Chronic venous insufficiency is a venous disease In chronic venous insufficiency, the veins in the legs are not able to carry blood back to the heart due to damaged valves, resulting in a flow backward, causing blood to collect or pool in the legs. Venous diseases are fairly common conditions and affect millions worldwide.
Veins are responsible for carrying blood from various parts of the body to the heart. Veins have valves in them that allow the blood to flow in a single direction. If the valves are damaged, blood may leak backward or move in both directions. In chronic venous insufficiency, the veins in the legs are not able to carry blood back to the heart due to damaged valves, resulting in a flow backward, causing blood to collect or pool in the legs.
Anatomy Involved:
- Veins of the lower limb: Superficial veins (e.g., great and small saphenous veins), deep veins (e.g., femoral, popliteal), and perforator veins (connect superficial to deep veins).
- Venous valves: These one-way valves prevent backward flow of blood. When these valves are incompetent, blood flows backward (reflux), especially during standing or walking.
Pathophysiology of chronic venous insufficiency
- Normal Venous Flow Mechanism:
- Blood in the lower limbs is pumped upward against gravity by the calf muscle pump, aided by one-way venous valves that prevent backflow.
- Superficial veins (like the great and small saphenous), deep veins, and perforator veins maintain flow from the periphery to the heart.
- In CVI:
- Venous valve failure → reverse blood flow (reflux) → increased hydrostatic pressure
- Persistent venous hypertension → distended veins → leakage of plasma and proteins into tissues → chronic inflammation
Etiology/Causes
| Primary CVI | Secondary CVI (Post-thrombotic Syndrome) |
|---|---|
| – Idiopathic valve degeneration | – Deep vein thrombosis (DVT) |
| – Congenital valve insufficiency | – Vein obstruction from trauma/surgery |
| – Hereditary venous disease | – Previous venous surgery or catheter use |
Risk factors
- Demographics: Age > 50, female sex (due to hormonal factors)
- Genetic predisposition
- Multiple pregnancies
- Obesity
- Prolonged standing or sedentary lifestyle
- Smoking
- Prior DVT
- Lack of physical activity
- Tight clothing or posture restricting venous return
SIGNS AND SYMPTOMS
Subjective Symptoms:
- Heaviness, aching, or tightness in legs (especially after standing)
- Leg fatigue or cramping
- Itching, tingling, or burning sensation
- Restless leg syndrome
Objective Signs:
- Pitting edema (early stage, around the ankle)
- Varicose veins (tortuous, dilated superficial veins)
- Skin discoloration (hemosiderin deposition, brownish color)
- Lipodermatosclerosis (fibrosis of skin and subcutaneous fat)
- Atrophie blanche (white, scar-like skin patches)
- Venous eczema/stasis dermatitis (inflamed, scaly skin)
- Venous leg ulcers:
- Typically at medial malleolus
- Irregular margins, shallow, exudative
- Surrounding hyperpigmented or inflamed skin
Classification – CEAP system
| Component | Details |
|---|---|
| C (Clinical) | C0–C6 (from no signs to active ulcer) |
| E (Etiology) | Ec: Congenital, Ep: Primary, Es: Secondary |
| A (Anatomy) | Superficial, Deep, Perforator |
| P (Pathophysiology) | Reflux, Obstruction, or both |
What is Trump’s vein condition and how serious is it?
Diagnostic Evaluation:
- Clinical examination (inspection for varicose veins, edema, skin changes)
- Duplex Doppler Ultrasound: Gold standard to assess valve function and reflux
- Photoplethysmography: For venous refill time
- Venography (rarely used now): For detailed imaging
- Ankle-brachial index (ABI): To rule out arterial disease if ulcer present
COMPLICATIONS
- Chronic leg ulcers
- Cellulitis or secondary bacterial infections
- Superficial thrombophlebitis
- Deep vein thrombosis (DVT)
- Reduced mobility and psychological burden
- Bleeding from varicose veins
- Skin necrosis or malignancy (rare – Marjolin ulcer)
Treatment Options:
1. Conservative Management:
- Compression therapy:
- Graduated compression stockings (20–40 mmHg)
- Enhances venous return and reduces swelling
- Leg elevation: Elevate above heart level when resting
- Exercise: Calf muscle strengthening improves venous return
- Weight loss and healthy lifestyle
- Avoid prolonged standing or sitting
2. Pharmacological:
- Venoactive drugs (e.g., Diosmin, Horse Chestnut Extract)
- Anti-inflammatory drugs (if dermatitis is present)
- Antibiotics for secondary infections
3. Surgical/Procedural Interventions:
- Sclerotherapy: Injection to close varicose veins
- Endovenous Ablation: Laser or radiofrequency therapy
- Vein stripping and ligation: Removal of damaged vein
- Subfascial Endoscopic Perforator Surgery (SEPS)
- Skin grafting for non-healing ulcers
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