What is venous insufficiency

Venous insufficiency is a condition in which the veins (most often in the legs) have problems sending blood from the legs back to the heart. Venous insufficiency causes blood to pool in the blood vessels so that they become enlarged or varicose over time. Normally, blood circulates from the heart to the legs via arteries and back to the heart through veins. To push blood upward from the feet, veins rely on surrounding muscles and a network of one-way valves to prevent blood from flowing backward. If the muscles and one-way valves become weak or fail, the vein becomes incompetent and blood begins to collect in the vein rather than returning to the heart.

Varicose veins are superficial blood vessels that become enlarged and twisted. Any vein in the body may become varicose, but the condition most often occurs in the veins of the legs. Varicose veins are different from spider veins—the very small bluish and/or purple veins that are close to the skin and appear on the legs and/or face. Spider veins generally do not cause pain and are more of a cosmetic concern.

Vein problems are among the most common chronic conditions in North America. In fact, more people lose work time from vein disorders than from artery disease. By the age of 50, nearly 40 percent of women and 20 percent of men have significant leg vein problems. Spider veins occur much more frequently in women. It is estimated that at least 20 to 25 million Americans have varicose veins.

Your doctor will conduct a physical exam and may order a venous ultrasound to evaluate your vein function and check for blood clots. Treatment depends on the severity of the condition and ranges from lifestyle changes to venous ablation or phlebectomy.

Can venous insufficiency be cured?

Venous insufficiency is often a long-term (chronic) condition. Chronic venous insufficiency tends to get worse over time, ultimately leading to skin breakdown and ulcer formation. And these ulcers are difficult to heal leading to significant pain and increased costs of healthcare. Many patients end up in wound clinics where they are treated for months and years, without any significant benefit. These patients are also at an increased risk for deep vein thrombus and pulmonary embolism. In addition, any minor trauma is associated with torrential bleeding that can sometimes be fatal ¹.

However, chronic venous insufficiency can be managed if treatment is started in the early stages. By taking self-care steps, you may be able to ease the discomfort and prevent chronic venous insufficiency from getting worse. It is likely that you will need medical procedures to treat the chronic venous insufficiency.

Arterial vs Venous insufficiency

Arterial insufficiency is any condition that slows or stops the flow of blood through your arteries. Arteries are blood vessels that carry blood from the heart to other places in your body. One of the most common causes of arterial insufficiency is atherosclerosis or “hardening of the arteries.” Fatty material (called plaque) builds up on the walls of your arteries. This causes them to become narrow and stiff. As a result, it is hard for blood to flow through your arteries.

When enough plaque builds up on the inside of an artery, the artery becomes clogged, and blood flow is slowed or stopped. This slowed blood flow may cause “ischemia,” which means that your body’s cells are not getting enough oxygen. Clogged peripheral arteries in the lower part of the body (also referred to as peripheral artery disease) most often cause pain and cramping in the legs.

The risk factors for atherosclerosis in the peripheral arteries are the same as those for atherosclerosis in the coronary arteries. Smoking, diabetes, high blood pressure, and high cholesterol are believed to lead to the development of plaque.

Blood flow may be suddenly stopped due to a blood clot. Clots can form on the plaque or travel from another place in the heart or artery (also called embolus).

Arterial insufficiency symptoms

Symptoms depend on where your arteries become narrowed:

• If it affects your heart arteries, you may have chest pain or a heart attack.
• If it affects your brain arteries, you may have a stroke.
• If it affects the arteries that bring blood to your legs, you may have frequent leg cramping when you walk.
• If it affects the arteries in your belly area, you may have pain after you eat.

Patients may feel pain in their calves, thighs, or buttocks, depending on where the blockage is. Usually, the amount of pain you feel is a sign of how severe the blockage is. In serious cases, your toes may turn a bluish color, your feet may be cold, and the pulse in your legs may be weak. In severe cases, the tissue dies (this is called gangrene) and amputation may be needed.

Sometimes leg cramps develop when a person walks, and the leg pain usually gets worse with increased activity. This cramping is called intermittent claudication. Like the chest pain of angina, the leg pain of intermittent claudication usually goes away with rest. Cold temperatures and some medicines may also cause leg pain.

