Chronic venous insufficiency knowledge - ailments

The following information does not replace a physician’s diagnosis and advice under any circumstances whatsoever.

Chronic venous insufficiency

Chronic venous insufficiency: what’s that?

Chronic venous insufficiency (CVI) is a blood vessel disease which is accompanied by a venous drainage obstruction as a cause of circulatory problems. The leg vein system is affected. It is structured in the epifascial (surface) and subfascial (deep-lying) parts as well as the perforating veins (connecting veins) which regulate blood flow.

Risk factors of chronic venous insufficiency:

CVI is the consequence of vein weakness or leg vein thrombosis. The most common risk factors include family history, age and gender. Further favouring factors include lack of exercise, overweightness and an unbalanced diet.

Figure 1: Schematic depiction of the leg vein system consisting of deep (dark blue) and surface (light blue) leg veins.

Symptoms of chronic venous insufficiency:

The legs of the persons affected are frequently swollen with oedema (fluid accumulation). Moreover, itching and burning of the body regions concerned, as well as the feeling of heavy legs may result. The skin of patients with CVI may tend to feelings of tension and discolouration due to pigmentation. Moreover, spider veins (starburst varices) and consequently varicose veins (varices) may be formed. Finally, chronic wounds (ulcerations) may be incurred on the lower leg.

Figure 2: Selected skin symptoms in case of chronic venous insufficiency.

Stages of chronic venous insufficiency:

With reference to the stage classification of CVI, several classifications exist. The best known include classification according to Widmer and the categorisation of chronic venous diseases according to CEAP. According to Widmer, four gradual stages are distinguished. However, in international use in connection with diagnosis and its clinical categorisation, CEAP classification of chronic venous diseases has asserted itself. The capital letters stand for clinical (Clinical condition), aetiologic (Etiology), anatomic (Anatomic location) and pathophysiologic (Pathophysiology).

In this context, the term “chronic venous insufficiency” is a functional abnormality of the venous system and is normally reserved as a term for advanced stages such as varicosis with oedema (C3), trophic skin changes (C4) or venous ulcerations (C5-C6).¹

Stage	Clinical indications
C₀	No visible or palpable signs of venous insufficiency
C₁	Spider veins and/or reticular varices
C₂	Varicosis
C₃	Varicosis with oedema
C₄	Varicosis with trophic skin changes
C_4a	Varicosis with pigmentation or eczema
C_4b	Varicosis with dermatoliposclerosis (hardening of the fatty tissue) or white atrophy (white pathological areas)
C₅	Healed ulcus cruris venosum (healed lower leg wound)
C₆	Florid ulcus cruris venosum (open lower leg wound)

Diagnosis of chronic venous insufficiency:

Several methods exist to diagnose a CVI. The treating physician will pose questions regarding family history and relating to varicose veins and venous disorders in an anamnesis interview. Also the skin, in particular in the malleolus region, will be examined thoroughly during the inspection. In case of suspected oedema, palpation (pressure test) of the swollen leg is made. If a dent appears which only disappears again slowly, this indicates an oedema.

Moreover, a colour-coded duplex sonography is carried out for imaging recording of the CVI in order to detect blood congestion in the surface and deep vein system. Additionally, a functional examination such as the venous occlusion plethysmography can be applied in order to establish the venous capacity and the efflux.

How can chronic venous insufficiency be prevented?

A CVI can be prevented with compression stocking therapy. Also, healthy nutrition and sufficient fluid intake can have a preventive effect. Moreover, exercise and body training such as the BORT AktiVen® vein gymnastics (german version) can help to reduce the risk of developing a CVI.

Therapy for chronic venous insufficiency

In principle, the therapy is split to an operative and conservative course of treatment. As with so many diseases, there is no one single correct treatment here. It is always individual for the respective patient and must be decided in dialogue with the treating physician. However, the fact of the matter is: Compression therapy constitutes the basic measure for venous diseases, in particular CVI. Your treating physician will prescribe you short-stretch bandages or category I-III compression stockings. The compression is intended to press the leg veins together and thus increase blood flow of the venous blood in the direction of the heart. Moreover, the pressure enables venous flaps which are not completely destroyed to at least in-part close again.

The compression therapy has the greatest effect if the muscle pump is activated simultaneously. Therefore, it is always an integral part of the treatment of CVI that the patients have regular exercise. The treating physician may also prescribe additional physical therapy such as remedial gymnastics or manual lymph drainage, where the drainage of lymphatic fluid and water retention in tissue should be stimulated. The treatment of varicose veins can also result in the improvement of CVI – to this end various treatment options from surgical vein stripping and vein-maintaining operations via thermal procedures such as laser or radio wave treatment up to atrophy exist. Also, expert wound care in case of ulcus cruris is an important therapeutic component. In order to promote healing, the wound must be cleaned regularly and freed of dead tissue. If the ulcus cruris does not close again despite these measures, additional surgical interventions such as shaving and skin transplants may follow. The course of treatment to be followed is always decided on by the treating physician.

Sources:

¹Eklöf B, Rutherford RB, Bergan JJ, et al. Revision of the CEAP classification for chronic venous disorders: Consensus statement. J Vasc Surg. 2004;40(6):1248-1252. doi:10.1016/j.jvs.2004.09.027