Chronic venous insufficiency (CVI)

Chronic venous insufficiency (CVI) is a condition characterized by impaired venous return in the deep veins of the lower extremities. In its mild form, it causes discomfort, swelling, increased fatigue, and nocturnal cramps. In severe cases, it manifests as pigmentation disorders and the development of trophic ulcers.

The prevalence

The prevalence of the disease varies from 15 to 25% worldwide, depending on the level of medical advancement in each country. Symptoms of Chronic venous insufficiency (CVI) are observed in every second person aged 20-50 years, with up to 15% having a confirmed diagnosis, and 4% experiencing the disease in a severe form with complications such as trophic ulcers.

CVI is primarily caused by prolonged standing, resulting in excessive pressure on the legs. Contributing factors include congenital and acquired pathological conditions, injuries, and prolonged physical exertion. CVI does not always present visible changes in the veins; in most cases (mild form), symptoms include leg heaviness, evening swelling, increased fatigue, and pain when standing for long periods.

The most common cause of CVI is varicose vein dilation, as well as other conditions such as congenital venous system pathology, congenital aplasia and hypoplasia of deep veins, congenital arteriovenous fistulas, congenital osteohypertrophic nevus with varicose veins, previous acute thrombosis of major veins, Klippel-Trenaunay syndrome, and previous phlebothrombosis.

In recent years, a new cause of chronic venous insufficiency has emerged, known as phlebopathy. This term refers to venous stasis in the absence of clinical signs of pathology. In rare cases, CVI may develop after trauma (bruising, rupture, deep burns, or hypothermia).

The mechanism of onset and development of the disease:

Under the influence of gravity, blood descends into the lower extremities, requiring the body to exert effort to pump it back up. Venous valves prevent blood from flowing downward, actively assisted by physical activity, muscle contraction, and knee flexion. These factors collectively ensure normal blood flow.

Maintaining constant resistance to gravity is possible due to physiological changes in the vascular lumen when changing body positions, the functioning of the valve apparatus, and the tone (elasticity) of the venous wall. If one of these mechanisms is disrupted, pathological processes begin to affect the entire system. Loss of elasticity in the venous segment below the valve and its dilation lead to valve incompetence, making it unable to retain blood flow for subsequent upward movement. Fluid stasis leads to increased pressure to propel blood upwards. However, over time, increased pressure enlarges the volume of the vein segment that has lost elasticity.

Venous reflux (backward flow of blood from top to bottom) may accompany the pathological process. Fluid begins to stagnate, exerting pressure on the vessel walls. As a result, plasma seeps into the surrounding tissues, causing edema. A similar situation develops with initial valve insufficiency.

Simultaneously with circulatory insufficiency, the lymphatic system becomes overloaded. Trophic disturbances contribute to the formation oftrophic ulcers. Trophic ulcers are long-lasting wounds (lasting 6 months or more) affecting the skin and tissues. They typically form on the shin, surrounded by an inflamed area, and carry a high risk of infection.

Risk factors for chronic venous insufficiency (CVI):

Several factors significantly increase the risk of developing chronic venous insufficiency, including:

  • Genetic predisposition, including connective tissue disorders and vascular wall weakness.
  • Use of hormone-containing substances, including hormonal contraceptives.
  • Low physical activity, sedentary lifestyle, constant heavy lifting, and excess weight.
  • Chronic constipation.

Chronic venous insufficiency (CVI) is more commonly diagnosed in women because high concentrations of estrogen (female sex steroid hormones) influence the development of venous insufficiency. Pregnancy and childbirth, as well as the use of hormonal contraceptives, have a negative impact. With age, the likelihood of developing the disease increases in both sexes due to prolonged exposure to unfavorable factors.

Classification of Chronic venous insufficiency (CVI):

  1. Grade 1: Characterized by a feeling of heaviness, dull aches, transient mild swelling, and nocturnal cramps.
  2. Grade 2: Persistent swelling, hyperpigmentation (darkening of areas of the affected limb), lipodermatosclerosis (dystrophic changes in adipose tissue), dry and weeping eczema (serous inflammation of the dermis).
  3. Grade 3: In addition to the above symptoms of stage 2, trophic ulcers, either current or already healed, develop.
  4. There is also a 0 grade, where the patient does not observe any changes or complaints, yet pathological processes are already underway. The treatment approach for patients with grade 0 CVI differs from the therapy for patients in other stages.

In international practice, chronic venous insufficiency is classified based on clinical manifestations into 6 grades, including grade 0 (CEAP system). Additionally, the disease has an etiological classification based on the causes of its development:

  • EC: Congenital pathology.
  • ES: Acquired form resulting from thrombosis, varicose veins, or trauma.
  • EP: Unclear reason for the development of venous insufficiency.

