Venous Insufficiency

What is Venous Insufficiency?

Chronic venous insufficiency (CVI) is a condition that slows down the blood flow in the veins, often leading to high blood pressure in the veins. This may cause several health issues such as swelling in the lower legs, skin changes, and discomfort. CVI is a common disease globally and may reduce the quality of life and work productivity due to health restrictions. In most cases, CVI happens because the valves in the veins are not working well. Each year, about 150,000 new patients are diagnosed with CVI, and nearly half a billion dollars are spent on their healthcare. If CVI isn’t treated, it usually worsens over time, potentially leading to postphlebitic syndrome (a long-term complication from blood clots) and venous ulcers (open sores from poor vein function). Other common symptoms are pain, leg swelling, itchiness, skin discoloration, feeling of heaviness in the limb, and swelling that lessens when the leg is raised.

To diagnose CVI, doctors rely on certain symptoms as well as diagnostic tests. An international group of experts developed a system called the Clinical, Etiology, Anatomic, and Pathophysiology (CEAP) classification to help doctors diagnose and manage CVI more consistently. The main way to confirm a CVI diagnosis is a type of ultrasound called a venous duplex ultrasound. This test is considered the most reliable method. To help assess how severe CVI is and to measure the effectiveness of its treatment, the revised Venous Clinical Severity Score was developed.

Treating CVI usually involves a variety of methods, like conservative therapies such as compression, keeping the leg elevated, and exercise. There also are drug treatments and more invasive methods such as sclerotherapy (a procedure that scars veins to close them), endovenous laser or radiofrequency ablation (techniques that use heat to close problematic veins), and surgery to tie off the veins. Delaying treatment can make the disease progress faster, leading to complications like venous ulcers, infections, and deep vein thrombosis (a blood clot in a deep vein, typically in the leg).

What Causes Venous Insufficiency?

Chronic Venous Insufficiency (CVI) occurs when there’s a problem with the blood flow in our legs. Although the exact cause of CVI isn’t fully understood, it’s usually tied to a condition called “valvular reflux.” This is when the valves in our veins, which make sure blood flows in the right direction, start to malfunction and allow blood to flow backwards.

CVI can also be caused by blockages in the veins, problems connecting the arteries and veins, or issues with the muscles in our calves that help pump blood. Sometimes, genetic conditions like Klippel-Trenaunay and Parkes-Weber can also lead to CVI. Ultimately, these issues can cause long-lasting inflammation in the lining of the veins and other changes within the body.

Several factors can increase your chances of developing CVI. They include:

• Being over 55 years old
• Having a family history of varicose veins or other vein issues
• Being overweight
• Using birth control pills
• Smoking
• Being pregnant
• Having a history of deep vein thrombosis (blood clots in the legs) or thrombophlebitis (vein inflammation due to a blood clot)
• Having had a leg injury in the past
• Sitting or standing for long periods
• Leading a sedentary lifestyle
• Being female

Risk Factors and Frequency for Venous Insufficiency

In the US, between 10% and 35% of adults suffer from Chronic Venous Insufficiency (CVI), with about 4% of those aged 65 years or older developing venous ulcers. Varied studies suggest between 1% and 17% of men and 1% and 40% of women in the general population may suffer from this condition. The reported numbers for people with varicose veins—another condition related to CVI—range wildly from less than 1% to 70%. These variations may be due to different ways of diagnosing the conditions and differences in the populations studied.

More developed nations like Western Europe and the US usually have higher rates of CVI because people lead more sedentary lives. In fact, venous ulcers, which are a common issue related to CVI, affect around 1% to 3% of the US population. The global adult population also experiences lower leg ulcers at roughly the same rate, with an increase to 3% in those over 65 years old.

Getting an ulcer is serious business, as around 40% of those affected will experience recurrence, even with standard treatments. CVI management makes up about 2% of the total US healthcare costs, emphasizing the condition’s widespread impact.

