Chronic Venous Insufficiency

Understanding chronic venous insufficiency (CVI) is the first step toward effective management and improving your quality of life. Early diagnosis and treatment are important to prevent the condition from worsening and to manage symptoms effectively.

What is chronic venous insufficiency (CVI)?

CVI is a condition that occurs when the veins in your legs are unable to effectively pump blood back to your heart. This can lead to blood pooling, increased pressure, and a range of symptoms from mild discomfort to severe skin changes and ulcers. AHN has the heart specialists with advanced understanding of this condition who will be able to help you find effective treatment.

CVI care at AHN: Why choose us?

AHN Cardiovascular Institute experts have deep a understanding of heart conditions like chronic venous insufficiency (CV). Our skilled and compassionate providers are adept at supporting patients through treatment with options that are focused on a holistic and patient-centered approach. We coordinate care across specialists — from vascular surgeons and interventional cardiologists to wound care experts and rehabilitation therapists — to ensure every aspect of your CVI is addressed.

CVI symptoms and signs

The symptoms and signs of CVI can vary from person to person. It’s important to understand and be aware of how this condition can show up in the body because it is a progressive condition that can worsen over time. The common symptoms of CVI can include:

• Leg pain, aching, or heaviness: This is a very common complaint. The legs can feel tired, heavy, or achy, especially after standing or sitting for long periods.
• Swelling (edema) in the legs and ankles: Often worse at the end of the day or after prolonged standing, and typically improves overnight or with leg elevation.
• Leg cramps: Muscle cramps, particularly at night, can be a symptom.
• Itching (pruritus): The skin on the legs can become very itchy, often due to dryness or irritation from stagnant blood.
• Restless legs syndrome-like symptoms: An uncomfortable sensation in the legs that creates an irresistible urge to move them.
• Throbbing or burning sensation: Some patients describe these specific discomforts.

The signs, which are often more noticeable or detectable by your health care provider, can include:

• Varicose veins: These are enlarged, twisted, bulging veins, often dark blue or purple, visible just under the skin. They are a classic sign of underlying venous reflux.
• Spider veins (telangiectasias): While not CVI themselves, these small, web-like veins can sometimes be associated with early or mild venous issues.
• Skin discoloration (stasis dermatitis): Over time, hemosiderin (a pigment from red blood cells that have leaked out of damaged veins) deposits in the skin, causing a reddish-brown or brownish discoloration, particularly around the ankles and shins.
• Skin texture changes (lipodermatosclerosis): The skin on the lower legs can become thick, hardened, and leathery, sometimes resembling an inverted champagne bottle shape (narrower at the ankle, wider at the calf).
• Venous ulcers: These are open sores or wounds, typically located around the ankles (medial malleolus is common), that are slow to heal and often recurrent. They are a sign of advanced CVI.
• Flaking or itchy skin: Especially over areas of swelling or discoloration.
• Hair loss: On the lower legs due to poor circulation.
• Thickening of toenails: Less common but can be observed.

Causes and risk factors

CVI results from damaged or weakened valves within the veins of the legs. These valves are supposed to act like one-way gates, preventing blood from flowing backward down the leg and instead pushing it up toward the heart. When these valves don't function properly, blood pools in the veins, leading to increased pressure and symptoms. Often this is caused by or the risk is increased because of:

