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Chronic venous insufficiency

What is chronic venous insufficiency?

Chronic venous insufficiency (CVI) is an umbrella term for the stages C3 to C6 of the CEAP classification system. The term CVI is often used as a synonym for chronic venous disease. However, CVI only refers to the more severe stages of chronic venous disease that are associated with swelling/edema (stage C3), skin changes (stage C4), or open wounds (ulcers) on the legs (stage C5 and C6).

Whereas chronic venous disease in general affects every third to fourth adult person worldwide, fewer people develop CVI.

What causes chronic venous insuffiency?

A properly functioning venous system depends on vessels with well-working valves and muscle pumps that ensure blood is transported back to the heart. The vein valves usually open to allow the venous blood return to the heart, and close to prevent a backflow of venous blood to the lower legs. Non-working vein valves result in venous blood pooling in the legs. This causes higher pressure inside the venous system, also called venous hypertension.

Diagram of leg veins showing superficial, deep, and perforating veins. A close-up highlights blood flow through the veins and valves.

There are several reasons why the vein valves may not be working properly:

Failure of the valves in superficial veins: pre-existing weakness of the vein valves, direct injury, inflammation, enlarged veins and vein valves caused by hormonal changes or venous hypertension.
Failure of the valves in deep veins: damage results from blood clots in the deep veins, also called deep vein thrombosis.

Risk factors for CVI include age, gender, family members who are also affected by chronic venous disease such as varicose veins, being overweight, pregnancy, previous leg injuries or inflammation of the veins (also called phlebitis). Prolonged sitting or standing is one of the behavioral factors that can result in CVI.

Symptoms of chronic venous insufficiency

Early stages of chronic venous disease, including spider veins or varicose veins, are often a mainly cosmetic concern. The more severe stages of chronic venous insufficiency, however, pose a considerable impairment to quality of life and can cause severe medical complications. The symptoms of the CVI are reflected by the CEAP classification, which is an internationally accepted standard for describing chronic venous disease.:

Edema (C3) = Swelling that primarily occurs around the ankle and ascends to the leg
Skin changes (C4)
- C4a: changes in skin color (pigmentation) and/ or inflammatory skin changes (eczema)
- C4b: hardening of the subcutaneous fatty tissue (lipodermatosclerosis) or/and scarring as a result of healed ulcers (atrophie blanche)
- C4c: visible blue veins around the ankle with red spots (Corona phlebectatica)
Healed venous leg ulcer (C5)
Active (non-healed) venous leg ulcer (C6)
- Repeated (recurrent) active ulcer (C6r)

How can chronic venous insufficiency be diagnosed?

Your healthcare professional will take your complete medical history and will perform a physical exam, including the inspection and palpation of the skin. You may also receive a Duplex ultrasound, which is a noninvasive testing that visualizes the blood flow and the structure of the leg veins.

In most cases, this will be enough to confirm the diagnosis of a chronic venous disease. Further imaging techniques are:

Magnetic resonance venography
Computer tomography venography
Invasive imaging (venogram or intravascular ultrasound)

Treatment options of chronic venous insufficiency

Wearing compression garments is an integral part of treatment for all types of chronic venous disease, independent of their severity. The same applies to maintaining a healthy weight and regular exercise.

However, chronic venous insufficiency might require additional, and sometimes more invasive treatment. Treatment options also vary depending on the clinical manifestation of CVI, including the presence of edema, skin changes or eczema, or leg ulcers.

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How to prevent chronic venous insufficiency

CVI results from a venous disease that was not or insufficiently treated. Therefore, early recognition and appropriate intervention are important to prevent the development of more severe stages of chronic venous disease. Here are some basic strategies to prevent CVI:

Exercise regularly
Maintain a healthy weight
Avoid long periods of sitting or standing
Take short breaks to raise the legs
Wear compression stockings

The goal of all these strategies is to prevent the pooling of blood in your legs and thus to prevent venous hypertension.

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