Signs and Symptoms of Venous Insufficiency

Chronic Venous Insufficiency (CVI) is a health condition where your veins can’t efficiently send blood from your legs back to your heart. Patients with CVI often initially report signs like swelling in the legs, discomfort, tiredness, and itching. There can be differences in how symptoms show up in different people, but the following features are quite common:

• Small, broken capillaries, or telangiectasias
• Web-like veins, or reticular veins
• Twisted, enlarged veins, or varicose veins
• Pain
• Cramping
• Itching
• Prickling sensation
• Throbbing sensation

People with CVI often share that their symptoms get better when they rest and elevate their legs. As the disease progresses, patients can observe more varicose veins, tenderness, stubborn swelling, and changes in skin color. In severe cases, the skin becomes discolored and narrowed, and ulcers start to form, typically around the inside of the ankle.

When examining patients, healthcare professionals must check for any ulcers, the strength of the pulse in the feet, and any loss of sensation (neuropathy), both when standing and lying down. A test called “Trendelenburg test” can help to check if the vein problems are in the surface veins or deeper veins. It’s also important to ask about previous blood clots, jobs that involve prolonged standing, the level of physical activity, and birth control use, as these can all impact CVI.

Doctors use a classification system called ‘CEAP’ to grade the severity of CVI and guide its management. This stands for ‘Clinical’, ‘Etiology’, ‘Anatomic’, and ‘Pathophysiology’. Another helpful tool is the Venous Clinical Severity Score (VCSS), which grades a range of features on a scale from ‘absent’ to ‘severe’. This helps to assess how bad the condition is and measure how well treatments are working.

Below is the CEAP classification system:

• Clinical classification:
  • C0: No visible or palpable signs of venous disease
  • C1: Small, broken capillaries, or telangiectasias
  • C2: Varicose veins
  • C3: Swelling
  • C4a: Pigmentation and eczema
  • C4b: Fibrous skin changes and atrophy
  • C5: Healed venous ulcer
  • C6: Active venous ulcer
• Etiologic classification:
  • Ec: Present from birth
  • Ep: Primary, cause unknown
  • Es: Secondary, caused by another disease or condition
  • En: No venous cause identified
• Anatomic classification:
  • As: Superficial veins
  • Ap: Perforator veins
  • Ad: Deep veins
  • An: No specific venous location identified
• Pathophysiologic classification:
  • Pr: Reflux, problematic flow of blood back to the heart
  • P0: Obstruction, blockage in the veins
  • Pr/o: Both reflux and obstruction
  • Pn: No venous pathophysiology identifiable

Testing for Venous Insufficiency

Diagnosing chronic venous insufficiency (CVI) — a condition that affects blood flow in your veins — depends largely on physical symptoms and is confirmed using various diagnostic tests. The primary test to confirm CVI is called a venous duplex ultrasound, but your doctor might use additional studies as well.

Venous Duplex Ultrasound

The most reliable way to diagnose CVI is a venous duplex ultrasound. Medical societies, including the American Venous Forum and the Society for Vascular Surgery, suggest that these scans should be done with you standing upright if you are able to do so safely. They believe that being in a supine (laying down) or steep reverse Trendelenburg (head lower than feet) position is not ideal. To diagnose a problem with the valves in your veins, they look at how long the blood flow is moving in the wrong direction (reflux). In simpler terms, if the blood flows backward for more than 0.5 seconds in small veins (superficial) and more than 1.0 seconds in deeper veins (such as femoral and popliteal), it is indicative of CVI.

Air Plethysmography

Air Plethysmography (APG) is a test that helps to assess potential issues that might be causing CVI, like improper blood flow (reflux), blockages (obstruction), and muscle pump failure. This test measures the air that is displaced in a cuff that’s wrapped around your calf as you move your legs in different ways. When a duplex ultrasound isn’t clear or adequate, APG is usually the next step. This test can help determine the severity of CVI and how well treatment is working.

