Cardiology >  Chronic Venous Insufficiency (CVI)

Background

Chronic venous insufficiency (CVI) is a condition in which the veins of the lower extremities fail to return blood effectively to the heart due to valvular incompetence, venous obstruction, or impaired calf muscle pump function. This leads to venous hypertension, causing venous dilation, edema, skin changes, and potentially venous ulcers if untreated.

II) Classification/Types

By Etiology:

• • Primary CVI: Idiopathic valvular insufficiency, often hereditary, without prior thrombosis.
  • Secondary CVI: Post-thrombotic syndrome following deep vein thrombosis (DVT), trauma, or surgery.

By Anatomic Involvement (CEAP classification):

• • Superficial (e.g., great saphenous vein)
  • Deep (e.g., femoral vein)
  • Perforator veins

By Clinical Stage (CEAP C1–C6):

• • C1: Telangiectasias or reticular veins
  • C2: Varicose veins
  • C3: Edema
  • C4: Skin changes (pigmentation, eczema, lipodermatosclerosis)
  • C5: Healed venous ulcer
  • C6: Active venous ulcer

III) Pathophysiology

Incompetent venous valves allow retrograde blood flow (venous reflux), increasing hydrostatic pressure in the veins of the legs. This leads to venous dilation, capillary leakage, inflammation, and tissue damage. Over time, the cycle of inflammation and hypoxia results in fibrosis, skin changes, and ulceration.

IV) Epidemiology

• • Sex: More common in women, especially during and after pregnancy.
  • Age: Prevalence increases with age.
  • Geography: Higher prevalence in Western countries due to sedentary lifestyles and obesity.
  • Comorbidities: Often associated with obesity, sedentary behavior, previous DVT, and occupations requiring prolonged standing.

Etiology

I) Causes

• • Valvular incompetence (primary or idiopathic)
  • Deep vein thrombosis (post-thrombotic syndrome)
  • Obesity
  • Pregnancy
  • Trauma or prior surgery involving the veins
  • Prolonged standing or immobility
  • Arteriovenous fistulas (rare)

II) Risk Factors

• • Age >50 years
  • Female sex
  • Family history of varicose veins or CVI
  • Sedentary lifestyle or prolonged standing
  • Obesity
  • Pregnancy, especially multiple
  • Prior DVT or leg trauma
  • Smoking

Clinical Presentation

I) History (Symptoms)

• • Leg heaviness, aching, or fatigue that worsens with prolonged standing and improves with elevation
  • Leg swelling, especially at the end of the day
  • Burning, itching, or tingling in lower limbs
  • Skin discoloration (brown or reddish), thickening, or eczema
  • Ulcers near the medial malleolus (advanced disease)

II) Physical Exam (Signs)

Vital Signs:

• • Usually normal unless significant comorbidities

Lower Limb Exam:

• • Telangiectasias or varicose veins
  • Pitting edema (typically around ankles)
  • Hyperpigmentation (hemosiderin deposition)
  • Lipodermatosclerosis (woody skin induration)
  • Atrophie blanche (white scarred areas)
  • Venous ulcers (typically medial ankle, shallow with irregular margins)

Special Tests:

• • Positive Trendelenburg test
  • Incompetent perforators (manual testing or Doppler)

Differential Diagnosis (DDx)

• • Lymphedema
  • Congestive heart failure
  • Cellulitis
  • Deep vein thrombosis
  • Peripheral arterial disease
  • Lipedema
  • Stasis dermatitis (can coexist)

Diagnostic Tests

Initial Tests:

• • Duplex Ultrasonography:
    Gold standard to assess for venous reflux and obstruction in superficial, deep, and perforator veins
  • Photoplethysmography:
    Assesses venous refill time, used in some specialized settings

Additional Tests (if indicated):

• • D-dimer and venous duplex: If DVT is suspected
  • Ankle-brachial index (ABI): To rule out arterial disease before compression therapy
  • MRI/CT venography: Rarely used; for suspected pelvic vein obstruction or complex anatomy

Treatment

I) Conservative/Medical Management:

• • Compression Therapy (cornerstone of treatment):
    Graduated compression stockings (20–40 mmHg) improve venous return, reduce edema, and prevent ulcer recurrence
  • Lifestyle Modifications:
    Weight loss, regular exercise (calf muscle activation), leg elevation, avoiding prolonged standing
  • Pharmacologic Options (adjunctive):
    Venoactive drugs (e.g., micronized purified flavonoid fraction, horse chestnut seed extract)
     Diuretics (short-term use for severe edema)
  • Wound Care:
    Moist dressings, debridement, topical agents for venous ulcers

II) Interventional/Surgical:

• • Endovenous Thermal Ablation (laser or radiofrequency):
    Minimally invasive treatment for superficial venous reflux
  • Sclerotherapy:
    For telangiectasias or varicose veins
  • Surgical Ligation and Stripping:
    Less commonly performed with advent of minimally invasive methods
  • Subfascial Endoscopic Perforator Surgery (SEPS):
    Used for perforator vein incompetence in ulcer disease
  • Skin Grafting/Biologicals:
    For refractory or large venous ulcers

Patient Education, Screening, Vaccines

• • Importance of consistent compression use
  • Elevate legs above heart level when possible
  • Encourage daily walking and calf exercises
  • Maintain ideal body weight
  • Avoid prolonged standing/sitting
  • Skin care to prevent dermatitis or ulceration

Vaccinations:

• • Influenza and pneumococcal vaccines (especially if comorbid heart or lung disease)
  • COVID-19 vaccination as per guidelines

Consults

• • Vascular Surgery: For advanced disease or procedural intervention
  • Dermatology: For chronic skin changes or non-healing ulcers
  • Wound Care Specialist: For venous ulcers
  • Primary Care/Internal Medicine: For risk factor modification
  • Physical Therapy: For lymphedema or mobility support

Follow-Up

• • Regular follow-up for patients with compression therapy to ensure compliance and proper fit
  • Duplex ultrasound for assessment post-intervention or for progression
  • Monitoring and documentation of ulcer healing (e.g., size, depth, granulation tissue)
  • Reassess need for reintervention if symptoms recur
  • Educate patients on early signs of complications (e.g., cellulitis, ulceration)