CHRONIC VENOUS INSUFFICIENCY (CVI)

Definition of CVI

Chronic venous insufficiency (CVI), also called chronic venous disease (CVD), is a condition caused by weak, worn or damaged valves in the veins of the legs.

Before describing how this disease develops, here is a short reminder: arteries bring oxygen-rich blood from the heart to the rest of the body while veins return oxygen-poor blood back to the heart. Then blood circulates to the lungs, where carbonic acid is released by the red blood cells and oxygen captured so the blood regains its bright red colour and continues the circle of distribution and delivery of life. A typical feature exists in the veins, i.e. the presence of a system of valves - or one-way flaps - resulting from the adaptation of the humans to the standing position and preventing the return of blood towards the feet. Thanks to the valves of the veins, the blood is kept flowing in the right direction, as the blood in the leg veins must go against gravity to return to the heart and veins have a far thinner muscle wall than arteries. Another mechanism is also very useful in the fight against gravity: while walking, the vessels in the foot sole are compressed and propel the blood upwards. This activity is then taken over by the calf muscles, which when contracting allows the blood to be pumped further upwards. This mechanism is so important that it is sometimes called the second heart.

If the valves are not working as they should, the blood has difficulty in circulating upwards against gravity to the heart. Prolonged augmented pressure in the veins outstretches their valves, preventing them from closing properly. Consequently, the blood flows back, entering also smaller veins and accumulating in the leg tissues, which causes swelling, also called oedema. Another consequence is the decreased delivery of oxygen to the leg tissues, leading to suffering of the cells with inflammation and pain.

Frequency of CVI

One person out of three in industrialized Western countries is presenting a form of CVI. In France, statistics show that women are twice as likely to suffer from CVI than men (57% versus 26%). The mean prevalence in Europe is 40% in subjects aged 30 to 70 years, ranging from 15% at 25 years, to 50% at 50 years and 70% at 90 years.
In pregnant women, 50% present an oedema of the ankle and 20% varicose veins.
In Africa and Asia, the risk of presenting CVI is markedly lower than in the other parts of the world.

Costs of CVI

CVI has a major impact on the socio-economic level and represents a real problem of public health, as their treatment represents 1.5 to 2% of the global health costs in Germany, France, Italy and Great-Britain.
In Italy, the total direct costs of venous diseases reached about 384 million€ in 1999, including 288 million€ in hospitalisations. In France, CVI is responsible for 200.000 hospital stays and 6.400.000 days lost in absence from work per year.
In Holland, 0.6% of the population stops work each year for a mean duration of 50 days.

CVI symptoms

Common symptoms are :

• feeling of heavy, tired or restless legs
• swelling of the ankles and/or calves
• pain
• change in skin colour, usually around the ankle
• rash
• itching
• cramps

and in more advanced cases:

• swollen veins close to the surface of the skin, called varicose veins, which often look blue, bulging and twisted
• skin ulcers, usually on or near the ankle where the blood in the tissue may break down, leaving a brownish colour while the skin becomes dry, cracks and itches.

Diagnosis of CVI

After questioning about the current general health, past medical history and symptoms, as well as working conditions and sports, the doctor will conduct a physical examination, including measurement of the blood pressure in the legs as well as of calf and leg circumference and observation of the veins. To confirm the diagnosis, he will perform or send you to a specialist for a duplex ultrasound and another examination.

• Duplex ultrasound: it uses painless sound waves for measuring the speed of the blood flow and for seeing the structure of the veins in the legs as well as the presence of a blood reflux towards the feet.
• Venogram: it is an x-ray allowing to see the anatomy of the vein after injection of a contrast medium or dye
• Plethysmography: it is a non-invasive technique allowing to assess the overall physiologic function of the leg venous system and to measure the venous refill time after calf muscle contraction. It is useful for determining the absence or presence of venous disease.