Ancillary Diagnostic Studies

Further studies can include tests like computed tomography and magnetic resonance venography which require an IV contrast injected into your veins. This helps doctors see your veins and nearby structures more clearly on the scan, particularly for evaluating larger veins and spotting internal and external pressure points. These procedures are especially useful before treatment to get a clearer picture of complex venous anatomy, such as blockages in the large veins in your lower body (iliofemoral venous blockage).

Photoplethysmography is a test which measures the time it takes for your veins to fill up by the amount of infrared light it reflects. This test is typically used to assess smaller veins just under the skin’s surface. Other non-invasive tests include strain-gauge plethysmography and foot volumetry.

In case further investigation is needed, invasive tests including contrast venography, intravascular ultrasound, or ambulatory venous pressure measurement may be considered. These tests provide more detailed information but are used less frequently due to their invasive nature and the availability of less invasive diagnostic options.

Treatment Options for Venous Insufficiency

Chronic venous insufficiency (CVI) is a condition that affects the blood flow in your legs, leading to a variety of symptoms such as discomfort, swelling, skin changes, and ulcers. Treatment for CVI is dependent on how severe the disease is. The main goals of treatment are to lessen discomfort and swelling, stabilize the appearance of the skin, reduce the backward flow of blood (venous reflux) and varicose veins, and help heal ulcers.

The cornerstone of treatment involves conservative approaches like elevating your legs, doing resistance exercises, managing your body weight, and using compression therapy. Compression therapy involves using devices such as special stockings or bandages to provide pressure to the legs which helps combat rising blood pressure in the veins. Regular use of compression therapy can improve symptoms like backwards blood flow, pain, swelling, skin discoloration, and ulcers healing. It is important to note, compression therapy works best when used consistently over a long period of time.

Other conservative treatments include elevating your legs above your heart for around 30 minutes, three times a day; this can help reduce the pressure in your veins and prevent ulcers. Regular resistance exercises that involve moving your ankles and toes can improve the pumping action of muscles in your calves, which helps push blood back towards the heart. Exercising, along with maintaining a healthy weight can reduce the risk of developing CVI and improve existing symptoms.

It’s also crucial to take care of your skin and wound care. This can be achieved by using topical moisturizers, commonly containing lanolin, to prevent the skin from cracking or breaking down. Any ulcers or wounds should be cleaned and dressed regularly to prevent infection. In some cases, specially engineered bio-skin replacements have been used to treat ulcers.

If conservative treatments are not enough, your doctor may suggest advanced procedures. This can include methods to treat superficial (close to the skin) vein reflux, such as foam sclerotherapy, endovenous thermal ablation, or stripping, which help to close or remove problematic veins.

Sclerotherapy involves injecting a special solution into affected veins that causes them to shrink and get absorbed by the body. On the other hand, endovenous thermal ablation uses heat to damage and close off problematic veins. Both these treatments are minimally invasive, meaning they don’t require large incisions, and have shown to be successful in dealing with venous reflux.

In cases when the deep veins are involved, other procedures may include valve reconstruction or valve transplant. Another procedure available is subfascial endoscopic perforator surgery (SEPS), which closes off the problematic veins linking your deep and superficial veins.

If these methods don’t work or are not suitable, surgical intervention might be necessary. This could involve procedures like ligation and stripping, which involves tying off and removing affected veins, or valve reconstruction procedures in the deep veins. Any surgical procedure will come with its own set of risks, such as infection, nerve or arterial injury, poor cosmetic result, scarring, or deep vein thrombosis (blood clot in the vein). Despite this, surgery can help alleviate pain, improve venous blood flow, and promote ulcer healing when paired with compression therapy. Remember to talk to your doctor about all your options to decide what is best for you.

What else can Venous Insufficiency be?