• Valve dysfunctio/damage: The most common cause. The valves inside the leg veins become damaged or weakened, failing to close properly. This allows blood to flow backward (reflux) and collect in the lower veins.
• Post-thrombotic syndrome (PTS): This occurs after a deep vein thrombosis (DVT), which is a blood clot in a deep vein. The DVT can damage the vein walls and valves, even after the clot has dissolved, leading to CVI.
• Deep vein thrombosis (DVT): While often leading to PTS, an active DVT can directly cause CVI by blocking blood flow and increasing pressure in the veins.
• External compression: Less common, but sometimes a tumor, swelling, or anatomical structure can press on a vein and obstruct blood flow.
• Genetics/family history: If your parents or other close relatives have CVI or varicose veins, you are more likely to develop it. This is one of the strongest risk factors.
• Age: CVI becomes more common with increasing age as valves and vein walls naturally weaken over time.
• Gender: Women are more prone to CVI than men, partly due to hormonal changes, particularly during pregnancy and menopause.
• Pregnancy: Increased progesterone can relax vein walls and increased blood volume puts pressure on the veins.
• Obesity: Excess weight puts increased pressure on the leg and pelvic veins, making it harder for blood to flow back to the heart.
• Prolonged standing or sitting: Occupations or lifestyles that involve long periods of standing (e.g., nurses, teachers, factory workers) or sitting (e.g., office workers, long-haul drivers) contribute to blood pooling in the legs and increase pressure on vein valves.
• Lack of exercise/sedentary lifestyle: Muscle contractions in the calves act as a "venous pump" to help blood return to the heart. A lack of movement weakens this pump.
• Smoking: Can damage blood vessels and impair circulation.
• Previous leg injury or trauma: Damage to the leg, especially to the veins, can disrupt normal blood flow and valve function.
• May-Thurner Syndrome: A rare anatomical variant where the left common iliac vein is compressed by the right common iliac artery, leading to increased pressure and risk of DVT and CVI in the left leg.

CVI screening and diagnosis

CVI screening typically begins with a thorough medical history and physical examination. Your AHN heart specialist will talk with you about the symptoms you’ve been having, look at any swelling or skin changes, and discuss your risk factors. A physical examination will look at your legs for signs of CVI, such as varicose veins, skin discoloration (hyperpigmentation), swelling (edema), skin changes (lipodermatosclerosis), and any open sores or ulcers. The provider may feel your legs for tenderness or warmth, and assess the degree of edema. In some cases, an ABI may be performed to rule out peripheral artery disease, which can have similar symptoms. This involves comparing blood pressure in your ankles to blood pressure in your arms.

If your health care provider feels it’s necessary, they may order some diagnostic tests to get a closer look at the potential condition. A duplex ultrasound, a noninvasive imaging technique, will likely be used to look at blood flow in your leg veins. It can identify:

• Venous reflux: Backward flow of blood in the veins, indicating incompetent valves.
• Obstruction: Blockages in the veins, such as those caused by blood clots (post-thrombotic syndrome).
• Anatomy: The structure and size of the veins.

After these steps, your provider will be able to determine the presence and severity of CVI and recommend appropriate management.

Types and stages of CVI

CVI shows up differently in different people. The different types are based on how severe it is in the patient. It can also progress into different stages depending on the severity of the condition. Often the types of CVI are linked to the stages and are classified as:

• Stage 0: No obvious signs yet. You might not see anything specific, but you might feel some tired, aching legs, especially after standing.
• Stage 1: Spider veins and small varicose veins. These are those very small, often red or blue veins, or slightly larger rope-like veins that you can see or feel just under the skin. At this point, the problem is usually more cosmetic, but it's a sign that the valves might be starting to struggle.
• Stage 2: Larger varicose veins. These are the more noticeable, bulging, twisted veins. You might also start to feel more symptoms like heaviness, aching, or throbbing in your legs. This is a clear sign the valves are not working well.
• Stage 3: Swelling (edema). This is when your ankles and lower legs start to swell, especially by the end of the day or after you've been on your feet for a while. The swelling usually goes down if you put your feet up. This happens because the blood pooling in your legs pushes fluid out into the surrounding tissues.
• Stage 4: Skin changes. Because of the ongoing pressure and fluid buildup, the skin on your lower legs can start to change. It might become discolored, often turning brownish or reddish. You might get itchy rashes (like eczema). The skin can also get thicker, harder, and sometimes painful, almost like it's tightening up.
• Stage 5: Healed ulcers. This means you've had an open sore on your leg due to CVI in the past, but it has now closed up.
• Stage 6: Active ulcers. This is the most advanced stage, where you have an open wound or sore on your lower leg that struggles to heal. These are called venous ulcers and need careful treatment.

CVI treatment

The treatment for Chronic Venous Insufficiency (CVI) largely depends on the severity of the condition, the specific symptoms you're experiencing, and your overall health. The primary goals of treatment are to reduce symptoms, prevent progression of the disease, and improve your quality of life.

