Chronic venous insufficiency (CVI)
Chronic venous insufficiency (CVI) is a medical condition in which blood pools in the veins, straining the walls of the vein. The most common cause of CVI is superficial venous reflux which is a treatable condition. As functional venous valves are required to provide for efficient blood return from the lower extremities, this condition typically affects the legs. If the impaired vein function causes significant symptoms, such as swelling and ulcer formation, it is referred to as chronic venous disease. It is sometimes called chronic peripheral venous insufficiency and should not be confused with post-thrombotic syndrome in which the deep veins have been damaged by previous deep vein thrombosis.
Most cases of CVI can be improved with treatments to the superficial venous system or stenting the deep system. Varicose veins for example can now be treated by local anesthetic endovenous surgery.
Rates of CVI are higher in women than in men. The condition has been known since ancient times and Hippocrates used bandaging to treat it.
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Signs and symptoms
Signs and symptoms of CVI in the leg include the following:
Chronic swelling of the legs and ankles
CVI in the leg may cause the following:
Stasis dermatitis, also known as varicose eczema
Contact dermatitis. Patients with venous insufficiency have a disrupted epidermal barrier, making them more susceptible than the general population to contact sensitization and subsequent dermatitis.
Atrophie blanche. This is an end point of a variety of conditions, appears as atrophic plaques of ivory white skin with telangiectasias. It represents late sequelae of lipodermatosclerosis where the skin has lost its nutrient blood flow.
Lipodermatosclerosis. This is an indurated plaque in the medial malleolus.
Malignancy. Malignant degeneration is a rare but important complication of venous disease since tumors which develop in the setting of an ulcer tend to be more aggressive.
Pain. Pain is a feature of venous disease often overlooked and commonly undertreated.
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The most common cause of chronic venous insufficiency is reflux of the venous valves of superficial veins. This may in turn be caused by several conditions:
Deep vein thrombosis (DVT), that is, blood clots in the deep veins. Chronic venous insufficiency caused by DVT may be described as postthrombotic syndrome.
Superficial vein thrombosis.
May–Thurner syndrome. This is a rare condition in which blood clots occur in the iliofemoral vein due to compression of the blood vessels in the leg. The specific problem is compression of the left common iliac vein by the overlying right common iliac artery. Many May-Thurner compressions are overlooked when there is no blood clot. More and more of them get nowadays diagnosed and treated (by stenting) due to advanced imaging techniques.
Deep and superficial vein thrombosis may in turn be caused by thrombophilia, which is an increased propensity of forming blood clots.
Arteriovenous fistula (an abnormal connection or passageway between an artery and a vein) may cause chronic venous insufficiency even with working vein valves.
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Further information: Ultrasonography of chronic venous insufficiency of the legs
B-flow ultrasonograph over a valve of the great saphenous vein, showing a venous reflux (flow toward right in the image).
History and examination by a physician for characteristic signs and symptoms are sufficient in many cases in ruling out systemic causes of venous hypertension such as hypervolemia and heart failure. An ultrasound can detect venous obstruction or valvular incompetence as the cause, and is used for planning venous ablation procedures, but it is not necessary in suspected venous insufficiency where surgical intervention is not indicated.
CEAP classification is based on clinical, causal, anatomical, and pathophysiological factors. According to Widmer classification diagnosis of chronic venous insufficiency is clearly differentiated from varicose veins.
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Venous insufficiency management
Conservative treatment of CVI in the leg involves symptomatic treatment and efforts to prevent the condition from getting worse instead of effecting a cure. This may include
Manual compression lymphatic massage therapy
Sequential compression pump
Blood pressure medicine
Frequent periods of rest elevating the legs above the heart level
Tilting the bed so that the feet are above the heart. This may be achieved by using a 20 cm (7-inch) bed wedge or sleeping in a 6 degree Trendelenburg position. Obese or pregnant people might be advised by their physicians to forgo the tilted bed.
Surgical treatment of CVI attempts a cure by physically changing the veins with incompetent valves. Surgical treatments for CVI include the following:
Linton procedures (i.e. subfascial ligation of perforating veins in the lower extremity, an older treatment)
Ligation. Tying off a vein to prevent blood flow
Vein stripping. Removal of the vein.
Endovenous Laser Ablation
Subfascial endoscopic perforator surgery. Tying off the vein with an endoscope.
Valve repair (experimental)
Valve transposition (experimental)
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What is the best treatment for venous insufficiency?
Treatment will depend on many factors, including the reason for the condition and your health status and history. Other factors your doctor will consider are:
your specific symptoms
the severity of your condition
how well you can tolerate medications or procedures
The most common treatment for venous insufficiency is prescription compression stockings. These special elastic stockings apply pressure at the ankle and lower leg. They help improve blood flow and can reduce leg swelling.
Compression stockings come in a range of prescription strengths and different lengths. Your doctor will help you decide what the best type of compression stocking is for your treatment.
