your provider any question that comes to mind. You may also want to ask:

• What stage of chronic venous insufficiency am I at?
• How can I manage CVI at home?
• How can you help me stick with compression therapy?
• Do I need a procedure or surgery?
• What can I do to prevent my CVI from getting worse?

A note from Cleveland Clinic

Vein problems are often more than just a cosmetic concern. Chronic venous insufficiency gets worse over time and can greatly interfere with your quality of life.

If you’ve been dealing with venous disease for a while, you’re probably frustrated and wish it would just go away. Luckily, there’s a lot you can do on your own to manage your symptoms and feel better. But sticking with the program is essential. Talk with your provider about strategies for keeping up a daily treatment plan and making compression therapy doable for you.