AHN uses the latest and most thoughtful treatment approaches to CVI, often starting with conservative measures and progressing to more invasive options if needed.

Conservative, noninvasive treatments

These are often the first line of defense, especially for earlier stages of CVI. Your AHN care team will review your specific needs and may use one or a combination of these approaches to treat your CVI:

• Compression therapy: This is often a cornerstone of CVI management because it helps to improve blood flow without invasive intervention.
• Compression stockings/garments: These specially designed stockings apply graduated pressure to your legs (tightest at the ankle, gradually looser up the thigh). This helps to:
  • Improve blood flow back to the heart
  • Reduce swelling (edema)
  • Prevent blood from pooling in the lower legs
  • Support the vein walls
• Compression bandages: Used for more severe swelling or to help heal active ulcers.
• Leg elevation: Elevating your legs above your heart for 15 – 30 minutes several times a day helps gravity drain pooled blood and reduce swelling. This is particularly helpful after prolonged standing or at the end of the day.
• Regular exercise: Activities like walking, cycling, or swimming help pump blood out of your legs by activating your calf muscles (often called the "calf muscle pump"). This is crucial for improving circulation.
• Avoid prolonged standing or sitting: If your job requires it, take frequent breaks to walk around or elevate your legs.
• Weight management: If you are overweight or obese, losing weight can significantly reduce pressure on your leg veins and improve CVI symptoms.
• Skin care: For skin changes or ulcers, meticulous skin care is essential to prevent infection and promote healing. This might involve emollients for dry skin, topical steroids for eczema, or specific wound care dressings for ulcers.
• Medications (adjunctive): While there isn't a specific drug to "cure" CVI, certain medications can help manage symptoms:
  • Diuretics: Sometimes prescribed short-term for severe swelling, but not a long-term solution.
  • Pentoxifylline: Can sometimes help with healing venous ulcers.
  • Aspirin: May be used in some cases, especially if there's a history of blood clots, but this is decided on an individual basis.

Minimally invasive procedures

These treatment options are typically performed in an outpatient setting for more advanced CVI where conservative measures are insufficient or when significant reflux is identified by ultrasound. The goal is to close off or remove the incompetent (faulty) veins. This can be done by using:

• Radiofrequency ablation (RFA) or laser ablation (EVLA): A thin catheter is inserted into the faulty vein (usually the great or small saphenous vein). Heat (radiofrequency energy or laser light) is then used to seal the vein shut. The blood is then redirected to healthy veins.
• Liquid sclerotherapy: A chemical solution is injected into small to medium-sized varicose veins or spider veins, causing them to scar and close.
• Foam sclerotherapy: The solution is mixed with air to create a foam, which can treat larger veins or clusters of veins more effectively.
• VenaSeal™ closure system (medical adhesive/glue): A medical adhesive (glue) is injected into the faulty vein, sealing it shut. This often requires fewer compression stockings post-procedure.
• Phlebectomy (microphlebectomy): Small incisions are made to physically remove varicose veins. This is often done in conjunction with ablation procedures.

Surgical treatments

These are less common now due to the effectiveness of minimally invasive techniques, but may still be necessary for very large veins, specific anatomical issues, or complex cases. Treatment can include:

• Ligation and stripping: Historically common, this involves tying off and then physically removing a long segment of a faulty vein.
• Vein bypass: In very rare cases, if deep veins are severely obstructed, a bypass might be considered, but this is a complex procedure.

Ulcer management

For patients with active venous ulcers, specialized care is crucial. Ulcer management is essential to treating CVI. This can include:

• Wound care: Regular cleaning, debridement (removal of dead tissue), and appropriate dressings to promote healing and prevent infection.
• High compression: Specialized compression bandages or systems are often used to reduce swelling and facilitate ulcer healing.
• Skin grafting: In persistent or very large ulcers, a skin graft may be necessary.

The treatment plan is always individualized. Your doctor will consider your symptoms, the results of your duplex ultrasound, your lifestyle, and your preferences to determine the most appropriate course of action.

