The following are key points to remember from a review on nonsurgical management of chronic venous insufficiency (CVI):

1. CVI comprises a constellation of symptoms and clinical manifestation, ranging from asymptomatic spider veins and varicose veins to leg ulcers. Varicose veins and CVI of the legs impact millions of people worldwide.
2. Beyond cosmetic issues, CVI increases the risk of venous thromboembolic events and is associated with substantial limitations in daily functioning and quality of life.
3. Risk factors for CVI include older age, female sex, obesity, pregnancy, prior deep vein thrombosis, and prolonged standing. There are also genetic markers that increase the risk of varicose veins.
4. Contraction of the foot and calf muscles initiates cephalad flow of blood and opens one-way valves within the lower extremity veins. These valves prevent retrograde flow when closed, encouraging blood flow from the feet back towards the heart. Venous valve dysfunction causes venous reflux, backflow of blood, and venous hypertension.
5. CVI is caused primarily by venous hypertension, which can result from structural or functional etiologies. Structurally, veins can reflux or be obstructed. Functionally, dependent edema, weak calf muscles, and obesity can contribute to venous hypertension.
6. The diagnosis of CVI is based on information obtained from a history and physical examination. Imaging tests are not required to make a diagnosis, but can be helpful to detect structural causes. Physical examination should be performed in the upright position to observe the effect of gravity and body weight.
7. Common clinical examination findings in CVI include hyperpigmentation (hemosiderin staining), scarred tissue (atrophie blanche), dilated reticular veins at the ankles and feet (corona phlebectatica), skin texture changes (lipodermatosclerosis), erythema, and skin breakdown (ulcers). Swelling is also a common finding. When swelling is seen on the dorsum of the foot and of the toes (Stemmer’s sign), this typically indicates lymphatic dysfunction.
8. Many medications are known to cause leg swelling. These include antiepileptics (e.g., gabapentin), antidepressants (e.g., escitalopram, paroxetine, venlafaxine), antipsychotics, antiparkinsonian (e.g., levodopa, carbidopa), antihypertensive (e.g., amlodipine, doxazosin, hydralazine), hormone therapies (e.g., estrogen, testosterone), glucocorticoids, nonsteroidal anti-inflammatory drugs (NSAIDs), chemotherapy, thiazolidinediones (e.g., pioglitazone, rosiglitazone), and proton-pump inhibitors.
9. The clinical, etiologic, anatomical, pathophysiological (CEAP) classification is useful for disease classification, while the Venous Clinical Severity Score (VCSS) is useful for assessing and documenting disease severity.
10. Treatment of CVI is focused on reducing a patient’s symptoms, which do not always correlate with findings on physical examination or imaging test.
11. Endovenous procedures and surgeries are effective treatment options for structural venous insufficiency. However, nonsurgical treatments are the mainstay of therapy for both structural and functional CVI.
12. Nonsurgical management of CVI includes reducing central venous hypertension, compression therapy, leg elevation, and exercises involving the calf and foot flexion/extension that provide a pump-function effect.
13. Obesity is an independent risk factor for CVI disease progression. Obstructive sleep apnea, diastolic dysfunction, and right heart failure all increase central venous pressure and lead to peripheral venous hypertension.
14. Diuretics should not be a first-line therapy for swelling and should only be used for volume overload.
15. Graduated compression therapy can considerably improve CVI symptoms, but there is little evidence that they are curative or slow disease progression. A compression level above 30 mm Hg is recommended for ulcer healing. Lower levels of compression (e.g., 20-30 mm Hg) are often used when patient compliance is a concern.

Clinical Topics: Vascular Medicine, Pulmonary Hypertension and Venous Thromboembolism

Keywords: Venous Insufficiency, Venous Thrombosis, Varicose Ulcer

< Back to Listings