What Is Chronic Venous Insufficiency?

Chronic venous insufficiency (CVI) or Venous Reflux Disease) is very common, affecting about 20 percent of the population — nearly 24 million Americans. When the leg veins cannot pump enough blood back to the heart, that condition is called chronic venous insufficiency, which is sometimes called chronic venous disease. There are three kinds of veins: superficial veins, deep veins and perforating veins, which connect the superficial to the deep veins (image 1). Deep veins lead to the vena cava (a large deep vein in the abdomen and chest), which runs directly to the heart.

When you are in an upright position, the blood in the leg veins must go against gravity to pump and return the blood to the heart. To accomplish this when you walk or are active, the leg muscles squeeze the deep veins of the legs to help move blood back to the heart. One-way flaps, called valves, in the veins open and close to keep blood flowing in the right direction — from the legs to the heart and prevent blood from flowing in reverse, back down the legs. The entire process of sending blood back to the heart is called the venous pump.

While walking, the leg muscles squeeze and the venous pump works well but when sitting or standing, especially for a long time, the blood in the leg veins can pool and increase the venous blood pressure. Deep veins and perforating veins are usually able to withstand short periods of increased pressures. However, sitting or standing for a long time can stretch vein walls from this increased pressure. Over time, in susceptible individuals, this can weaken the walls of the veins and damage the venous valves, causing CVI.

Duplex ultrasound uses painless sound waves higher than human hearing can detect, and allows a health care provide to measure the speed of blood flow and to see the structure of the leg veins.

CVI is due to reflux (backflow) of blood in the veins of the legs (image 2). This is because the valves in the veins, which prevent backflow, do not work properly. Risk factors include obesity, prolonged standing, pregnancy, trauma, weak muscles in the leg and heredity. Dilated veins and improper valve function result in an increase in venous blood pressure. This, in turn can result in swelling, skin color changes (hyperpigmentation), hardening of the skin and even ulcers. Varicosities (abnormal swelling of the vein) are common and the

Your health care provider will take a medical history and examine the legs. It is important to mention any trauma or history of blood clots or deep vein thrombosis (DVT). You should note whether the swelling in the legs disappears over-night. Any other risk factors should also be mentioned. The health care provider will rule out any other cause of swelling, such as heart or thyroid disease. After the medical history and physical exam, a duplex ultrasound will be performed. This non-invasive (no needles) test determines if the valves are working and whether reflux is present. It will also check to make sure there are no blood clots. If ulcers are present on the ankles, your arterial circulation may also be checked with an ankle/brachial index (ABI). Your health care provider will conduct an ABI by measuring the blood pressure in your ankles and arms to make sure the ulcers are not caused by decreased arterial circulation and that you can use compression devices without a problem.

Venous ulcers are irregular in shape, usually occur on the ankles and are often beefy red at the base. If they are infected, the infection must be cleared first in order for them to heal.

The daily use of compression hose is the most common treatment for venous ulcers. They come in a variety of types and usually are needed only up to the knee. They are used if arterial disease has been ruled out. Elevation of the leg (legs) above the heart during the day and at night (image 3) may help with swelling and with healing. Walking is encouraged but standing is discouraged. Good nutrition and weight loss (if needed) are equally important. Other methods of compression include multilayer elastic dressings and dressings such as Unna's boot. This is a firm, inelastic dressing, which must be changed by the health care provider regularly. Another method of compression is sequential pump therapy. This is a sleeve for the leg which inflates and deflates to push the blood up the leg and return it to the heart.

Sometimes, surgery is needed to clear up venous ulcers. Excision (cutting out) of the ulcers, possibly with a skin graft, may be necessary, but the underlying venous disease must be addressed. Compression may prove to be adequate, but other procedures may also be required.

Perforating veins which connect the superficial and deep venous systems may need to be closed off through procedures called subfascial endoscopic perforating vein surgery (SEPS), radiofrequency ablation (RFA) and ligation (tie off) or ultrasound guided sclerotherapy. If the superficial system is affected, sometimes surgical ligation and stripping of the greater or lesser saphenous veins may be necessary. However, there are newer procedures now available. Endovenous laser treatment (EVLT) and RFA are two of them (image 4). EVLT uses laser-generated heat to injure the vein wall and cause it to close off. EVLT is not generally used below the knee, but is often used on the greater saphenous vein above the knee. RFA heats the vein with alternating current, causing scarring and congealing of the blood leading to closing of the veins. Both procedures have excellent results. Contraindications to the two procedures include: isolated reflux, blood clots, arterial disease, intention to become pregnant and obesity, which hinders needed visualization of the landmarks.

Treatment is aimed at improving the symptoms and, whenever possible, correcting the underlying problem. Superficial veins can safely be removed or ablated without any major consequences because the incompetent vein has already proved itself unnecessary.

Both EVLT and RFA are performed on an outpatient basis under adequate sedation and local anesthesia. Complications include blood clots, phlebitis (inflammation of the vein), hyperpigmentation (change in color of the skin), redness, bruising, infection and pain. These occur infrequently, however. Duplex ultrasound is performed pre- and postoperatively to make sure there are no blood clots. The patient's progress is then followed on a regular basis.

Compression therapy of some kind is generally recommended following all treatment modalities, and sometimes other veins become problematic, requiring further treatment. However, careful following of instructions can prevent most recurrences of problems. The ulcers should heal and swelling should decrease. Consultation with a venous disease specialist often yields new options for patients with chronic venous disease.

Note: All pictures and illustrations in this article are provided with permission from Glenn Buczkowksi, RPA-C.

About the Author: Glenn Buczkowski, RPA-C, practices at the Venous Institute of Buffalo in North Tonawanda, New York, and is an Adjunct Assistant Professor of Surgery at Daemen College in Amherst, New York.

About the Author: Robert R. Ross, PA-C, is the president of Triad Diagnostic Technologies, LLC of Michigan and is an affiliate professor for the University of Detroit Mercy physician assistant program. He lectures locally and nationally on topics about peripheral arterial disease and chronic venous insufficiency.