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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.
Some studies have shown that combining elastic socks with prescription medication to improve blood flow is very effective when the socks alone do not control symptoms.
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Can venous insufficiency be cured?
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
Is venous insufficiency serious?
Chronic venous insufficiency is not a serious health threat. But if left untreated, it can be painful and disabling.
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Is walking good for venous insufficiency?
Many doctors recommend at least 30 minutes of physical activity a day. If necessary, you can break that time up and exercise for 10 minutes, three times a day.
Walking is highly beneficial and usually safe for people of all ages and fitness levels. Regular walks can help you lose weight, maintain a healthy blood pressure, and strengthen your bones and muscles.
How can I repair my veins naturally?
Regular exercise encourages better blood circulation in the legs, which helps to push along the blood that has collected in the veins. Exercise also helps to lower a person’s blood pressure, which is another contributing factor to varicose veins.
Low-impact exercises help to get the calf muscles working without excessive strain. Effective, low-impact exercises include:
2. Compression stockings
Compression stockings are available from most pharmacies and can help by applying pressure to the legs. This aids the muscles and veins to move blood toward the heart.
A study from 2018 found that people who used knee-high compression stockings with a pressure of 18 to 21 mmHg for one week, reported a reduction in the pain and aching associated with varicose veins.
3. Plant extracts
A review study from 2010 reports that sea pine extract, Pinus maritima, and Butcher’s broom extract, Ruscus aculeatus, may both reduce leg swelling, or edema, that is often associated with varicose veins. Ruscus aculeatus is available to purchase in health stores.
Plant extracts and essential oils should be diluted in carrier oils before being applied topically or used in a diffuser for aromatherapy.
4. Dietary changes
Potassium-high foods, such as almonds and pistachio nuts, can help varicose veins by reducing water retention in the body.
Salty or sodium-rich foods can cause the body to retain water, so cutting down on salty food can minimize water retention. Foods high in potassium can help to reduce water retention.
Foods that are high in potassium include:
almonds and pistachio nuts
lentils and white beans
some fish, such as salmon and tuna
Foods with fiber help to keep the bowels moving and prevent constipation. This may be important, as straining can aggravate damaged valves or make them worse.
Foods that are high in fiber include:
nuts, seeds, and legumes
oats, wheat, and flaxseed
People who are overweight are more likely to experience varicose veins, therefore, shedding any excess pounds can reduce the pressure on the veins and alleviate swelling and discomfort.
5. Eat more flavonoids
Adding foods that contain flavonoids may also help a person to shrink their varicose veins.
Flavonoids improve blood circulation, which will keep the blood flowing, and make it less likely to pool in the veins. They also help to reduce blood pressure in the arteries and can relax blood vessels, all of which can reduce varicose veins.
Foods that contain flavonoids include:
vegetables, including onions, bell peppers, spinach, and broccoli
citrus fruits and grapes, cherries, apples, and blueberries.
6. Herbal remedies
According to the National Institute of Health, taking grape seed extract, Vitis vinifera, orally may help to reduce swelling in the lower legs and other symptoms of chronic venous insufficiency, though there is currently limited evidence for its effectiveness.
A person prescribed with blood-thinning medication should avoid taking grape seed extract, as a dietary supplement, as it can interact with the medication and increase the risk of bleeding.
7. Choose non-restrictive clothing
Wearing tight-fitting clothes can restrict blood flow. A person may find that their circulation is improved by wearing loose-fitting clothes that do not restrict the blood supply to the lower body.
Wearing flat shoes instead of high heels may also help with varicose veins in the legs.
8. Keep the legs elevated
Keeping the legs elevated, ideally at the same height as the heart or above it will help to improve circulation. This reduces the pressure in the leg veins and gravity will help the blood to flow smoothly back to the heart.
A person should aim to keep their legs elevated if they are going to be sitting down for long periods of time, such as during work or rest.
Gently massaging the affected areas can help to keep the blood moving through the veins. A person can use gentle massage oils or moisturizer for optimal effects.
It is crucial to avoid pressing directly onto the veins, however, as this may damage fragile tissues.
10. Keep moving
Avoid sitting for long periods of time. If a person has to sit for long periods of time for work, they should aim to get up and move around or change position frequently to keep the blood flowing smoothly.
Avoid sitting with crossed legs, as this can further restrict blood flow to the legs and feet, which may add to circulation problems.
What is the most common cause of chronic venous insufficiency?
CVI most commonly occurs as the result of a blood clot in the deep veins of the legs, a disease known as deep vein thrombosis (DVT). CVI also results from pelvic tumors and vascular malformations, and sometimes occurs for unknown reasons. The causes of chronic venous insufficiency include: High blood pressure in the leg veins over time, due to sitting or standing for long periods. Lack of exercise. Smoking. Failure of the valves in leg veins to hold blood against gravity leads to sluggish movement of blood out of the veins, resulting in swollen legs.