CVI FAQs

Having questions about CVI is completely understandable, and AHN is here to provide you with answers that will help you feel confident in your care. These frequently asked questions are some of our patients’ most common concerns, so we’ve included them to help guide your conversations with your AHN care team. 

Can you live a normal life with chronic venous insufficiency?

Yes, many people with CVI can live a very normal and fulfilling life, especially with proper management and treatment. The key to living normally with CVI is consistent management. For many, this means regularly wearing compression stockings, staying active, elevating their legs, and making lifestyle adjustments. If the condition is more advanced, minimally invasive procedures or surgery can significantly alleviate symptoms and improve quality of life, allowing individuals to return to their normal activities without the pain, swelling, or skin problems CVI can cause. It's about understanding your condition, adhering to your treatment plan, and working closely with your health care provider to keep symptoms under control.

Can you reverse chronic venous insufficiency?

While you can't reverse the underlying damage to the valves in your veins, you can absolutely halt its progression, manage symptoms, and prevent further complications.

Think of it this way: If the valves in your veins are damaged, they won't repair themselves to their original, perfectly functioning state. However, modern treatments are highly effective at:

• Eliminating the problem veins: Procedures like ablation or sclerotherapy close off the faulty veins, redirecting blood flow to healthy veins, which effectively "reverses" the symptoms and problematic blood pooling.
• Preventing further damage: Conservative measures like compression and lifestyle changes support your healthy veins and prevent new damage.
• Healing complications: Treatments can successfully heal ulcers and resolve skin changes.

So, while the intrinsic valve function may not be restored, the effects of CVI can be very effectively reversed and controlled, allowing you to live without the negative impact of the condition.

What happens if chronic venous insufficiency is not treated?

If left untreated, CVI can worsen over time and lead to a range of increasingly severe and debilitating complications. The progressive nature of CVI means that without intervention, the continuous pooling of blood and pressure in the leg veins can cause:

• Worsening symptoms: Increased pain, aching, heaviness, cramping, and restless legs.
• Increased swelling (edema): More persistent and severe swelling in the ankles and lower legs.
• Skin changes: The skin can become chronically inflamed, discolored (brownish), thickened, hardened (lipodermatosclerosis), and itchy (venous eczema).
• Venous ulcers: The most serious complication, where skin tissue breaks down due to poor circulation, leading to open, slow-healing wounds, typically around the ankles. These are painful, prone to infection, and significantly impair mobility and quality of life.
• Bleeding: Varicose veins can sometimes bleed, particularly if bumped or scratched.
• Superficial thrombophlebitis: Inflammation and clotting in a superficial vein, which can be painful.
• Increased risk of deep vein thrombosis (DVT): While CVI itself isn't DVT, the stagnant blood flow can sometimes contribute to an increased risk of blood clots forming in the deeper veins.

Untreated CVI can significantly impact your mobility, comfort, and overall health, leading to a diminished quality of life.

How bad is chronic venous insufficiency?

How to classify CVI varies greatly from person to person and depends on its stage and impact on an individual's life.

• Mild CVI: In its early stages (like C1 with spider veins or C2 with small varicose veins), CVI might primarily be a cosmetic concern or cause mild, intermittent symptoms like tired legs. At this stage, it's generally not "bad" in terms of immediate health threat, but it indicates a developing issue that could worsen.
• Moderate CVI: With more pronounced varicose veins, noticeable swelling, and skin changes (C3-C4), CVI can cause significant discomfort, pain, and impact daily activities. It can be quite bothersome and affect sleep, work, and exercise.
• Severe CVI: When CVI progresses to active venous ulcers (C6), it can be severely debilitating. Ulcers are painful, can get infected, require intensive wound care, and can significantly limit mobility and independence. This stage carries a high risk of recurrence and significantly impacts quality of life.

In summary, CVI exists on a spectrum. While early CVI might be a minor inconvenience, it has the potential to become a very serious and life-altering condition if not properly addressed. The good news is that with current treatments, even advanced stages can be effectively managed, and symptoms can be significantly improved or resolved.

Contact us

If you have not been formally diagnosed, call (412) DOCTORS 412-362-8677 or request an appointment with AHN cardiovascular services, to be evaluated. If you have been diagnosed,contact your provider to discuss next steps.