Besides diagnosing the immediate condition, doctors also need to consider other illnesses or conditions that might be causing the symptoms. The following list includes those other conditions:

• Lymphedema (swelling caused by a blockage in the lymphatic system)
• Cellulitis (a skin infection)
• Stasis dermatitis (skin inflammation due to poor blood flow)
• Varicose veins (swollen, twisted veins)
• Acute deep vein thrombosis (a blood clot in a deep vein)
• Heart failure (when your heart can’t pump blood effectively)
• Cirrhosis (serious liver disease)
• Renal failure (when your kidneys can’t filter waste from your blood)
• Endocrine disorders (issues with your hormone-producing glands), like hypothyroidism
• Medication side effects, like those from calcium channel blockers, NSAIDs, and oral hypoglycemic agents
• Lipedema (fat buildup under the skin)
• Ruptured popliteal cyst (a fluid-filled swelling behind the knee)
• Soft tissue hematoma (a swelling of clotted blood within the tissues) or mass
• Exertional compartment syndrome (abnormal pressure in muscles during exercise)
• Gastrocnemius tear (a tear in the calf muscle)

What to expect with Venous Insufficiency

Chronic Venous Insufficiency (CVI), a condition where your veins have trouble sending blood from your limbs back to your heart, is not a minor health issue and can greatly affect a person’s quality of life. If left untreated, the condition continually gets worse. It can lead to the creation of venous ulcers, which are common and extremely hard to cure. These prolonged ulcers can be painful and debilitating. Despite receiving treatment, there’s a high chance they will recur if the blood pressure in your veins remains high.

About 60% of people with CVI develop phlebitis, an inflammation of the vein, which in over half of the patients can further progress into deep vein thrombosis, a serious condition where a blood clot forms in a vein deep inside your body. CVI might also result in serious bleeding. Surgical intervention for CVI has typically not provided satisfactory results, even though there are many procedures available.

Beyond the physical impact, managing and treating this condition can also result to significant financial burden for patients.

Possible Complications When Diagnosed with Venous Insufficiency

Chronic venous insufficiency, a condition where your veins struggle to send blood from your limbs back to the heart, can lead to several problems, including:

• Chronic venous ulcers: These are wounds that don’t heal due to poor blood circulation.
• Deep vein thrombosis: This is a serious condition where a blood clot forms in a deep vein, usually in the legs.
• Recurrent cellulitis: This is a common bacterial skin infection that keeps coming back.
• Lipodermatosclerosis: This is a skin condition usually affecting the lower legs, causing hard, tight skin.
• Secondary lymphedema: This is when the lymphatic system can’t drain fluid, leading to swollen limbs.
• Stasis dermatitis: This is a skin condition characterized by red and itchy skin.
• Chronic pain: Long-lasting pain.
• Superficial thrombophlebitis: This is inflammation of a vein near the surface of the skin, due to a blood clot.
• Secondary hemorrhage: This is bleeding following a vein treatment or surgery.
• Atrophie blanche: This is a skin condition that appears as white patches with red spots.
• Ankle joint stiffness from chronic scarring: This is when your ankle becomes less flexible due to scarring over time.

Preventing Venous Insufficiency

Patients need to understand how to use compression stockings correctly for them to be effective. They should wear these stockings consistently and ensure that they are tight enough to help with their condition. Compression stockings can help to relieve discomfort, reduce swelling, and lessen the stretch of veins. They can also aid in healing venous ulcers (sores caused by non-functioning veins) and help prevent them from coming back.

Moreover, patients should regularly check their skin to catch any signs of breakage or infection and use moisturizer regularly to prevent any skin cracks. It’s also a good idea to lift the legs to decrease any swelling and avoid standing or sitting in the same position for long periods of time.

At the same time, maintaining a healthy weight is crucial to manage their condition. If patients face challenges in losing weight, including mental health issues like depression, anxiety, or eating disorders, medicine that could contribute to weight gain, or mobility problems, it would be beneficial to discuss these concerns with a specialist or seek counseling.

Ultimately, patients need to understand that chronic venous disease is a long-term condition. Therefore, staying in regular contact with their healthcare providers and following the recommended treatment plans diligently is crucial to manage this disease effectively.