Venous Disease/Varicose Veins
What is Chronic Venous Insufficiency?
Chronic venous insufficiency (CVI) is a condition that occurs when the venous wall and/or valves in the leg veins are not working effectively, making it difficult for blood to return to the heart from the legs. CVI causes blood to pool or collect in these veins, and this pooling is called stasis.
Are you at Risk?
If you have risk factors for CVI, you are more likely than other people to develop the disease. The most important risk factors are:
- Deep Venous Thrombosis (DVT)
- Varicose veins and family history of varicose veins
- Being Overweight
- Female Sex
- Avoiding Exercise
- High Cholesterol
- Extended periods of standing or sitting
Signs & Symptoms
The seriousness of CVI, along with the complexities of treatment, increase as the disease progresses. That is why it is very important to see your doctor if you have any of the symptoms of CVI. The problem will not go away if you wait, and the earlier it is diagnosed and treated, the better your chances of preventing serious complications. Symptoms include:
- Swelling in the lower legs and ankles, especially after extended periods of standing
- Aching or tiredness in the legs
- New Varicose Veins
- Leathery looking skin on legs
- Flaking or itching skin on legs and feet
- Stasis Ulcer
If CVI is not treated, the pressure and swelling increase until the tiniest blood vessels in the legs (capillaries) burst. When this happens, the overlying skin takes on a reddish-brown color and is very sensitive to being broken if bumped or scratched.
At the least, burst capillaries can cause local tissue inflammation and internal tissue damage. At worst, this leads to ulcers, open sores on the skin surface. These venous stasis ulcers can be difficult to heal and can become infected. When the infection is not controlled, it can spread to surrounding tissue, a condition known as cellulitis.
CVI is often associated with varicose veins, which are twisted, enlarged veins close to the surface of the skin. They can occur almost anywhere, but most commonly occur in the legs.
How to Diagnose CVI?
To diagnose CVI, your doctor will perform a complete medical history and physical exam. During the physical exam, the doctor will carefully examine your legs.
A test called a vascular or duplex ultrasound may be used to examine the blood circulation in your legs. During the vascular ultrasound, a transducer (small hand-held device) is placed on the skin over the vein to be examined. The transducer emits sound waves that bounce off the vein. These sound waves are recorded, and an image of the vessel is created and displayed on a monitor.
How is chronic venous insufficiency treated or managed?
- Like any disease, CVI is most treatable in its earliest stages. Vascular medicine or vascular surgery specialists typically recommend a combination of treatments for people with CVI. Some of the basic treatment strategies include:
- Avoid long periods of standing or sitting: If you must take a long trip and will be sitting for a long time, flex and extend your legs, feet, and ankles about 10 times every 30 minutes to keep the blood flowing in the leg veins. If you need to stand for long periods of time, take frequent breaks to sit down and elevate your feet.
- Exercise regularly. Walking is especially beneficial.
- Lose weight if you are overweight.
- Elevate your legs while sitting and lying down, with your legs elevated above the level of your heart.
- Wear compression stockings.
- Take antibiotics as needed to treat skin infections.
- Practice good skin hygiene.
- The goals of treatment are to reduce the pooling of blood and prevent leg ulcers.
- Compression Stockings: The most conservative approach is to wear properly-fitting support hose (also called compression stockings). Compression stockings can be purchased at some pharmacies and medical supply stores and come in various styles, including below-the-knee, above-the-knee and pantyhose styles. They also come in different compressions varying from 8 to 10 mm Hg, up to 40 to 50 mm Hg. Your doctor can recommend the compression that is right for you. You will need a prescription for any stockings with more than 20 mm Hg compression.
- If you wear compression stockings, be sure to take them off at the end of the day to wash and dry them, and to clean and check your skin. Make sure the stockings fit so there is no bunching. Elastic stockings that fit poorly can actually make your condition worse by blocking blood flow in the area where they have bunched up.
- Antibiotics: Antibiotics may be prescribed to clear skin infections related to CVI, but the underlying disease must be treated to prevent a recurrence. Deeper infections and ulcers may also be treated with antibiotics.
- Other Medications: If you have post-thrombotic syndrome, your doctor may prescribe medication to prevent the formation of additional blood clots.
- A special medicated wrap, known as an Unna Boot, combines multilayer compression with a zinc oxide gel-based wound cover that forms a semi-rigid bandage. Other multilayer compression systems are available and are often used in combination with topical wound care products.
- Some patients have found benefit from the herbal dietary supplement Vena-Stat, which contains a derivative of horse chestnut extract. Keep in mind that herbal preparations should not be used in place of your prescription medications and should be used with caution, as they may interact with current prescription medications. Please ask your doctor or pharmacist about any potential drug interactions.
- Skin Care: Practicing good skin hygiene is important. Keep your skin moisturized so that it does not flake or crack easily. If the skin is not broken or leaking fluid but is inflamed, your doctor may recommend an anti-itch cream, such as one containing hydrocortisone; a cream containing zinc oxide to protect the skin; or an antifungal cream to prevent fungal infections
- Skin that is leaking fluid is treated with wet compresses. If you have ulcers on your legs, your doctor will show you how to apply layered compression bandages to protect the skin and maintain blood flow.
- Sclerotherapy: Sclerotherapy involves the injection of a solution directly into spider veins or small varicose veins that causes them to collapse and disappear. Several sclerotherapy treatments are usually required to achieve the desired results. Sclerotherapy is simple, relatively inexpensive, and can be performed in the doctors office. Sclerotherapy can eliminate the pain and discomfort of these veins and helps prevent complications such as venous hemorrhage and ulceration. It is also frequently performed for cosmetic reasons
- Endovenous Thermal Ablation: Endovenous thermal ablation is a newer technique that uses a laser or high-frequency radio waves to create intense local heat in the affected vein. The technology is different with each energy source, but both forms of local heat close up the targeted vessel. This treatment closes off the problem veins but leaves them in place so there is minimal bleeding and bruising. Compared with ligation and stripping, endovenous thermal ablation results in less pain and a faster return to normal activities, with similar cosmetic results.
- For the less than 10 percent of patients who require surgical treatment, the options include vein ligation and stripping, microincision/ambulatory phlebectomy, and bypass surgery. Here is a brief review of each of these techniques. Your doctor can recommend the treatment that is most appropriate for you.
- Ligation and stripping often are performed in combination. Vein ligation is a procedure in which a vascular surgeon cuts and ties off the problem veins. Most patients recover in a few days and can resume their normal activities. Stripping is the surgical removal of larger veins through two small incisions. Stripping is a more extensive procedure and may require up to 10 days for recovery. It usually causes bruising for several weeks after surgery.
- Microincision/ambulatory phlebectomy is a minimally invasive procedure in which small incisions or needle punctures are made over the veins, and a phlebectomy hook is used to remove the problem veins.
- Vein bypass in the leg is similar to heart bypass surgery, just in a different location. It involves using a portion of healthy vein transplanted from elsewhere in your body to reroute blood around the vein affected by CVI. Bypass is used for treatment of CVI in the upper thigh and only in the most severe cases, when no other treatment is effective.
Can chronic venous insufficiency be prevented?
To reduce your risk of developing CVI, follow these guidelines:
- Eat a healthy balanced diet.
- Quit smoking.
- Exercise regularly.
- Avoid wearing restrictive clothing such as tight girdles or belts.
- Lose weight if you are overweight.
- Avoid prolonged sitting or standing.