Arterial insufficiency diagnosis

Doctors can make a diagnosis by listening to you describe your symptoms and by checking for a weak pulse in the arteries in your feet. Further tests may include

• Ultrasound, which is a test that uses sound waves to produce an image of blood flow through your arteries.
• Arteriography, which is a test that may be performed if your doctor thinks your condition is serious enough for a percutaneous intervention or surgery. The test uses a harmless dye that is injected into the arteries. It lets doctors see where and how serious the blockage is.

Arterial insufficiency treatment

When the blockages are not severe, this form of peripheral artery disease can be controlled by losing weight, quitting smoking, and following a regular exercise program that has been approved by your doctor.

A percutaneous intervention (balloon angioplasty or a peripheral stent) may be needed for a severely blocked artery that is causing pain or other symptoms.

Your doctor may also recommend a procedure called a peripheral vascular bypass. This procedure creates a way for blood to flow around one or more of the narrowed vessels. After making an incision in your arm or leg or below your stomach, the surgeon will take an artificial vessel or one of your own veins (called a graft) and connect it to the blocked vessel at points above and below the blockage. This allows blood to flow around, or “bypass,” the blockage.

Venous insufficiency causes

Normally, valves in your deeper leg veins keep blood moving forward toward the heart. The cause of venous insufficiency is related either to poorly functioning vein valves or blockage in the veins. Vein valves are designed to allow blood to flow against gravity from the legs back to the heart. When the values fail to close properly, gravity wins and the flow reverses. Venous insufficiency results from venous hypertension which in turn is usually caused by reflux in the superficial venous compartment. This is called venous reflux.

Vein valves may fail to close due to:

• Vein wall weakness that causes the vein to enlarge so that the valves can not close
• A history of blood clots or deep vein thrombosis (DVT) in the vein that damage the valve
• An absence of vein valves since birth

Less common causes include:

• deep venous compression
• post-thrombotic stenosis or occlusion
• deep venous reflux
• venous hypertension caused by vascular malformations, arteriovenous fistulae, and neuromuscular disorders (rare)

Varicose veins are hereditary most of the time and generally occur in several members of the same family. Much less commonly, varicose veins develop after
a trauma or injury.

Regardless of the cause, defective valves cause a build up of pressure of the blood in the leg, leading to venous hypertension or high blood pressure in the vein. This may result in enlargement of the varicose veins and an increased likelihood of other symptoms such as swelling, skin changes and ulcers at the ankles or lower leg. Valve failure and venous reflux can also occur in the veins that are unseen, such as the saphenous veins (which run from the foot to the thigh) or in the deep veins. Reflux in these veins is often the underlying cause of painful varicose veins. Venous reflux is a condition that is progressive. If left untreated, it can worsen and cause more advanced symptoms of chronic venous insufficiency. On occasion, the cause of the problem it not even in the legs, but is in the pelvis. Here, blockage of the veins may severely aggravate the symptoms of varicose veins, thus requiring separate treatment.

Risk factors for venous insufficiency

Risk factors for venous insufficiency include:

• Family history of this condition
• Aging, which results in decreased elasticity of blood vessels
• Pregnancy and other conditions that put pressure on veins in the legs
• History of deep vein thrombosis in the legs
• Female gender (related to levels of the hormone progesterone)
• A history of smoking
• Standing or sitting for long periods of time
• Being overweight or obesity, which increases pressure on the legs
• Menopause
• Weakened blood vessel walls
• Inflammation of the veins (known as phlebitis)
• Chronic constipation and in rare cases, tumors
• Tall height

Venous insufficiency symptoms

When blood pools in the veins of the lower leg, fluid and blood cells leak out into the skin and other tissues. This can cause itchy, thin skin and lead to skin changes called stasis dermatitis. This is an early sign of venous insufficiency.