Risk factors for CVI

• Age: the incidence of CVI increases markedly with age
• Gender : IVC occurs more frequently in women than in men, because of the changing hormonal status during lifetime (puberty, pregnancy, menopause)
• Overweight: it increases the pressure on the legs and reduces venous return
• Smoking: it reduces the tonicity of the veins
• Life style: a sedentary lifestyle reduces to a minimum the pumping action of all the muscles in the calves, diminishing venous flow and causing increased venous pressure
• Diet: food rich in refined sugars and fats but poor in fibres and vitamins favour the development of CVI
• Certain professions: standing upright or sitting for several hours contributes to increased venous pressure in the legs
• History of varicose veins in the family
• History of deep vein thrombosis in the family: deep vein thrombosis makes the venous valves incompetent, leading to increased venous pressure.

Complications of CVI

• Varicose veins are the most frequent complication of CVI
• Varicose ulcer occurs upon simply bumping the skin at the level of a varicose vein, causing a wound that is difficult to heal and easily infected
• In a few cases, phlebitis may occur, this is a serious condition as a blood clot is present inside a vein. If the blood clot occurs inside a deep vein, it may reach the heart and the pulmonary arteries, with the risk of pulmonary embolism, a very serious condition.

Prevention and management of CVI

Several approaches are available:

Conservative treatment

The initial treatment of CVI involves conservative measures to reduce symptoms and help to prevent the development of secondary complications and disease progression:

• General preventive measures
  • Avoid long periods of standing or sitting
  • Begin a walking program starting with a few steps and then increasing the distance. Indeed, while walking, the muscles of the lower limbs contribute to pumping the venous blood back to the heart
  • Practice sports regularly (swimming, bicycle riding) for a better venous reflux, but avoid those squashing the foot sole (fencing, tennis)
  • Keep your legs slightly raised during the night
  • Avoid crossing the legs or dangling them over the edge of a chair while sitting
  • Avoid wearing girdles, leg garters or other tight-fitting clothes
    
  • Avoid hot tub baths, sauna, sun-bathing, waxing of the hair on the legs, as heat dilates the veins
    
  • Prevent excess weight which can aggravate venous diseases
    
  • Eat food poor in sugars and fats, but rich in fibers and anti-oxidants that have a protective effect on the vein walls, such as vitamin C, E, or A and selenium and zinc
    
  • Drink at least 1.5 litre water per day to favour draining of the tissues.
    

• Therapeutic measures
  • Venoactive drugs (also called venotonics, vasoprotectors, phlebotonics, phlebotropics, venotropics, oedema-protective agents) are of synthetic or plant origin. They reduce calf and leg oedema and have a protective effect on the vessel walls and an anti-oxidant action. They are recommended to relieve venous symptoms in all classes of chronic venous disease ranging from no visible varicose vein with venous symptoms to painful venous ulcers. They may be given orally and/or locally, alone or in combination with compressive therapy. Venoactive drugs also constitute an alternative to compressive therapy in certain cases, especially in contraindications such as arterial disorders, skin infections, intolerance to compressive stockings, low patient compliance and hot climate making the wearing of such stockings quite unpleasant
  • Compressive stockings are indicated for mild cases. They are elastic stockings that squeeze the legs, preventing excess blood from flowing backwards.
    

• Interventional treatment
  
  • Sclerotherapy involves the injection of a chemical product into the affected veins. The product irritates and scars the veins from inside out so they can no longer fill with blood and thus the blood returns to the heart through other veins. The veins that received the injection will eventually be absorbed by the body.
  • Ablation uses a thin flexible tube called a catheter that is inserted into the affected vein where tiny electrodes at the tip of the tube heat the walls and destroy the tissue of the vein. The treated vein will be absorbed by the body and the blood will flow upwards through other veins
  • Stripping necessitates a small incision in the groin area as well as in the ankle area. Then all the vein associated with the saphenous vein (the main superficial vein in the leg) are disconnected and removed
  • Laser treatment includes inserting a tiny fibre into the affected vein through a catheter. The energy emitted by the laser destroys the diseased section of the vein, followed by closure of the vein and eventual absorption by the body.

Any medical information on this website is not intended as a substitute for informed medical advice. No action should be taken before consulting with a healthcare professional.

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