What is venous insufficiency?

Understanding Venous Insufficiency

Venous insufficiency is a common chronic medical condition resulting from primary valvular incompetence or, less commonly, prior deep venous thrombosis (DVT) or extrinsic venous obstruction, causing symptoms ranging from cosmetic concerns to chronic discomfort, swelling, skin changes, and ulceration. 1

Definition and Prevalence

• Venous insufficiency occurs in approximately 9.4% of men and 6.6% of women, with over 11 million men and 22 million women aged 40-80 in the United States affected by varicose veins 1, 2
• Advanced chronic venous disease affects over 2 million adults in the United States 1
• Approximately 25% of the population has C2-C3 disease and 5% has C4-C6 disease according to the CEAP classification 1
• Chronic leg ulcers, mostly venous in origin, have a prevalence of nearly 1%, with treatment costs estimated at over $2.5 billion per year in the United States 1

Pathophysiology

• Venous insufficiency results from venous hypertension caused by:

  • Primary valvular incompetence (most common) 1
  • Prior deep venous thrombosis causing valve damage 1
  • Extrinsic venous obstruction 1
  • Muscle pump dysfunction 2

• The pathophysiologic mechanism involves:

  • Incompetent valves allowing blood to flow in the reverse direction (reflux) 1
  • Loss of elasticity in the vein wall causing failure of valve leaflets to fit together 1
  • Increased venous pressure leading to vein dilation, elongation, and tortuosity 1
  • Venous hypertension causing ambulatory pressure to remain high during walking 1
  • Inflammatory cascade triggered by venous hypertension leading to skin changes 3

Risk Factors

• Family history of venous disease 1
• Female sex 1, 4
• Older age 1, 4
• Obesity 1, 4
• Pregnancy and increased parity 1, 4
• Chronic constipation or conditions increasing intra-abdominal pressure 1
• Prolonged standing 1, 4
• History of deep venous thrombosis 1, 4

Clinical Presentation and Classification

• Symptoms vary widely and may include:

  • Pain, burning, itching, and tingling at varicose vein sites 1
  • Aching, heaviness, cramping, throbbing, and swelling in legs 1
  • Symptoms typically worsen by the end of the day or with prolonged standing 1
  • Symptoms improve with rest or limb elevation 1
  • Venous claudication (bursting leg pain during exercise) in cases of major venous obstruction 1

• Physical findings may include:

  • Varicose veins (dilated, tortuous subcutaneous veins ≥3mm in diameter) 1
  • Telangiectasias (intradermal veins <1mm) and reticular veins (subdermal veins 1-3mm) 1
  • Edema 1
  • Skin changes: hyperpigmentation, eczema, lipodermatosclerosis 1
  • Venous ulceration in severe cases 1

• CEAP Classification System (widely used for standardized assessment):

  • Clinical severity (C0-C6)
  • Etiology (congenital, primary, secondary)
  • Anatomical distribution (superficial, deep, perforator veins)
  • Pathophysiological dysfunction (reflux, obstruction) 1

Diagnosis

• Diagnosis is primarily clinical based on characteristic symptoms and signs 1

• Venous duplex ultrasonography is the modality of choice when:

  • Venous disease is severe 1
  • Interventional therapy is being considered 1
  • Documentation of valvular reflux is needed 1

• Other diagnostic modalities that may be considered in specific situations:

  • Catheter venography for evaluating proximal occlusions or stenosis 1
  • CT venography for detailed anatomic characterization prior to interventions 1

Treatment Options

Conservative Management

• Compression therapy is the mainstay of treatment:

  • Compression stockings can provide symptomatic relief 1, 5
  • Compression reduces venous hypertension and inhibits inflammatory processes 5
  • First-line treatment in pregnant women 1

• Lifestyle modifications:

  • Elevation of affected legs 1
  • Avoidance of prolonged standing 1
  • Weight loss in obese patients 1
  • Exercise programs (though evidence is limited) 2

• Pharmacologic options:

  • Horse chestnut seed extract may provide symptomatic relief 1, 5
  • Flavonoid supplements may improve venous function but have limited FDA approval in the US 2, 5
  • Diosmiplex (flavonoid medical food) is FDA-approved for CVI management 2

Interventional Treatments

• Referral for interventional treatment should not be delayed for a trial of external compression if valvular reflux is documented 1

• Treatment options include:

  • Endovenous thermal ablation (laser or radiofrequency) 1, 5
  • Chemical sclerotherapy 1, 5
  • Surgical removal (stripping) of the great saphenous vein 1, 6
  • Subfascial endoscopic perforator surgery (SEPS) for incompetent perforator veins 6

• Endovascular laser ablation may be better tolerated than sclerotherapy and surgery, with fewer adverse effects and equal effectiveness 1

Complications and Prognosis

• If untreated, venous insufficiency can progress to:

  • Persistent edema 1
  • Skin changes including lipodermatosclerosis 1
  • Venous ulceration (occurring in approximately 1% of the population) 1
  • Reduced quality of life comparable to chronic conditions like osteoarthritis and chronic lung disease 1

• Recurrence rates after interventions range from 15-35% at 2 years post-treatment 1

• Proper treatment can significantly improve symptoms and quality of life, even in advanced disease 4

Special Considerations

• Post-thrombotic syndrome (PTS) is a form of secondary venous insufficiency following DVT, with similar symptoms and management approaches 1

• Venous ulcers are often recurrent, contributing to the high healthcare costs associated with advanced venous disease 1

• Understanding venous anatomy through appropriate imaging can help reduce recurrence rates and complications after interventions 1