Other early signs include:

• Leg swelling, heaviness, and cramping
• Dark red, purple, brown, hardened skin (this is a sign that blood is pooling)
• Itching and tingling

Venous insufficiency causes symptoms such as:

• Twisted and bulging veins
• The appearance of dark purple or blue colors at the surface of the skin
• Leg swelling, itching, aching, burning, throbbing and muscle cramping
• Dull aching, heaviness, or cramping in legs
• Itching and tingling
• Pain that gets worse when standing
• Pain that gets better when legs are raised
• Skin discoloration
• Varicose veins

Skin changes in the legs include:

• Swelling of the legs
• Irritated or cracked skin if you scratch it
• Red or swollen, crusted, or weepy skin (stasis dermatitis)
• Varicose veins on the surface
• Thickening and hardening of the skin on the legs and ankles (lipodermatosclerosis)
• Wound or ulcer that is slow to heal on the legs or ankles

Venous insufficiency complications

Complications of venous insufficiency include:

• pain
• inflammation and swelling
• skin ulcers
• bleeding when veins close to the surface of the skin burst
• blood clots, which can lead to deep vein thrombosis
• superficial thrombophlebitis, a condition in which superficial (closer to the skin) veins within the legs become tender, inflamed, and cord-like in nature

Venous insufficiency diagnosis

Your health care provider will do a physical exam and ask about your symptoms and medical history. Diagnosis is often made based on the appearance of leg veins when you are standing or sitting with your legs dangling.

A duplex ultrasound exam of your leg may be ordered to:

• Check how blood flows in the veins
• Rule out other problems with the legs, such as a blood clot

Venous insufficiency test

Venous Doppler ultrasound is considered the primary imaging modality of choice. Typically the great saphenous vein and the small saphenous vein and their primary tributaries are assessed.

The presence of reflux is determined by the direction of flow because any significant flow toward the feet is suggestive of reflux. The duration of reflux is known as the “reflux time” (replacing the commonly used “valve closure time”):

• a reflux time of > 0.5 (or 1.0 according to some publications) second has been used to suggest the diagnosis the presence of reflux, although a more refined definition with a variable “cutoff” based on location has been suggested
• the longer the duration of reflux or the greater the reflux time implies more severe disease

Venous duplex imaging may provide information about local valve function to construct an anatomic map of disease in terms of the systems and levels of involvement.

The presence and location of perforators are also documented. The patient should be able to stand for this procedure.

Venous insufficiency treatment

Your doctor may suggest that you take the following self-care steps to help manage venous insufficiency:

• Do not sit or stand for long periods. Even moving your legs slightly helps keep the blood flowing.
• Care for wounds if you have any open sores or infections.
• Lose weight if you are overweight.
• Exercise regularly.

You can wear compression stockings to improve blood flow in your legs. Compression stockings gently squeeze your legs to move blood up your legs. This helps prevent leg swelling and, to a lesser extent, blood clots.

When more advanced skin changes are present, your doctor:

• Should explain which skin care treatments can help, and which can make the problem worse
• May recommend some drugs or medicines that may help

Your doctor may recommend more invasive treatments if you have:

• Leg pain, which may make your legs feel heavy or tired
• Skin sores caused by poor blood flow in the veins that do not heal or recur
• Thickening and hardening of the skin on the legs and ankles (lipodermatosclerosis)

Choices of procedures include:

1. Sclerotherapy — Sclerotherapy works best for spider veins. These are small varicose veins. Salt water (saline) or a chemical solution is injected into the vein. The vein hardens and then disappears.
2. Phlebectomy — Small surgical cuts (incisions) are made in the leg near the damaged vein. The vein is removed through one of the incisions. This may be done along with other procedures, such as ablation.
3. Ablation uses intense heat to treat the vein. There are two methods. One uses radiofrequency energy and the other uses laser energy. During these procedures:
   • Your doctor will puncture the varicose vein.
   • Your doctor will thread a flexible tube (catheter) through the vein.
   • The catheter will send intense heat to the vein. The heat will close off and destroy the vein and the vein will disappear over time.
4. Laser therapy. Laser treatment can be used on the surface of the skin. Small bursts of light make small varicose veins disappear.
5. Varicose vein stripping — Used to remove or tie off a large vein in the leg called the superficial saphenous vein.

Risks of venous insufficiency treatment

These treatments are generally safe. Ask your provider about specific problems that you might have.

The risks for any anesthesia and surgery are:

• Allergic reactions to medicines
• Breathing problems
• Bleeding, bruising, or infection

The risks of varicose vein therapy are:

• Blood clots
• Nerve damage
• Failure to close the vein
• Opening of the treated vein
• Vein irritation
• Bruising or scarring
• Return of the varicose vein over time

After the procedure

Your legs will be wrapped with bandages to control swelling and bleeding for 2 to 3 days after your treatment.

