Chronic Venous Insufficiency

Chronic Venous Insufficiency

If you have not heard of Chronic Venous Insufficiency, then this may be the perfect article for you to read! Chronic venous insufficiency refers to the problem in the lower legs where it becomes swollen with skin changes and discomfort. This is usually due to a phenomenon called venous hypertension. 

Every year, it has been noted that around 150,000 people are diagnosed with chronic venous insufficiency and more than 500 million dollars are used for the treatment of patients with CVI. Statistically speaking, in the United States alone, it has been estimated that 6 to 7 million people have chronic venous insufficiency.

CVI is more prevalent in women than in men, with a 1 to 40% and 1 to 17% risk, respectively. (1)Chronic Venous Insufficiency may also occur with swelling of the lower legs. This usually affects 7.5% of men and 5% of women. This prevalence would increase with age at about 2% in those less than 50 years of age and 10% in those 70 years of age. (2)

To further understand Chronic Venous Insufficiency, we will be discussing it in parts on how it starts, what further hastens the disease, its signs, and symptoms, how it will be treated, and what will happen if you are living with Chronic Venous Insufficiency.

How does Chronic Venous Insufficiency start?

Chronic venous insufficiency can be divided into two. Chronic venous insufficiency’s etiology is classified whether it is primary chronic venous insufficiency or secondary to deep vein thrombosis.

In primary chronic venous insufficiency, the person would often have absent venous valves since birth or has an abnormality in the walls of his/her veins since he/she was born. This abnormality would bring about the signs and symptoms of chronic venous insufficiency.

The veins of persons with primary deep venous thrombosis would often have lesser elastin, a protein found in veins that allow it to stretch, contract, or be elastic. This would make the veins lose their shape and become stretched out. On the other hand, the other classification of chronic venous insufficiency is often secondary to deep vein thrombosis.

So what is deep vein thrombosis? Deep vein thrombosis or DVT is a disease where there is a blood clot formation inside the veins. This clot could also form in the veins of the arms, brain, and even in the veins of the intestines. (3) Deep vein thrombosis triggers inflammation which causes the walls of the veins to become injured causing chronic venous insufficiency.

So aside from DVT, what else could cause chronic venous insufficiency? There are risks involved such as female gender, smoking, obesity, pregnancy, prolonged standing, and having May-Thurner syndrome. (1)

So, what happens to the veins in chronic venous insufficiency? The veins work to bring blood back to the heart. Its flow is upwards from the legs and to do this, the muscles of the calves and the valves of the veins work together. In chronic venous insufficiency, there may be leakage of the blood or obstruction in the pathway of the blood. This may result to increase in venous pressure of the lower extremities.

In chronic venous insufficiency secondary to deep vein thrombosis, injury to the walls of the veins causes the veins to develop scars that thicken the passageway of the blood which subsequently causes a higher venous pressure. Dysfunction of superficial veins, veins closer to the skin, is often due to abnormal valves. Other causes of valve defects could be due to prolonged standing, trauma, or hormonal changes. (4)

Venous pressure is affected by the blood flow, the presence of a block in the veins, the valves, and the quality of the pumping action of the calf muscles. Persons with venous insufficiency might feel pain, swelling, skin color changes, and skin thickening in the lower limbs. (4)

Additional resources:

Blog article: Arterial vs Venous Insufficiency

How does chronic venous insufficiency present? 

Chronic Venous Insufficiency

Initially, patients present with leg discomfort, swelling of the ankles and leg, itching, and weariness. Other signs and symptoms may be prickling, cramping, aching, and heaviness of the lower limbs after prolonged standing. Varicose veins are also seen.

Symptoms of leg pains, swelling, and cramping are often relieved with leg elevation and the use of compression stockings. (2) Severe cases of chronic insufficiency will present with skin ulcers, skin pigmentation, skin thickening, and delayed wound healing. Nonhealing ulcers are often seen at the inner bony side of the ankles.

In evaluating possible chronic venous insufficiency patients, the doctor might ask of previous pregnancies, family history of CVI, work which involves heavy lifting or prolonged standing, obesity, and hypertension. The legs are physically examined while taking note of their size, skin texture, and skin color. D-dimer, protein which is released in the formation of blood clots, may also be requested as it is often increased in patients with CVI. (5) In diagnosing chronic venous insufficiency, several modalities are used but the most important imaging done is the venous duplex ultrasound scan. It is the best way to diagnose venous insufficiencies. (6)

Another modality used is magnetic resonance venography. It is used to assess the lower limbs and the pelvis. Unlike venous duplex ultrasound scan, magnetic resonance venography is quite invasive but it is still used for difficult cases of venous insufficiency. (7) Venous plethysmography is also a noninvasive test that makes use of infrared light. It assesses the amount of blood pumped during exercise. This allows the physician to measure the amount of leakage, obstruction, or muscle use in venous insufficiency.

