Chronic Venous Insufficiency

What is chronic venous insufficiency?

Chronic venous insufficiency (CVI) describes the condition in which blood pools in a patient’s legs and feet elevating the blood pressure in the veins of the legs because they are unable to pump a sufficient amount of blood back to the heart.  Normal veins are able to pump blood back up to the heart, against gravity, because they have one-way valves which prevent the blood from flowing back down after skeletal muscle movement has squeezed the veins to force blood upward.  Sometimes, when a person sits or stands for a long period of time without flexing the leg muscles, the blood in the leg veins can pool, increasing the pressure in those veins.  Over long periods of time, increased pressure in the veins of the legs can cause them to stretch and may weaken the venous walls or damage the one-way valves of some patients.  Damaged valves may not close properly allowing blood that was pumped toward the heart during leg muscle contraction to flow back down due to gravity while the skeletal muscles are relaxed.  Doctors refer to veins with damaged walls or valves that are unable to pump blood efficiently as incompetent.

What causes chronic venous insufficiency?

Any condition that causes abnormal blood flow or high pressure in the veins of the legs can contribute to chronic venous insufficiency.  Blood clots, trauma to the legs from injury or surgery, obesity, pregnancy, prolonged standing, genetic defects, deep vein thrombosis, and phlebitis can all increase venous pressure and damage valves.  The three types of veins include superficial veins, deep veins, and perforating veins.  Superficial veins are closest to the skin, while deep veins lie deeper in the body, close to an artery, and are closely associated with muscles.  Perforating veins connect the superficial veins to the deep veins which connect to the vena cava, the body’s largest vein.  The vena cava collects blood from most other veins in the body and returns to the heart.  When a superficial vein becomes enlarged, damaged, twisted, or clotted due to a damaged valve, this is called a varicose vein.  Varicose veins affect about 60% of Americans and are often harmless.  When a deep or perforated vein becomes enlarged, clotted, or damaged, it is a more serious condition.  When a blood clot blocks blood flow in a deep or perforated vein, it is called deep venous thrombosis (DVT).  This blood clot could potentially break off and be carried in the blood to the heart and out to the lungs.  Additionally, a blood clot in one of these larger veins can cause the pressure in the vein to increase and the vein to expand as blood collects in the vein.  When the venous pressure increases and the vein expands, the one-way valves inside the vein may not work properly.  Venous expansion can permanently stretch or damage a one-way valve.  Phlebitis describes the inflammation of a vein and can occur in any vein.  Phlebitis occurs most often in women’s legs; it can be caused by a blood clot or several conditions and medications.  Phlebitis can damage venous valves of deep veins and cause CVI.  Obesity, pregnancy, and prolonged sitting or standing can put pressure on leg veins and damage the valves causing incompetent, insufficient veins.

What are the symptoms of chronic venous insufficiency?

Leg and ankle swelling and ulcers are common symptoms of chronic venous insufficiency as well as tightness in the calves and brown colored skin near the ankles.  The brown colored skin is a result of hemoglobin leaking from the veins and being broken down and deposited in the skin.  A patient’s legs may hurt or feel hard, heavy, itchy, tired, or restless.  Varicose veins can also be a symptom of CVI.

What are the dangers of chronic venous insufficiency?

Chronic venous insufficiency is not always a serious condition.  Sometimes a patient will have CVI with few complications.  However, about one fourth of people with CVI will get ulcers on or around their ankles.  Ulcers are raw areas that are the result of patient’s loss of an area of skin.  These ulcers can be uncomfortable and problematic because they can become infected or spread and do not heal on their own.  CVI can be the result of phlebitis or thrombophlebitis, and it can also cause these two vein inflammation disorders.  While phlebitis is simply the inflammation of a vein, thrombophlebitis is the inflammation of a vein due to a blood clot.  Thrombophlebitis can be dangerous because a blood clot in a vein can break off and travel through the heart to the lungs.

What are the risk factors for chronic venous insufficiency?

Conditions and lifestyles that put additional pressure on the legs can increase a patient’s risk for developing chronic venous insufficiency.  Some of the risk factors include the following: a family history of CVI, obesity, pregnancy, advanced age, a personal history of venous thrombosis, leg trauma, varicose veins or phlebitis, female sex, and an inactive lifestyle.

How is chronic venous insufficiency found and diagnosed?

The symptoms of chronic venous insufficiency are often enough for a doctor to diagnose the condition and begin treatment, but some tests may help find the cause of the problem and determine the best treatment.  In a medical examination, the doctor will likely look for a personal or family medical history of venous insufficiency, deep vein thrombosis, phlebitis, or varicose veins and will check to see if the patient has indications of CVI, which can include ulcers, swelling, or altered blood pressure in the legs.  If the medical examination reveals CVI, the doctor may order a duplex ultrasound or a venogram.  A duplex ultrasound is a painless, completely non-invasive test that uses high-pitched, noiseless sound waves to look at leg veins; the doctor can measure the speed of the blood flow and view the structures of a patient’s leg.  This test can detect blood clots or insufficient blood vessels in the legs.  A venogram is an x-ray procedure that uses a special dye (contrast medium) to clearly view the veins of an area of a patient’s leg.

What are the treatment options available for chronic venous insufficiency?

The treatment for chronic venous insufficiency usually focuses on improving blood circulation in the legs and treating any leg ulcers.  Surgical and nonsurgical treatment options are available for CVI, and the best option for a patient varies; surgery is only recommendable for about one tenth of patients with CVI.  Doctors often recommend that a patient elevate his legs or participate in physical therapy in order to reduce the pressure in the leg veins.  Compression stockings can help improve blood flow through the veins by applying a large amount of pressure at the ankle and gradually decreasing the pressure as the stocking rise to the knee or thigh.  Patients with ulcers may use compression stockings with special bandages to help the ulcers heal.  It is essential that patients strictly follow doctor’s orders when undergoing compression therapy with the stockings.  Doctors can prescribe certain drugs to help patients with CVI including the following: diuretics, which help with swelling; aspirin; anticoagulants, which prevent blood from clotting in the slow moving veins; and pentoxifylline, which can improve blood flow.  Doctors may recommend sclerotherapy for patients with advanced CVI.  Sclerotherapy is an aggressive treatment in which incompetent veins are scarred by a chemical so that they no longer carry blood back to the heart.  The blood that would have traveled through the scarred veins is now diverted and travels to the heart through different veins. 

What surgical treatment options are available for chronic venous insufficiency?

There are many surgical treatments for chronic venous insufficiency, though they are only used in the more serious cases.  Ligation is a surgical procedure in which the surgeon ties off a problematic vein.  If the vein that is tied off in ligation is extensively damaged, the surgeon may remove it in a procedure called venous stripping.  Veins and their valves may be able to be repaired surgically or in a minimally-invasive catheter-based procedure.  A healthy vein may be harvested from another part of the body and transplanted to replace an incompetent vein in the legs.  Doctors may recommend subfascial endoscopic perforator vein surgery (SEPS) or its open surgery equivalent to help heal ulcers and improve circulation by disconnecting incompetent veins around the ankle