You should be able to start normal activities within 1 to 2 days after treatment. You will need to wear compression stockings during the day for 1 week after treatment.

Your leg may be checked using ultrasound a few days after treatment to make sure the vein is sealed.

Prognosis

These treatments reduce pain and improve the appearance of the leg. Most of the time, they cause very little scarring, bruising, or swelling.

Wearing compression stockings will help prevent the problem from returning.

Chronic venous insufficiency

Chronic venous insufficiency is a long-term condition. Chronic venous insufficiency occurs due to inadequate functioning of venous wall and/or valves in lower limb veins resulting in excessive pooling of blood. Chronic venous insufficiency is most commonly due to malfunctioning (incompetent) valves in the veins. Chronic venous insufficiency may also occur as the result of a past blood clot in the legs.

Chronic venous insufficiency is one of the causes of dystrophic soft tissue calcification.

Chronic venous insufficiency is a common cause of leg pain and swelling, and is commonly associated with varicose veins. Chronic venous insufficiency may affect up to 20 percent of adults. Each year approximately 150,000 new patients are diagnosed with chronic venous insufficiency, and nearly $500 million is used in the care of these patients ². Results across studies suggest that in the general population between 1% to 17% of men and 1% to 40% of women may experience chronic venous insufficiency ².

Chronic venous insufficiency may be a result of deep vein thrombosis (DVT) or blood clots in the deep veins of the legs. If a clot forms in the superficial veins, there is a very low risk of DVT occurring. Over time, chronic venous insufficiency may result in varicose veins, swelling and discoloration of the legs, itching and the development of ulcers near the ankles. Among all chronic venous insufficiency patients, approximately 1% to 2.7% will develop a venous stasis ulcer ². Formation of an ulcer carries a poor prognosis, with 40% of patients developing recurrence despite standard treatment. Management of chronic venous insufficiency accounts for approximately 2% of the United States total healthcare ³.

Chronic venous insufficiency is best managed by a team of healthcare professionals that include a wound care nurse, vascular surgeon, general surgeon, bariatric nurse, and physical therapist. Most cases of chronic venous insufficiency can be treated, but the key is compliance. Patients should be encouraged to wear compression stockings, unless there is a contraindication. Just the use of stockings alone can markedly improve the symptoms and appearance. In addition, the patient should be encouraged to lose weight and avoid standing in one position for prolonged times ⁴.

Key facts

• Chronic venous insufficiency is a very common condition caused by venous reflux and obstruction.
• Given that chronic venous insufficiency can be associated with considerable complications and sequelae, including venous leg ulcer, early diagnosis and adequate treatment are of great importance.
• Symptoms typically include a tendency for edema and a feeling of heaviness in the legs, as well as pruritus, pain, and nocturnal cramps.
• Color‐flow duplex ultrasound is the gold standard for nearly all diagnostic issues related to chronic venous disease.
• There is a wide range of therapeutic options, including sclerotherapy as well as surgical and endovenous procedures. Compression is a fundamental treatment principle in all disease stages. Despite great therapeutic advances, there is to date no intervention that can definitively prevent the recurrence of chronic venous disease.

Chronic venous insufficiency causes

The cause of chronic venous insufficiency can also be classified as either primary or secondary to deep venous thrombosis (DVT).

Primary chronic venous insufficiency refers to the symptomatic presentation without a precipitating event and is due to congenital defects or changes in venous wall biochemistry. Recent studies suggest that approximately 70% of patients have primary chronic venous insufficiency and 30% have the secondary disease. Studies into primary chronic venous insufficiency have identified reduced elastin content, increased extra-cellular matrix remodeling and inflammatory infiltrate. The culmination of which alters the integrity of the vein promoting dilation and valvular incompetence.

Secondary chronic venous insufficiency occurs in response to a DVT which triggers an inflammatory response subsequently injuring the vein wall. Irrespective of the specific etiology, chronic venous insufficiency promotes venous hypertension. The most common non-modifiable risk factors are female gender and non-thrombotic iliac vein obstruction (May-Thurner syndrome). Several studies have also suggested a genetic component contributing to vein wall laxity. Modifiable risk factors include smoking, obesity, pregnancy, prolonged standing, DVT, and venous injury ⁵.

