Chronic Venous Insufficiency

Chronic Venous Insufficiency (CVI), also known as chronic venous disease, is a condition where blood pools in the veins, straining their walls. The most common cause is superficial venous reflux, a treatable issue. This condition primarily affects the legs, as efficient blood return requires functional venous valves.

When vein impairment leads to significant symptoms such as swelling and ulcer formation, it is termed chronic venous disease. It should not be confused with post-thrombotic syndrome, which involves deep vein damage from previous deep vein thrombosis. CVI is more prevalent in women and is influenced by factors like genetics, smoking, obesity, pregnancy, and prolonged standing.

Signs and Symptoms

Chronic venous insufficiency

CVI in the legs presents various signs and symptoms:

• Varicose veins
• Itching (pruritus)
• Hyperpigmentation
• Phlebetic lymphedema
• Chronic swelling of the legs and ankles
• Leg ulcers

It may also lead to complications like venous stasis, venous ulcers, stasis dermatitis (varicose eczema), and contact dermatitis. Advanced conditions include atrophie blanche, lipodermatosclerosis, and even malignancy, which is rare but aggressive. Pain, anxiety, depression, inflammation, and cellulitis are also associated with CVI.

Causes

Venous valves

CVI typically arises from the reflux of venous valves in superficial veins, but several conditions can instigate it:

• Deep vein thrombosis (DVT)
• Superficial vein thrombosis
• Phlebitis
• May–Thurner syndrome, a rare condition where blood clots form in the iliofemoral vein due to vascular compression in the leg.

Deep and superficial vein thrombosis can stem from thrombophilia (increased blood clot formation propensity), and arteriovenous fistulae may cause CVI even if vein valves are functional.

Diagnosis

B-flow ultrasonograph over a valve of the great saphenous vein, showing a venous reflux (flow toward right in the image).

Diagnosis involves clinical history and examination to rule out systemic causes like hypervolaemia and heart failure. Duplex ultrasound can detect venous obstruction or valvular incompetence and is used for planning venous ablation procedures. Invasive venography is reserved for surgery candidates or suspected venous stenosis. Other diagnostic tools include ankle-brachial index, air or photoplethysmography, intravascular ultrasound, and ambulatory venous pressures.

Classification

Acute venous ulcer (45 x 30 mm).

The CEAP classification system (Clinical, Etiological, Anatomical, and Pathophysiological) categorises CVI:

• Clinical: From no obvious features (C0) to acute ulcers (C6)
• Aetiology: Primary, secondary, congenital, or unknown causes
• Anatomical: Superficial, deep, perforator, or no obvious location
• Pathophysiology: Obstruction, reflux, or both

Management

Conservative

Conservative management aims to alleviate symptoms and prevent worsening:

• Manual compression lymphatic massage therapy
• Red vine leaf extract
• Sequential compression pump
• Ankle pump
• Compression stockings
• Blood pressure medication
• Hydroxyethylrutoside medication
• Frequent leg elevation
• Bed tilting to elevate feet above heart level

Surgical

Surgical interventions aim to cure by altering veins with incompetent valves:

• Ligation (tying off a vein)
• Vein stripping (removal)
• Surgical repair
• Endovenous Laser Ablation
• Vein transplant
• Subfascial endoscopic perforator surgery (tying off with an endoscope)
• Experimental valve repair and transposition
• Hemodynamic surgeries

The CHIVA method is a minimally invasive, ultrasound-guided surgery for treating varicose veins under local anaesthetic.

Prognosis

CVI can lead to significant morbidity, with chronic venous ulcers being particularly challenging to treat. Recurrences are common without resolving venous hypertension. Phlebitis and deep vein thrombosis are frequent complications, and severe haemorrhage is possible. Surgical outcomes remain unsatisfactory despite various procedures.

Self-assessment MCQs (single best answer)

What is the most common cause of Chronic Venous Insufficiency (CVI)?

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Which of the following is NOT a symptom of CVI in the legs?

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Which diagnostic tool is primarily used to detect venous obstruction or valvular incompetence?

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In the CEAP classification system, what does "C6" indicate?

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Which of the following is NOT a conservative management technique for CVI?

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Which surgical method for CVI involves the removal of veins?

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Which of the following is a complication associated with CVI?

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What is the purpose of using compression stockings in CVI management?

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Which condition involves deep vein damage resulting from previous deep vein thrombosis and should not be confused with CVI?

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Which of the following is a rare but aggressive complication of CVI?

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