Chronic venous insufficiency (CVI) is a condition in which the veins in the legs do not efficiently return blood to the heart. This causes blood to build up in the legs, leading to symptoms such as swelling, aching, tiredness, or heaviness in the legs or ankles, especially after standing for long periods. CVI can also cause the development of varicose veins (enlarged, bulging, or twisted veins) or spider veins. In more advanced cases of CVI, skin can become discolored, flake, or feel leathery, tight or hard, and painful sores or ulcers may develop, especially just above the ankles.

CVI is a common condition in the United States, affecting between 10% and 35% of adults. The risk of developing CVI increases with age. The condition is more common in women, usually showing up as varicose or spider veins. However, men are more likely to have severe disease. People who have had a blood clot that blocks the blood flow in a vein (deep vein thrombosis or DVT) are more likely to develop CVI. Venous ulcers, a serious complication of CVI, affect about 1% of the adult population, with higher rates in people over age 65.

Once it develops, CVI doesn’t go away. However, the condition can be managed effectively with treatment and lifestyle changes.

CVI is a condition that affects the veins in the legs, making it difficult for blood to flow back up to the heart. In healthy veins, a series of one-way valves and the action of the calf muscles work together to push blood upward, against gravity, toward the heart. These valves open and close to allow blood to move in the right direction and prevent blood from flowing backward. When someone has CVI, the vein walls or valves in the veins become weakened, damaged, or stretched and allow blood to leak backward and pool in the lower legs. This causes increased pressure in the veins, and can lead to a range of changes in the skin and tissues of the legs.

The condition tends to progress over time, with symptoms ranging from mild discomfort to severe skin changes and ulcers. CVI can have a significant impact on quality of life and can affect the ability to work productively.

CVI develops when the walls of the leg veins and/or the one-way valves inside the veins become damaged, weakened, or stretched, or the calf muscle pump is not functioning effectively, allowing blood to flow backward and pool in the lower legs. The calf muscle pump is the process in which the calf muscles squeeze the veins to push blood up the legs, toward the heart. There are several possible causes of these vein wall and valve problems.

The most common causes include:

• Previous blood clots in the legs (deep vein thrombosis, or DVT), which can damage the valves and lead to long-term problems with blood flow (known as post-thrombotic syndrome)
• Direct injury or trauma to the leg, which can harm the veins or their valves
• Prolonged standing or sitting, which increases pressure in the leg veins over time
• Obesity, which can put extra pressure on veins
• Pregnancy, which can increase blood volume and pressure on veins in legs
• Inflammation of the veins (phlebitis), which can cause blood clots and damage the vein walls
• Tumors or abnormal growths in the pelvis, which can block blood flow and cause blood to back up in the legs
• Weakness or malformation of the veins or their valves present at birth (congenital)

In many cases, the exact cause of CVI is not known. Primary venous insufficiency refers to cases where the underlying cause is not identified, while secondary venous insufficiency is due to a known event such as a blood clot or injury.

Risk factors for CVI include:

• Advancing age
• Family history of CVI or varicose veins
• Previous DVT or blood clots
• Previous leg injury or trauma
• Obesity
• Pregnancy
• Prolonged standing or sitting
• Limited mobility or use of walking aids
• Female sex
• Smoking
• Inflammation of the veins
• Tumors in the pelvis
• Congenital weakness or malformation of the veins or valves

Symptoms of CVI may include:

• Swelling in the legs or ankles (swelling may worsen throughout the day and improve with leg elevation)
• Aching, heaviness, or tiredness in the legs
• Pain or throbbing in the legs
• Varicose veins (enlarged, bulging, or twisted veins)
• Skin discoloration, such as darkening or reddening of the skin between the knee and ankle
• Itching or flaking of the skin on the legs or feet
• Leathery, thickened, tight, or hard skin texture
• Hardening of the skin and underlying tissue (lipodermatosclerosis)
• Skin inflammation (stasis dermatitis)
• Development of sores or ulcers, usually near the ankle, that are slow to heal
• Cramping or restlessness in the legs, especially at night
• Burning sensation in the legs

To diagnose CVI, your doctor will review your medical history, conduct a physical exam, and may order one or more diagnostic tests.

Your doctor may ask you about symptoms, such as aching, tiredness, or skin changes in your legs, and whether you have any risk factors like a history of blood clots, leg injury, or family history of vein problems. During the physical exam, your doctor will look for signs such as swelling, varicose veins, skin discoloration, thickening or hardening of the skin, and the presence of sores or ulcers, especially near the ankles.