Vein valves may fail to close due to:

• Vein wall weakness that causes the vein to enlarge so that the valves can not close
• A history of blood clots or deep vein thrombosis (DVT) in the vein that damage the valve
• An absence of vein valves since birth

Less common causes include:

• deep venous compression
• post-thrombotic stenosis or occlusion
• deep venous reflux
• venous hypertension caused by vascular malformations, arteriovenous fistulae, and neuromuscular disorders (rare)

Varicose veins are hereditary most of the time and generally occur in several members of the same family. Much less commonly, varicose veins develop after
a trauma or injury.

Regardless of the cause, defective valves cause a build up of pressure of the blood in the leg, leading to venous hypertension or high blood pressure in the vein. This may result in enlargement of the varicose veins and an increased likelihood of other symptoms such as swelling, skin changes and ulcers at the ankles or lower leg. Valve failure and venous reflux can also occur in the veins that are unseen, such as the saphenous veins (which run from the foot to the thigh) or in the deep veins. Reflux in these veins is often the underlying cause of painful varicose veins. Venous reflux is a condition that is progressive. If left untreated, it can worsen and cause more advanced symptoms of chronic venous insufficiency. On occasion, the cause of the problem it not even in the legs, but is in the pelvis. Here, blockage of the veins may severely aggravate the symptoms of varicose veins, thus requiring separate treatment.

Chronic venous insufficiency pathophysiology

Chronic venous insufficiency pathophysiology is either due to reflux (backward flow) or obstruction of venous blood flow. Chronic venous insufficiency can develop from the protracted valvular incompetence of superficial veins, deep veins or perforating veins which connect them. In all cases, the result is venous hypertension of the lower extremities. Superficial incompetence is usually due to weakened or abnormally shaped valves or widened venous diameter which prevents normal valve congruence. Deep vein dysfunction is usually owing to the previous DVT which results in inflammation, valve scarring and adhesion, and luminal narrowing. Perforating vein valvular failure allows a higher pressure to enter the superficial venous system. The subsequent dilation prevents the proper closure of the valve cusps in the superficial veins. Most patients will also have the disease in the superficial veins. The resting venous pressure is a summation of the outflow obstruction, capillary inflow, valve function, and muscle pump function. Regardless of the cause, the persistently elevated venous hydrostatic pressure may result in lower extremity pain, edema, and venous microangiopathy. Some patients develop permanent skin hyperpigmentation from hemosiderin deposition as red blood cells extravasate into the surrounding tissue. Many of these patients will also have lipodermatosclerosis, which is skin thickening from fibrosis of subcutaneous fat. As the disease progresses, the perturbed microcirculation and dermal weakening can result in ulcer formation ⁶.

Chronic venous insufficiency symptoms

Patients with chronic venous insufficiency commonly present initially with a combination of dependent pitting edema, leg discomfort, and fatigue, and itching. Although there can be variation in presentation among patients, certain features are more prevalent: pain, cramping, itching, prickling, and throbbing sensation. Patients may describe symptoms that improve with rest and leg elevation, and with no association for exercise. This latter feature can be used to distinguish venous from arterial claudication. As their disease progresses, the presence of varicose veins and tenderness can be noted along with refractory edema and skin changes. Patients with advanced disease will present with a severe blanched skin lesion, dermal atrophy, hyperpigmentation, dilated venous capillaries, and ulcer formation most commonly overlying the medial malleolus. The physical exam must involve a detailed assessment of any ulcers, distal pulses, and neuropathy. A thorough history should note any hypercoagulable condition, oral contraceptive use, previous DVT or intervention, the level of physical activity, and occupation. The patient’s presentation should carefully be distinguished from other pathologies with similar symptoms: diabetic ulcers, ischemic ulcers, and dermatologic conditions including cancer.

Chronic venous insufficiency stages

The most commonly used classification of chronic venous insufficiency is the CEAP classification, which includes clinical, etiological, anatomical, and pathophysiological aspects and stages ⁷. Generally, only the C‐classification (clinical features) is used in everyday clinical practice. Although Widmer’s classification is still occasionally used, it reflects the actual disease stage less accurately and only includes chronic venous insufficiency.

