Chronic Venous Insufficiency

Chronic Venous Insufficiency (CVI) is a condition in which the veins in the legs cannot efficiently return blood to the heart, leading to poor circulation and the buildup of blood in the veins. This occurs when the valves inside the veins, which normally keep blood flowing upward towards the heart, become weakened or damaged. As a result, blood pools in the lower extremities, causing a variety of symptoms.

Predominantly, there are two types depending on the anatomical involvement

1. Superficial venous insufficiency. This is the more common type involving the superficial veins of the lower extremity
2. Deep venous insufficiency. This is less common and involves the deep veins of the lower extremity.
3. Mixed variant. This involves both the superficial and deep veins of the lower extremity. Less common.

🔹 Causes of Chronic Venous Insufficiency

CVI usually results from venous reflux (backward blood flow) and can be caused by:

1. Weak or damaged valves: The most common cause, where the valves inside the veins fail to close properly, causing blood to flow backward. There is an inherent defect causing the valves to malfunction. In a minority of cases, a blood clot in the deep veins leads to damage of these valves.
2. Venous hypertension: Increased pressure in the veins can damage the vein walls and valves.
3. Deep vein thrombosis (DVT): Previous blood clots can damage the veins and cause chronic problems with blood flow.
4. Injury to the veins: Physical trauma can lead to long-term venous insufficiency.
5. Obesity: Extra weight puts pressure on the veins, increasing the risk of CVI. Worsens the CVI.
6. Pregnancy: Increased blood volume and pressure on the veins can lead to CVI. Worsens the CVI.
7. Genetic factors: A family history of venous disease increases the risk of CVI.
8. Prolonged standing or sitting: Occupations that require standing for long periods can increase the likelihood of CVI. Worsens the CVI.

🔸 Symptoms of Chronic Venous Insufficiency

CVI can manifest in various ways, and symptoms often worsen over time. Common signs include:

1. Swelling in the legs and ankles: Often worse in the evening or after standing for long periods.
2. Pain or aching: A heavy, tired feeling in the legs, often relieved by elevating the legs.
3. Varicose veins: Enlarged, twisted veins that may be visible through the skin.
4. Skin changes:
• Hyperpigmentation (darkening of the skin, often around the ankles).
• Thickened skin.
• Itching or redness.
5. Venous ulcers: Open sores, typically near the ankle, that are slow to heal and may be painful.
6. Restless legs: An uncomfortable feeling in the legs, particularly at night.
7. Hardening of the tissue under the skin (lipodermatosclerosis), which may indicate advanced CVI.

🔹 Diagnosis of Chronic Venous Insufficiency

1. Physical Examination:
• The doctor will inspect your legs for signs of swelling, skin changes, varicose veins, and ulcers.
2. Duplex Ultrasound:
• A non-invasive test that uses sound waves to assess blood flow and identify areas where blood is pooling or where valves are damaged.

🔸 Treatment Options for Chronic Venous Insufficiency

The goal of treatment is to improve blood flow, reduce symptoms, and prevent complications such as venous ulcers. Treatment options include:

1. Conservative Measures

• Compression stockings: The most effective non-invasive treatment. Compression stockings help push blood back up toward the heart, reduce swelling, and alleviate symptoms.
• Leg elevation: Elevating the legs above the heart several times a day can help reduce swelling.
• Exercise: Regular walking or leg exercises can improve circulation and help strengthen the calf muscles, which assist in blood flow.
• Weight management: Maintaining a healthy weight reduces pressure on the veins and helps with circulation.
• Avoid prolonged standing or sitting: Moving frequently or changing positions can help prevent blood from pooling in the legs.

2. Minimally Invasive Procedures

• Endovenous Laser Therapy (EVLT): A laser fiber is inserted into the vein to heat and collapse the vein, which is then absorbed by the body.
• Sclerotherapy: A solution is injected into smaller varicose veins, causing them to shrink and eventually disappear.
• Endovenous Radiofrequency Ablation (RFA): Similar to EVLT, but uses radiofrequency energy to close off the problematic vein.

• Microstab Phlebectomy: Involves making small incisions to remove or interrupt varicose veins in cases where minimally invasive methods are not sufficient.

• Venography with possible stenting if there is central venous obstruction or compression in selected cases.
• Vein Stripping and Ligation: In more severe cases, the damaged vein is surgically removed, though this is less common today due to the availability of less invasive treatments. Very rarely used and is associated with delayed recovery.

3. Surgical Treatments

• Venous Bypass Surgery: A graft is used to bypass the blocked or damaged vein. Very rarely done given the high risk of complications.

4. Wound Care for Venous Ulcers

• Compression therapy: Helps reduce swelling and promote healing of ulcers.
• Topical treatments: Medications and creams may be used to treat ulcers and prevent infection.
• Debridement: The removal of dead tissue from ulcers to promote healing.

🔹 Prevention and Management

1. Early intervention: If CVI is caught early, many symptoms can be managed or reversed with conservative measures like compression stockings and lifestyle changes.
2. Regular monitoring: Those with risk factors (such as varicose veins or a history of DVT) should monitor symptoms and seek treatment before complications like ulcers develop.
3. Healthy lifestyle: Regular exercise, maintaining a healthy weight, and avoiding prolonged periods of immobility can help prevent the progression of CVI.

🔸 Complications of Chronic Venous Insufficiency

Without treatment, CVI can lead to serious complications, such as:

• Venous ulcers: These are painful, slow-healing sores, often on the lower legs or ankles.
• Skin changes: Severe pigmentation changes or skin thickening can occur.
• Bleeding: Varicose veins, particularly near the skin surface, can bleed easily from minor trauma.
• Deep vein thrombosis (DVT): More seen with deep venous insufficiency. Rarely associated with superficial venous insufficiency [eg. Varicose veins], which is more common.
• Infection: Ulcers and skin changes may become infected if not properly managed.

🔹 Prognosis

CVI is a chronic condition that can worsen over time if not properly managed. However, with early intervention, lifestyle changes, and appropriate treatment, most people with CVI can manage their symptoms effectively and avoid serious complications.