What is chronic venous insufficiency (CVI)?
Chronic venous insufficiency (CVI) is a condition that occurs when the venous wall and/or valves in the leg veins are not working effectively, making it difficult for blood to return to the heart from the legs. CVI causes blood to “pool” or collect in these veins, and this pooling is called stasis.
Valve Inside Vein
What causes chronic venous insufficiency?
Veins return blood to the heart from all the body’s organs. To reach the heart, the blood needs to flow upward from the veins in the legs. Calf muscles and the muscles in the feet need to contract with each step to squeeze the veins and push the blood upward. To keep the blood flowing up, and not back down, the veins contain one-way valves.
Chronic venous insufficiency occurs when these valves become damaged, allowing the blood to leak backward. Valve damage may occur as the result of aging, extended sitting or standing or a combination of aging and reduced mobility. When the veins and valves are weakened to the point where it is difficult for the blood to flow up to the heart, blood pressure in the veins stays elevated for long periods of time, leading to CVI.
CVI most commonly occurs as the result of a blood clot in the deep veins of the legs, a disease known as deep vein thrombosis (DVT). CVI also results from pelvic tumors and vascular malformations, and sometimes occurs for unknown reasons. Failure of the valves in leg veins to hold blood against gravity leads to sluggish movement of blood out of the veins, resulting in swollen legs.
Chronic venous insufficiency that develops as a result of DVT is also known as post-thrombotic syndrome. As many as 30 percent of people with DVT will develop this problem within 10 years after diagnosis.
What are the symptoms of chronic venous insufficiency?
The seriousness of CVI, along with the complexities of treatment, increase as the disease progresses. That’s why it is very important to see your doctor if you have any of the symptoms of CVI. The problem will not go away if you wait, and the earlier it is diagnosed and treated, the better your chances of preventing serious complications.
- Swelling in the lower legs and ankles, especially after extended periods of standing
- Aching or tiredness in the legs
- New varicose veins
- Leathery-looking skin on the legs
- Flaking or itching skin on the legs or feet
- Stasis ulcers (or venous stasis ulcers)
If CVI is not treated, the pressure and swelling increase until the tiniest blood vessels in the legs (capillaries) burst. When this happens, the overlying skin takes on a reddish-brown color and is very sensitive to being broken if bumped or scratched.
At the least, burst capillaries can cause local tissue inflammation and internal tissue damage. At worst, this leads to ulcers, open sores on the skin surface. These venous stasis ulcers can be difficult to heal and can become infected. When the infection is not controlled, it can spread to surrounding tissue, a condition known as cellulitis.
CVI is often associated with varicose veins, which are twisted, enlarged veins close to the surface of the skin. They can occur almost anywhere, but most commonly occur in the legs.
What are the risk factors for chronic venous insufficiency?
If you have risk factors for CVI, you are more likely than other people to develop the disease. The most important risk factors are:
- Deep vein thrombosis (DVT)
- Varicose veins or a family history of varicose veins
- Extended periods of standing or sitting
- Female sex
- Age over 50
Who is affected by chronic venous insufficiency?
An estimated 40 percent of people in the United States have CVI. It occurs more frequently in people over age 50, and more often in women than in men.
How is CVI diagnosed?
To diagnose CVI, your doctor will perform a complete medical history and physical exam. During the physical exam, the doctor will carefully examine your legs.
A test called a vascular or duplex ultrasound may be used to examine the blood circulation in your legs. During the vascular ultrasound, a transducer (small hand-held device) is placed on the skin over the vein to be examined. The transducer emits sound waves that bounce off the vein. These sound waves are recorded, and an image of the vessel is created and displayed on a monitor.
How is chronic venous insufficiency treated or managed?
Like any disease, CVI is most treatable in its earliest stages. Vascular medicine or vascular surgery specialists typically recommend a combination of treatments for people with CVI. Some of the basic treatment strategies include:
- Avoid long periods of standing or sitting: If you must take a long trip and will be sitting for a long time, flex and extend your legs, feet, and ankles about 10 times every 30 minutes to keep the blood flowing in the leg veins. If you need to stand for long periods of time, take frequent breaks to sit down and elevate your feet.
- Exercise regularly. Walking is especially beneficial.
- Lose weight if you are overweight.
- Elevate your legs while sitting and lying down, with your legs elevated above the level of your heart.
- Wear compression stockings.
- Take antibiotics as needed to treat skin infections.
- Practice good skin hygiene.
The goals of treatment are to reduce the pooling of blood and prevent leg ulcers.
The most conservative approach is to wear properly-fitting support hose (also called compression stockings). Compression stockings can be purchased at some pharmacies and medical supply stores and come in various styles, including below-the-knee, above-the-knee and pantyhose styles. They also come in different compressions varying from 8 to 10 mm Hg, up to 40 to 50 mm Hg. Your doctor can recommend the compression that is right for you. You will need a prescription for any stockings with more than 20 mm Hg compression.