Widmer’s chronic venous insufficiency classification:

• Stage 1: Reversible edema, corona phlebectatica, perimalleolar reticular veins
• Stage 2: Persistent edema, hemosiderosis and purpura on the lower leg, lipodermatosclerosis, atrophie blanche, stasis dermatitis
• Stage 3: Leg ulcer
• Stage 3a: Healed leg ulcer
• Stage 3b: Active leg ulcer

C (clinical) classes of the CEAP classification of chronic venous insufficiency:

• C0: No visible or palpable signs of venous disease. At this stage, no structural or functional abnormality is found in the venous system in the lower limbs. The patient may complain of symptoms caused by the presence of certain mediators released following a slowing of blood flow, triggered by prolonged standing: feeling of heavy legs, pains in the legs and pruritus. At this stage, however, there are no clinical or palpable signs of venous disease.
• C1: Presence of telangiectasia or reticular veins. Stage at which the first clinical signs of venous disease appear: presence of telangiectasia or reticular veins. These form due to increased venous pressure in certain areas of the leg veins or due to other factors, such as: a hormonal influence during pregnancy, the use of oral contraception, significant weight variation, etc.
• C2: Varicose veins. An increased venous pressure in all or a major proportion of the venous system in the lower limbs causes visible and palpable varicose veins to form, which reflect marked dilation of the vein diameter. This condition can develop either from following an obstruction to venous blood circulation or because of congenital weakness of the venous walls.
• C3: Edema. The increase in venous pressure causes leakage of intravascular fluid into the tissues and makes it difficult for the venous network to reabsorb fluids. The visible result of this venous hypertension is venous oedema (without trophic changes).
• C4: Varicose veins with trophic skin lesions. Progression of the disorders cited in stage 3 leads to extravasation of blood cell elements and, in particular, macromolecules (proteins, different pro-inflammatory mediators, etc.), which exacerbate stasis. All these phenomena trigger areas of tissue damage, which, once repaired, leave behind traces, such as atrophie blanche, which simply consists of small scars. Extravasation of red cells and their disintegration leads to pigmented purpuric dermatitis. Other trophic changes, such as varicose eczema, can also develop.
• C4a: Pigmentation, purpura, eczema
• C4b: Lipodermatosclerosis, atrophie blanche.
• C5: Trophic changes indicated in stage 4 with healed ulcer. Once healed, a leg ulcer is always a weak point in terms of skin trophicity and the risk of recurrence from a healed ulcer is greater than the risk of developing a venous leg ulcer on skin that has never previously had one, particularly if the trophic changes persist after the wound has healed.
• C6: Trophic changes indicated in stage 4 with active ulcer. A venous leg ulcer, which is the last stage in chronic venous insufficiency, is full-thickness loss of skin substance. It results from an accumulation of cell metabolic waste products that have not been properly eliminated and the capillary ischaemia that accompanies the development of venous oedema. The ulcer may form following a minor injury or develop spontaneously. A leg ulcer is a sign that venous hypertension has reached a critical level.

Patients with chronic venous insufficiency frequently complain of ‘heavy legs’ and a tendency for evening edema, as well as pruritus, pain or nocturnal leg cramps ⁸. The initial stages (C 1–C 2) of chronic venous disease, on the other hand, are not associated with any specific symptoms.

Initial signs of chronic venous insufficiency frequently include telangiectases (commonly known as spider veins) and reticular veins, usually around the ankles (paraplantar corona phlebectatica). These are considered to be “warning veins”. Telangiectases are dilated intradermal veins with a diameter of less than 1 mm, whereas reticular veins run subcutaneously and have a diameter of 1–3 mm ⁹. However, they do not constitute definitive proof of chronic venous insufficiency and are primarily a cosmetic problem for patients ¹⁰.

The next stage of chronic venous disease (CEAP class C2) refers to the development of varicose veins. These are incompetent subcutaneous veins with a diameter of more than 3 mm ¹¹. If the dysfunction remains untreated, their diameter can markedly increase up to a point where the varicose veins can be perceived with the naked eye.