There is also an anatomical classification based on the location of the disease, considering pathophysiology, disability scales, and other factors.

Symptoms of chronic venous insufficiency:

In the early stage, CVI presents a wide range of clinical features, typically appearing or worsening after prolonged sitting or standing and during periods of increased physical activity:

  • Heaviness in the legs.
  • Fatigue, buzzing sensation.
  • Dull pains.
  • Transient swelling.
  • Numbness, temporary loss of sensation.
  • Nighttime cramps.

If you regularly experience at least one of these symptoms, it’s essential to consult a doctor. As the pathology progresses (stages 2 and 3), additional symptoms may include:

  • Persistent swelling.
  • Increased pain during exertion.
  • Formation of ulcers and eczema.
  • Varicose vein dilation.

Circulatory insufficiency not only affects the affected area but also the entire body. Dizziness, fainting, high mental and physical fatigue may occur. Signs of heart failure such as irregular heartbeat, pale skin, and shortness of breath may also be observed.

Diagnosis and treatment of Chronic venous insufficiency (CVI):

During a consultation with a phlebologist at the Outpatient Surgery Center, a diagnosis is made based on medical history, patient complaints, and examination results. The primary method of instrumental examination is duplex ultrasound scanning. In our clinic, functional diagnostic physicians not only confirm the presence of CVI but also help surgeons determine the extent of venous system involvement and choose the appropriate treatment strategy. In some cases, the attending physician may prescribe duplex angiography or X-ray contrast studies (phlebography).

The treatment of chronic venous insufficiency involves a combination of measures aimed at restoring the functionality of the venous and lymphatic systems, eliminating pathologies that have arisen as a result, and preventing recurrences. The therapy method is individually tailored to each patient, considering the degree of pathological changes, medical history, age, and concomitant diseases.

Conservative treatment:

Course treatment is prescribed, typically lasting an average of 2-3 months, followed by a period of renewal. The course usually includes:

  • Medications (phlebotropic drugs).
  • Topical use of antiseptic ointments.
  • Corticosteroid preparations.
  • Elastic compression (bandages and compression garments).
  • Treatment of associated secondary infections.
  • Elevation of the legs while lying down.

In some cases, antibiotics and diuretics may be prescribed to reduce swelling. Elastic compression, including pneumatic and device-assisted compression, and leg elevation play the most significant role in routine CVI treatment. Compression is recommended for all patients, even those with ulcers. In this case, elastic bandaging is used, followed by wearing special stockings. They should provide distal pressure of 20–30 mmHg for patients with the first stage, 30–40 mmHg for the second stage, and up to 60 mmHg for the third stage.

The effectiveness of therapy depends directly on the active participation of the patient. It is essential to strictly follow the doctor’s recommendations and adjust one’s lifestyle to avoid conditions that exacerbate the disease.

Surgical treatment:

Surgical intervention is performed in only 10% of patients who have:

  • Severe comorbidities.
  • Trophic disorders.
  • Transformed inflow of large (small) subcutaneous veins.
  • Recurrent varicose veins and other similar cases.

For this purpose, minimally invasive surgery techniques such as mini-phlebectomy are chosen. The operation is performed under local anesthesia. Through small punctures, the vascular surgeon gains access to the affected vein segments to ligate (tie off the vessel), remove the vein, and reconstruct the valve. The vascular surgeon’s tasks include eliminating pathological blood reflux and truncating varicose veins. After the operation, the patient can go home after an hour; hospitalization is not required.

Prognosis and prevention:
The greatest danger to the patient is delayed medical care. Typically, in the early stages of the disease, symptoms are attributed to fatigue after a workday. Some people do not attach much importance to the disease itself; others prefer to use “folk remedies” or self-medicate. Ultimately, both groups end up in line to see a phlebologist, but already with aggravated pathological processes.

Preventive measures to prevent the development of chronic venous insufficiency should be started in advance, before the appearance of the first symptoms. This applies primarily to people at risk. Prevention includes:

  • Exercise and daily walks for those leading a sedentary lifestyle.
  • Proper nutrition, limiting salt intake, and weight loss.
  • Limiting the time spent in a static position (sitting, standing), or at least alternating between static and active actions.
  • Elevating the legs 2-3 times a day for an average of 30 minutes.

It is important to avoid taking hormonal medications without consulting a doctor. Constipation should be prevented by following an appropriate diet, or, if necessary, using laxatives. People at risk should wear compression garments, especially during periods of increased activity and static positions. Avoid visiting the sauna, solarium, and prolonged exposure to direct sunlight during hot weather. Refrain from performing strength exercises and stretching activities such as yoga and Pilates.