Additional tests may be needed to make a diagnosis and assess extent or cause of the condition. These may include:

• Duplex ultrasound: This imaging test uses sound waves to show how blood flows through the veins and to detect valve problems, blockages, or blood clots. It is the most common and often the only test needed to diagnose CVI.
• Ankle-brachial index (ABI): This ultrasound test compares the blood pressure in the ankle and arm.
• Photoplethysmography (PPG): This test assesses vein function by measuring how quickly your veins refill with blood after gentle exercise.
• Air plethysmography: This test evaluates blood flow in the legs and can help determine the severity of venous insufficiency.
• Venography (venogram): This test uses X-rays and a special dye injected into a vein to show blockages or abnormal areas in the veins.
• Advanced imaging (computed tomography [CT] or magnetic resonance venography [MRV]): These tests may be used to look for blockages or vein abnormalities.
  

In most cases, a combination of your medical history, physical exam, and noninvasive imaging tests is enough to confirm the diagnosis and guide treatment.

There is no cure for CVI, but a variety of treatments can help manage symptoms, prevent complications, and improve quality of life. Treatment plans are tailored to each person’s needs and may include a combination of the following:

• Compression therapy: Wearing specially fitted compression stockings or bandages helps reduce swelling, improve blood flow, and prevent sores or ulcers from forming or worsening.
• Leg elevation: Raising the legs above the level of the heart several times a day and while sleeping helps decrease swelling and relieve discomfort.
• Exercise and physical activity: Regular walking, swimming, or other activities that use the calf muscles can improve blood flow and reduce symptoms.
• Skin and wound care: Keeping the skin clean, dry, and moisturized helps prevent infection and skin breakdown. Special dressings and wound care are used for ulcers or sores.
• Medications to treat symptoms or complications: Pentoxifylline, an anti-inflammatory medication, may help heal venous ulcers. Topical corticosteroids can be used for short periods to reduce skin inflammation and itching, but not on ulcers. Antibiotics are prescribed if there is a skin infection.
• Weight management: Maintaining a healthy weight or losing excess weight can reduce pressure on the veins.
• Minimally invasive procedures: Treatments such as sclerotherapy (injecting a foam or liquid to block affected veins) or endovenous ablation (using heat or chemicals to close affected veins) may be used to improve symptoms.
• Physical therapy: Exercises to improve ankle joint mobility and calf muscle strength can help support blood flow in the legs.
• Pneumatic compression devices: In certain cases, sleeves that inflate and deflate around the legs may be used to help move fluid out of the legs, especially for people with severe swelling or lymphedema.
• Supplements: Certain dietary supplements, such as those containing flavonoids and horse chestnut seed extract, may help reduce swelling, pain, and inflammation.
• Surgery: Surgical procedures such as vein ligation and stripping (removal of affected veins), valve repair, or placement of venous stents (mesh wire tubes that hold a vein open, allowing blood to flow) may be recommended for severe cases or when other treatments have not been effective.

People with CVI may be at increased risk for certain complications, including:

• Venous ulcers: Broken blood vessels can create open sores, usually near the ankle, that are slow to heal and can become infected.
• Skin infections (cellulitis): Bacterial infections of the skin and underlying tissue, often occurring around ulcers or areas of skin breakdown.
• Varicose veins: Enlarged, twisted veins that can cause discomfort and may bleed.
• Lipodermatosclerosis: Hardening and thickening of the skin and underlying tissue, often just above the ankle.
• Hyperpigmentation: Darkening of the skin due to the breakdown of red blood cells.
• Atrophie blanche: White, scar-like patches on the skin surrounded by areas of discoloration, which can develop into ulcers.
• Edema: Persistent swelling in the legs and ankles, which can worsen throughout the day.
• Impaired mobility: Pain, swelling, and skin changes can make it difficult to walk or perform daily activities.
• Bleeding: Ulcers or varicose veins near the surface of the skin may bleed easily.
• Phlebolymphedema (secondary lymphedema): Swelling caused by a buildup of lymph fluid, which can occur with venous insufficiency.
• Recurrent ulcers: Even after healing, ulcers may return if the underlying vein problem is not managed.

The outlook for people with CVI can vary depending on factors such as the severity of the condition and the presence of complications like ulcers or infections. Some people experience only mild symptoms that are easily managed, while others may develop more advanced disease with significant skin changes and persistent swelling or sores.

Most people with CVI can manage their symptoms and prevent serious complications with appropriate care, including compression therapy, lifestyle changes, and, when needed, medical or surgical treatments. Ongoing management is important, as symptoms may return or worsen if treatment is not continued, and complications such as ulcers can recur. With consistent treatment and regular follow-up, many people can maintain an active life.

“Yale Vascular Surgery provides the full complement of diagnostic and treatment modalities aimed at improving the health of our patients with chronic venous insufficiency,” says Raul Guzman, MD, a Yale Medicine vascular and endovascular surgeon. “We offer a team-based approach utilizing physicians, nurse practitioners, physical therapists, and wound care specialists to provide state-of-the-art care for our patients. We are at the forefront of clinical investigations aimed at developing new treatments for patients with the most advanced CVI symptoms. Our patient-centered approach is focused on identifying specific causes of CVI in the individual and tailoring the treatment strategy to achieve the best results in the most efficient manner.”