Other diagnostic tools used are MRI or CT scans which are performed to rule out other disease entities. 

How is Chronic Venous Insufficiency classified? 

So how is chronic venous insufficiency classified? This is often used by physicians and just to give you an overview of how CVI is classified, here is a brief discussion below.

The Clinical, Etiology, Anatomic, Pathophysiology (CEAP) classification is used to achieve a uniform classification of chronic venous insufficiency to allow clearer communication between physicians. (8)CEAP classification makes use of clinical manifestations which describes the symptoms if it is present or not. Another classification used is an etiologic classification which describes the manner of causation of the disease.

Anatomic classification refers to the specific group of veins involved while pathophysiological classification delves on the mechanism by which the disease occurs. 

CEAP Classification of Manifestations of Chronic Venous Insufficiency

Table 1.CEAP Classification. (8)

Another tool used to classify chronic venous insufficiency is the Venous Clinical Severity Score. It goes hand and hand with CEAP Classification. This severity scoring makes use of 10 attributes which could be labeled as absent, mild, moderate, or severe. This is often used in assessing the patient’s response to treatment. It is recommended in the guidelines of CVI.(8)

Venous Insufficiency Severity Score

Table 2.Venous Clinical Severity Score. (8)

What are the treatments available for Chronic Venous Insufficiency?

CEAP classification and as well as the Venous Clinical Severity Scoring is used in determining how severe the disease is. Based on this classification and scoring, treatment of chronic venous insufficiency is determined. The first goal of treatment is to improve the circulation of blood and to prevent further damages to the veins.

Other goals are to enhance the quality of life of the patient by reducing the swelling of the lower limbs, heal venous ulcers, and to remove the pain. So, what are the possible treatments for chronic venous insufficiencies? Are there medications to treat CVI? When do we need surgery? 

Lifestyle change

Smoking is one of the risk factors of chronic venous insufficiency. As we already know, smoking causes a lot of damage to our health and this includes your vein’s health. It greatly restricts the blood flow on our lower limbs. Nicotine also affects the elasticity of the vessels.

Quitting your smoking habits could significantly improve your health. Taking care of one’s health through proper diet could also improve your health. Weight loss could lessen the burden on your lower limbs. This lifestyle change aids in reducing your risk factors without any cost.

Improving blood flow of the lower limbs

Blood flow in the lower limbs could be improved by elevation of the lower limbs. This may be done in a sitting position with the legs raised above the level of the thighs or in a lying position with the legs above the level of the heart. This mechanism is simply caused by gravity. This also reduces the swelling of the legs. Another way to improve blood flow is to do regular exercises.

Rehabilitation through exercise is also available. A study that focused on structured calf muscle exercise on patients with severe CVI proved to be beneficial after 6 months. (10)The cornerstone in treatment is the use of graduated compression. Compression stockings greatly aid in restoring venous blood flow. To restore normal venous flow, 30-40 or 40-50 mmHg of ankle compression is used while a lower compression is made on the higher levels of the leg. (9)  

Medications

No medications for the treatment of chronic venous insufficiency have been approved by the US Food and Drug Administration. Drugs given for CVI are often used for discomfort reduction. Diuretics are given to lessen leg swelling. Herbal medications such as horse chestnut seed extracts, French maritime pine bark extract, and flavonoids are also suggested to be effective in constricting veins but studies are not yet sufficient enough to prove this. (2)

Venoablation 

So what is venoablation and how does it help in the treatment of Chronic Venous Insufficiency? Venoablation is a surgical treatment for those with severe chronic venous insufficiency that does not respond to medical management. We will mention a few techniques involved in venoablation but we won’t be delving into the techniques as it is far too advanced. Venoablation is simply the removal of veins that serve as reflux pathways. (9) Removal of these veins may lead to better ulcer healing and resolution of symptoms. 

