Venous Insufficiency

Venous insufficiency is a general term that can be applied to venous conditions in which the blood flow through the veins is impaired, such as dysfunctional veins in the superficial, deep or perforating venous systems. Chronic venous insufficiency (CVI) is a more specific term used when there are visible signs of long standing venous disease.

The veins in the lower extremities that are not working very well can be called dysfunctional. These veins can occur from vein valve or vein wall weakness. When the vein valves become weak, the flaps separate and blood can flow backward through the valves. The backward flow of blood is referred to as venous insufficiency or reflux. The backflow of blood fills the veins and stretches the walls even more. As a result, the veins get bigger, swell, and often get twisted as they try to squeeze into their normal space.

Problems commonly arise in the superficial veins, but can occur in perforating and deep veins as well. Dysfunctional veins in the superficial venous system come in three sizes. These three are varieties of the same condition.

• Spider veins or thread veins are the smallest and are really tiny varicose veins or telangiectasias. They are long, tortuous and their color varies from bright red to dark purple. Varicose veins have no color but protrude to cause the skin to look as though it is covering a bunch of grapes.
• Reticular varicosities are medium in size and are flat, blue-green veins seen through the skin usually at the back of the knees.
• Gross varicose veins are the largest in size.

Causes

Venous insufficiency can be caused by a number of disorders of the veins. Primary venous insufficiency occurs when the venous valves or vein wall become weak, often due to heredity, advancing age, female gender, obesity, hormones, weakness of the leg muscles, ankle laxity, and standing or sitting occupations. Secondary venous insufficiency is often caused by a deep vein thrombosis (DVT). At least a quarter of patients who have a DVT will develop CVI within 10 years after diagnosis.

Signs and Symptoms

• Aching, tenderness
• Heaviness, fatigue
• General restlessness in the legs
• Burning pain
• Throbbing pain
• Itching around the veins
• Leg cramps, particularly at night
• Soreness behind the knees
• Ankle swelling

Signs and Symptoms of CVI

Patients with CVI may have any of the above symptoms. In addition, one or more of the following physical findings indicate the presence of advanced venous insufficiency:

• Brownish skin discoloration around the ankle (hyperpigmentation)
• Dermatitis or eczema (dry, flaky skin) near the ankle
• Atrophe blanche (white patches around the ankle)
• Thickening and hardening of the skin near the ankle (lipodermatosclerosis)
• Ulceration on the lower leg usually near the ankle

Diagnosis

Diagnosis of venous insufficiency is made by using a Duplex Doppler ultrasound examination. This examination can detect the direction of blood flow in the superficial and deep veins and detect obstruction such as deep venous thrombosis. It is a painless, outpatient test that can be performed either in a medical office or in a vascular laboratory.

Treatment Options

Venous insufficiency and/or CVI may be treated with lifestyle changes and medical procedures. The goals of treatment are to relieve symptoms and to prevent life-threatening complications.

• Lifestyle Changes – These changes are often the first treatment for varicose veins. Lifestyle changes can significantly reduce symptoms. These changes include:
  • Avoid standing or sitting for long periods of time
  • Exercise
  • Weight Loss
  • Leg elevation

• Compression Stockings – Your doctor may recommend compression stockings to reduce symptoms, leg swelling and decrease the risk of thrombophlebitis. Medical grade compression stockings require a prescription. Over the counter support hose or Thrombo Embolic Deterrent (TED) hose are not adequate to reduce symptoms in venous disease.

• Vein Procedures – The goal of treatment is to remove the dysfunctional veins from superficial venous circulation, thereby reducing symptoms and progression of disease.  A number of new techniques and devices have made treatment of superficial venous insufficiency simpler and more effective.

Effective treatment of deep venous insufficiency is not available. But, patients with deep venous insufficiency usually have associated superficial venous insufficiency. Therefore, therapy is aimed at treatment of the superficial venous disease.  For patients where venous insufficiency is secondary to blood clots, in a few cases the blood clots may be removed with new technology. In the majority of cases however, the patient may be required to take anticoagulants or blood thinners to prevent new clots from forming. There are two main types of procedures.

• Foam Sclerotherapy – This procedure involves the injection of a foamed sclerosant medication into the vein. The solution irritates the vein lining, causing it to collapse. The collapsed vein is eventually broken down by the body and vanishes over several weeks.
• Endovenous Ablation – The endovenous ablation procedures use heat to collapse and close the vein, instead of a chemical solution as in sclerotherapy. Heat is generated by laser (also known as endovenous laser therapy EVLT) or radiofrequency sources (VNUS Closure®).