Chronic venous insufficiency
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|Chronic venous insufficiency|
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Chronic venous insufficiency or CVI is a medical condition where the veins cannot pump enough blood back to the heart. The commonest cause of CVI is superficial venous reflux which is a treatable condition. As functional venous valves are required to provide for efficient blood return from the lower extremities, this condition typically affects the legs. If the impaired vein function causes significant symptoms, such as edema and ulceration, it is referred to as chronic venous disease. It is important to realise that CVI includes varicose veins and superficial venous reflux ("hidden varicose veins") which can now be treated by local anaesthetic endovenous surgery.
The condition has been known since ancient times and Hippocrates used bandaging to treat it. However nowadays, most patients with CVI can be cured with treatments to the superficial venous system or stenting the deep system. It is sometimes described as chronic peripheral venous insufficiency but it should not be confused with Post-thrombotic syndrome in which the deep veins have been damaged by previous deep vein thrombosis.
Signs and symptoms
Symptoms of CVI in the leg include the following:
- Varicose veins
- Itching (pruritus)
- Phlebetic lymphedema
- Chronic swelling of the legs and ankles
- Venous ulceration
CVI in the leg may cause the following:
- Venous stasis
- Stasis dermatitis, also known as varicose eczema
- Contact dermatitis. Patients with venous insufficiency have a disrupted epidermal barrier, making them more susceptible than the general population to contact sensitization and subsequent dermatitis.
- Atrophie blanche. This is an end point of a variety of conditions, appears as atrophic plaques of ivory white skin with telangiectasias. It is a late sequelae of lipodermatosclerosis where the skin has lost its nutrient blood flow.
- Lipodermatosclerosis. This is an indurated plaque in the medial malleolus.
- Malignancy. Malignant degeneration is a rare but important complication of venous disease since tumors which develop in the setting of an ulcer tend to be more aggressive.
- Pain. Pain is a feature of venous disease often overlooked and commonly undertreated.
- Skin thickening
CVI in the leg may be caused by the following:
- Blood clots in the deep veins. This is called Deep vein thrombosis, or DVT. CVI caused by DVT may be described as postthrombotic syndrome
- Arteriovenous fistula (an abnormal connection or passageway between an artery and a vein).
- May-Thurner syndrome. This is a rare condition in which blood clots occur in the iliofemoral vein due to compression of the blood vessels in the leg. The specific problem is compression of the left common iliac vein by the overlying right common iliac artery.
An alternative explanation has shown Chronic venous insufficiency as the result of venous valves incompetence instead and/or obstacles to the flow (see)
Surgical treatment of CVI attempts a cure by physically changing the veins with incompetent valves. Surgical treatments include:
- Linton procedures (an older treatment)
- Ligation. Tying off a vein to prevent blood flow
- Vein stripping. Removal of the vein.
- Surgical repair.
- Endovenous Laser Ablation
- Vein transplant.
- Subfascial endoscopic perforator surgery. Tying off the vein with an endoscope.
- Valve repair (experimental)
- Valve transposition (experimental)
- Hemodynamic surgeries.
Treatment of CVI in the leg involves managing the symptoms (and preventing the symptoms getting worse) instead of effecting a cure. It is sometimes called conservative treatment. Conservative treatments include:
- Manual compression lymphatic massage therapy
- Skin lubrication
- Sequential compression pump
- Ankle pump
- Compression stockings
- Blood pressure medicine,
- Frequent periods of rest elevating the legs above the heart level
- Tilting the bed so that the feet are above the heart. This may be achieved by using a 20 cm (7-inch) bed wedge or sleeping in a 6 degree Trendelenburg position. Obese or pregnant patients might be advised by their physicians to forgo the tilted bed.
- Atrophie blanche
- Compression stockings
- Heavy legs
- Linton flap
- Musculovenous pump
- Varicose veins
- Venous stasis ulceration
- Venous stasis
- Venous ulcer
- "Chronic Venous Insufficiency". Society for Vascular Surgery. December 1, 2009.
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-  Ann Vasc Surg. 2007 Sep;21(5):652-62. Dermatologic complications of chronic venous disease: medical management and beyond. Barron GS1, Jacob SE, Kirsner RS. PMID 17823046