Sclerotherapy which is also under venoablation is one treatment option. It is done by infusing a substance in the specific vein which destroys the vessel, but it is often used in smaller widened veins rather than CVI. Another venoablation technique is the radiofrequency ablation or RFA. What it does is to cause a thermal injury to a specific vessel with the use of a special radiofrequency catheter. This technique is said to have a good long term effect. (9)

In CVI, less than 8% of patients require venoablation as it is only used when it is appropriate for the patient’s condition. CVI which presents with severe symptoms is often treated with vein ligation with stripping but before this treatment, careful ultrasound mapping is done for the safety of the patient. (11) 

What are the complications of Chronic Venous Insufficiency?

In the event of chronic venous insufficiency without treatment, patients with this disease may develop deep vein thrombosis. Pulmonary embolism is also one complication of untreated CVI. What happens in pulmonary embolism? A clot from the lower limbs may travel up to the vessels of the lungs. This will block the passage of blood and may rapidly cause deterioration and even death as it will prevent oxygenation of the lungs. Other complications of untreated CVI are venous ulcerations and secondary lymphedema. The most common complications are chronic leg pains, swelling, and non-healing leg ulcers. 

What is the prognosis of Chronic Venous Insufficiency?

If you are suffering from chronic venous insufficiency, leaving it untreated would lead to a very high chance of having a disability in the end. Chronic venous insufficiency, once it starts, does not stop from progressing. Pain, skin breakdown and ulceration will progress. You might have a higher chance of developing deep vein thrombosis and pulmonary embolism which could cause death. Early treatment is always best. This could help you save healthcare costs in the end.

Additional resources:

Blog article: Varicose Vein Treatment Cost

Conclusion

As a recap, we have discussed chronic venous insufficiency in detail in this article. We have answered the following questions about CVI: 

Table of Contents

Living with chronic venous insufficiency can be made bearable and we can provide you the treatment you have been looking for!

If you want to learn more you can book a free consultation!

References: 

  1. De Popas, E., & Brown, M. (2018). Varicose Veins and Lower Extremity Venous Insufficiency. Seminars in interventional radiology, 35(1), 56–61. https://doi.org/10.1055/s-0038-1636522
  2. Jameson, J. L., Kasper, D. L., Longo, D. L., Fauci, A. S., Hauser, S. L., &Loscalzo, J. (2018). Harrisons principles of internal medicine 20th edition. New York: McGraw-Hill Education.
  3. Waheed, S. M., Kudaravalli, P., &Hotwagner D. T. (2020). Deep vein thrombosis. StatPearls.Treasure Island: StatPearls Publishing 
  4. Spiridon, M., &Corduneanu, D. (2017). Chronic Venous Insufficiency: a Frequently Underdiagnosed and Undertreated Pathology. Maedica, 12(1), 59–61.
  5. Bounds E. J., Sankar P., Kok S. J. (2020) D imer. StatPearls. Treasure Island: StatPearls Publishing
  6. Necas M. (2010). Duplex ultrasound in the assessment of lower extremity venous insufficiency. Australasian journal of ultrasound in medicine, 13(4), 37–45. https://doi.org/10.1002/j.2205-0140.2010.tb00178
  7. Tamura, K., & Nakahara, H. (2014). MR Venography for the Assessment of Deep Vein Thrombosis in Lower Extremities with Varicose Veins. Annals of vascular diseases, 7(4), 399–403. https://doi.org/10.3400/avd.oa.14-00068
  8. Eberhardt, R. T., &Raffetto, J. D. (2014). Chronic venous insufficiency. Circulation: Clinical Summaries. 130:293–294. https://doi.org/10.1161/CIR.0000000000000083 
  9. Weiss, R., Anariba, D. E. Z., Lanza, J., &Lessnau, K. D. (2018). Venous insufficiency. Retrieved from https://emedicine.medscape.com/article/1085412-treatment
  10. Kahle B, Leng K. Efficacy of sclerotherapy in varicose veins: prospective, blinded, placebo-controlled study.Dermatol Surg. 2004; 30:723–728.
  11. Ombrellino, M., &Kabnick, L. S. (2005). Varicose vein surgery. Seminars in interventional radiology, 22(3), 185–194. https://doi.org/10.1055/s-2005-921951

Co-Author | Dr. Tee Villanueva, MD

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Dr. Nima Azarbehi

Dr. Nima Azarbehi, our leading physician, has years of experience including chronic complicated conditions, urgent and emergency care, hospital medicine, dermatology, gastroenterology with endoscopy, rheumatology, pediatrics, newborn and obstetrics, aesthetics, office procedures, allergy management and treatment, cardiopulmonary management and intensive care management in hospital setting.

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