The presence of leg edema – which is initially spontaneously reversible overnight but may persist in untreated cases – in combination with varicose veins (class C3) defines the onset of chronic venous insufficiency. Venous hypertension results in erythrocyte extravasation and dermal hemosiderin deposition, thus giving rise to the typical hyperpigmentation. Chronic edema may lead to stasis dermatitis, characterized by erythematous, scaly, and sometimes pruritic lesions on the lower legs (Figure 1) ¹². It is occasionally mistaken for erysipelas/cellulitis.

Continued progression of chronic venous insufficiency subsequently results in lipodermatosclerosis, a condition caused by chronic inflammatory processes in the dermis and subcutis. It is associated with erythema, induration, fibrosis, and – in acute phases – pain. Lipodermatosclerosis can be a warning sign of imminent ulceration ¹³.

Figure 1. Chronic venous insufficiency

Footnote: Massive stasis dermatitis of both lower legs as well as a dilated, incompetent accessory saphenous vein on the right thigh. Such a clinical presentation is only seen after many years without treatment.

Chronic venous insufficiency complications

Chronic venous insufficiency complications include:

• Venous ulcer
• Leg discoloration
• Thrombophlebitis
• DVT
• Pulmonary embolism
• Bleeding

With a prevalence of roughly 0.7 %, venous leg ulcer is a dreaded complication of chronic venous insufficiency ¹⁰, the medial malleolus most commonly affected; complete healing of leg ulcers frequently requires prolonged wound treatment (Figure 2).

Acute complications of chronic venous insufficiency include thromboembolic events. In rare cases, superficial thrombophlebitis may develop, presenting as erythematous, tender, indurated, and warm cord or nodule ¹⁴. It can be associated with deep vein thrombosis (DVT) in about 18–25 % of patients and with pulmonary embolism in about 7 % ¹⁵. Following deep vein thrombosis, 20–50 % of patients develop postthrombotic syndrome ¹⁶. Postthrombotic syndrome is characterized by obstruction of the deep venous system, which can be associated with venous valve incompetence, venous hypertension, and pathological reflux.

Figure 2. Venous leg ulcer

Footnote: Venous leg ulcer on the right ankle with lipodermatosclerosis and asteatotic eczema of the surrounding skin.

Chronic venous insufficiency treatment

Patients with chronic venous insufficiency should be treated based on their severity and nature of the disease. The treatment goals include reducing discomfort and edema, stabilizing skin appearance, removing painful varicose veins and healing ulcers. Most patients should initially be treated conservatively with leg elevation, exercise (which improves calf muscle pump), weight management, and compression therapy ².

Ulcers are treated best with compression bandaging systems. Chronic venous ulcerations entail a risk of infection and cancerous transformation (Marjolin ulcer). Compression therapy should be used with caution in patients with the coexisting peripheral arterial disease. Significant arterial insufficiency should be treated before instituting a compression regimen. Patients whose ulcers fail to respond to compression may ultimately need surgical intervention. Superficial vein reflux can be managed with foam sclerotherapy, endovenous thermal ablation, or stripping. Deep vein reflux may be treated with valve reconstruction or valve transplant. Perforator reflux can either be managed with sclerotherapy, endovenous thermal ablation, or with subfascial endoscopic perforator surgery. It should be noted, however, that compression therapy regimens that are adhered to are highly effective in treating all forms of venous pathophysiology ¹⁷.

Lifestyle changes may help prevent varicose veins from forming. These changes include:

• elevating legs while sitting or sleeping
• wearing compression stockings or dressings
• avoiding standing for extended periods of time
• losing weight
• exercising to improve leg strength

If lifestyle changes do not alleviate symptoms or the pain is severe, your doctor may recommend treatment options, including:

• Sclerotherapy: this minimally invasive treatment injects a solution directly into the vein that causes the vessel to shrink and eventually disappear. For larger veins, a foam is injected to close and seal the vein.
• Endovenous thermal ablation: this image-guided procedure uses radiofrequency or laser energy to heat and seal off an incompetent vein. Ultrasound helps visualize the incompetent vein, allowing the physician to guide a laser fiber or radiofrequency electrode through a catheter in the vein where heat is applied. Radiofrequency ablation and endovenous laser therapy are primarily used for trunk incompetence as they involve the endoluminal advancement of a catheter, which is difficult or impossible in veins that are not straight or even convoluted ¹⁸. Under ultrasound guidance, the vein is punctured (usually distally) and the radiofrequency ablation catheter or endovenous laser therapy laser fiber is proximally advanced to the site of venous incompetence. This usually means that the great saphenous vein is punctured just distal to the knee and the lesser saphenous vein in the mid‐lower leg region. Using procedure‐specific safety margins, the catheter/laser fiber is then advanced up to the saphenofemoral respectively saphenopopliteal junction. Tumescent anesthesia solution is then injected along the vein, which – apart from its local anesthetic effects – protects the surrounding tissue from thermal damage ¹⁹. The vascular endothelium is destroyed by the heat released from the tip of the catheter/laser fiber, resulting in venous occlusion. The effectiveness of radiofrequency ablation and laser therapy is about the same, however, radiofrequency ablation tends to be associated with fewer side effects and more rapid recovery ²⁰. Given that the corresponding studies compared radiofrequency ablation with lasers with shorter wavelengths, this statement may not apply to current laser systems. Based on other studies, lasers with longer wavelengths are associated with fewer side effects ²¹. With respect to laser fiber types, a distinction can be made between bare tip fibers and radial systems. They differ in the manner in which light is emitted, and may therefore be associated with different outcomes. The side effects of radiofrequency ablation and endovenous laser therapy include thrombophlebitis, hyperpigmentation, paresthesias, and bruising ²². The most significant complication, which can always occur in the context of vascular procedures, is deep vein thrombosis, with a reported incidence of 0.2–1.3 % ²³. Here, endovenous heat‐induced thrombosis in particular must be mentioned as this complication is exclusively associated with endovenous thermal procedures. Endovenous heat‐induced thrombosis designates the development of a thrombus that extends from the previously occluded vein segment into the deep venous system ²⁴.
• Phlebectomy (also known as vein stripping): this minimally invasive procedure uses a small scalpel or needle to remove varicose veins on the surface of the leg through tiny incisions in the skin.
• Vein stripping surgery: a surgical procedure performed under general anesthesia that involves stripping or removing the entire superficial vein in the leg. Due to advances in minimally invasive procedures, this procedure is rarely done today.

Comparison of treatment options

There is a host of options available for the treatment of chronic venous insufficiency. When selecting a therapeutic option, individual anatomical circumstances, underlying diseases as well as the patient’s wishes should always be taken into account. Only in exceptional cases should patients with more advanced chronic venous insufficiency be treated with compression therapy alone. However, in combination with surgical or endovenous procedures, adequate compression therapy is one of the therapeutic mainstays.

Sclerotherapy and phlebectomy are primarily used for isolated tributary or perforator incompetence, recurrent varicose veins, as well as in combination with other procedures ²⁵.

In the case of trunk incompetence, classic surgical methods such as saphenofemoral ligation and stripping or the newer endovenous methods should be employed. The efficacy and recurrence rates of endoluminal procedures – especially those of established methods such as radiofrequency ablation and endovenous laser therapy – are comparable to the postoperative outcome following saphenofemoral ligation and stripping ²⁰. Although some studies have found classic surgical procedures to be more efficacious, the validity of these studies is limited due to the use of older catheter systems.

The advantages of endoluminal procedures include fewer side effects, the possibility of local anesthesia, and a shorter downtime ²⁶. Given the great international and also regional variability in terms of cost and reimbursement of radiofrequency ablation and endovenous laser therapy by health insurers, a final cost assessment cannot be made, especially in comparison with saphenofemoral ligation and stripping. In any case, endoluminal methods tend to be associated with shorter downtimes, and the vast majority of procedures can be performed on an outpatient basis ²⁷, making them a good alternative in suitable patients.

Chronic venous insufficiency prognosis

Chronic venous insufficiency tends to get worse over time, ultimately leading to skin breakdown and ulcer formation. And these ulcers are difficult to heal leading to significant pain and increased costs of healthcare. Many patients end up in wound clinics where they are treated for months and years, without any significant benefit. These patients are also at an increased risk for deep vein thrombus and pulmonary embolism. In addition, any minor trauma is associated with torrential bleeding that can sometimes be fatal ¹.

However, chronic venous insufficiency can be managed if treatment is started in the early stages. By taking self-care steps, you may be able to ease the discomfort and prevent chronic venous insufficiency from getting worse. It is likely that you will need medical procedures to treat the chronic venous insufficiency.

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