If you wear compression stockings, be sure to take them off at the end of the day to wash and dry them, and to clean and check your skin. Make sure the stockings fit so there is no bunching. Elastic stockings that fit poorly can actually make your condition worse by blocking blood flow in the area where they have bunched up.
Some studies have shown that combining elastic socks with prescription medication to improve blood flow is very effective when the socks alone do not control symptoms.
Antibiotics may be prescribed to clear skin infections related to CVI, but the underlying disease must be treated to prevent a recurrence. Deeper infections and ulcers may also be treated with antibiotics.
If you have post-thrombotic syndrome, your doctor may prescribe medication to prevent the formation of additional blood clots.
A special medicated wrap, known as an Unna Boot, combines multilayer compression with a zinc oxide gel-based wound cover that forms a semi-rigid bandage. Other multilayer compression systems are available and are often used in combination with topical wound care products.
Some patients have found benefit from the herbal dietary supplement Vena-Stat, which contains a derivative of horse chestnut extract. Keep in mind that herbal preparations should not be used in place of your prescription medications and should be used with caution, as they may interact with current prescription medications. Please ask your doctor or pharmacist about any potential drug interactions.
Practicing good skin hygiene is important. Keep your skin moisturized so that it doesn’t flake or crack easily. If the skin is not broken or leaking fluid but is inflamed, your doctor may recommend an anti-itch cream, such as one containing hydrocortisone; a cream containing zinc oxide to protect the skin; or an antifungal cream to prevent fungal infections.
Skin that is leaking fluid is treated with wet compresses. If you have ulcers on your legs, your doctor will show you how to apply layered compression bandages to protect the skin and maintain blood flow.
Nonsurgical treatments include sclerotherapy and endovenous thermal ablation.
Sclerotherapy involves the injection of a solution directly into spider veins or small varicose veins that causes them to collapse and disappear. Several sclerotherapy treatments are usually required to achieve the desired results. Sclerotherapy is simple, relatively inexpensive, and can be performed in the doctor’s office. Sclerotherapy can eliminate the pain and discomfort of these veins and helps prevent complications such as venous hemorrhage and ulceration. It is also frequently performed for cosmetic reasons.
Endovenous thermal ablation is a newer technique that uses a laser or high-frequency radio waves to create intense local heat in the affected vein. The technology is different with each energy source, but both forms of local heat close up the targeted vessel. This treatment closes off the problem veins but leaves them in place so there is minimal bleeding and bruising. Compared with ligation and stripping, endovenous thermal ablation results in less pain and a faster return to normal activities, with similar cosmetic results.
When is surgical treatment necessary?
For the less than 10 percent of patients who require surgical treatment, the options include vein ligation and stripping, microincision/ambulatory phlebectomy, and bypass surgery. Here is a brief review of each of these techniques. Your doctor can recommend the treatment that is most appropriate for you.
Ligation and stripping often are performed in combination. Vein ligation is a procedure in which a vascular surgeon cuts and ties off the problem veins. Most patients recover in a few days and can resume their normal activities. Stripping is the surgical removal of larger veins through two small incisions. Stripping is a more extensive procedure and may require up to 10 days for recovery. It usually causes bruising for several weeks after surgery.
Microincision/ambulatory phlebectomy is a minimally invasive procedure in which small incisions or needle punctures are made over the veins, and a phlebectomy hook is used to remove the problem veins.
Vein bypass in the leg is similar to heart bypass surgery, just in a different location. It involves using a portion of healthy vein transplanted from elsewhere in your body to reroute blood around the vein affected by CVI. Bypass is used for treatment of CVI in the upper thigh and only in the most severe cases, when no other treatment is effective.
Can chronic venous insufficiency be prevented?
To reduce your risk of developing CVI, follow these guidelines:
- Eat a healthy balanced diet.
- Quit smoking.
- Exercise regularly.
- Avoid wearing restrictive clothing such as tight girdles or belts.
- Lose weight if you are overweight.
- Avoid prolonged sitting or standing.
Resources and References
Chen WY, Rogers AA. Recent insights into the causes of chronic leg ulceration in venous diseases and implications on other types of chronic wounds. Wound Repair Regen. 2007 Jul;15(4):434-449.
Kahn SR. The post-thrombotic syndrome: progress and pitfalls. Br J Haematol. 2006 Aug;134(4):357- 65. Epub 2006 Jul 4.
Patel NP, Labropoulos N, Pappas PJ. Current management of venous ulceration. Plast Reconstr Surg. 2006 Jun;117(7 Suppl):254S-260S
Rathbun SW, Kirkpatrick AC. Treatment of chronic venous insufficiency. Curr Treat Options Cardiovasc Med. 2007 Apr;9(2):115-26.
Wollina U, Abdel-Naser MB, Mani R. A review of the microcirculation in skin in patients with chronic venous insufficiency: the problem and the evidence available for therapeutic options. Int J Low Extrem Wounds. 2006 Sep;5(3):169-80.
Yosipovitch G, DeVore A, Dawn A. Obesity and the skin: skin physiology and skin manifestations of obesity. J Am Acad Dermatol. 2007 Jun; 56(6):901-16.
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