Chronic Venous Insufficiency, or CVI, is a condition where the veins in the legs are not able to adequately return blood from the tissues back to the heart. The reason the legs tend to be affected by vein problems the most often, is because gravity pulls more forcefully on them, compared to the arms or other parts of the body.
The veins that run deep with the muscles are called deep veins. These are the veins that do a lot of the work to bring blood back to the heart. Walking and exercising helps squeeze the deep veins to flow against gravity. There’s a second set of veins called superficial veins that run under the skin. These veins have one-way valves that are supposed to work against gravity. If those valves become leaky, then gravity causes backward flow and higher pressure inside the veins. This causes the veins to enlarge on the skin – often called varicose and spider veins. Additionally, these veins work against the normal direction of blood flow, and this negatively affects the health of the tissues. This causes symptoms that interfere with a person’s normal activities, and we call this condition Chronic Venous Insufficiency (CVI).
Signs and Symptoms of Chronic Venous Insufficiency
The earliest stage of chronic venous insufficiency is called spider veins. Spider veins can be caused by actual venous insufficiency, but they can also appear under the exposure of estrogen. Because of this, women tend to develop spider veins more often than men, but the presence of spider veins alone does not necessarily indicate chronic venous insufficiency.
Even though spider veins are a form of chronic venous insufficiency, it doesn’t necessarily mean that you will require treatment. Those who can maintain good overall health will rarely develop significant symptoms
Varicose veins are a more severe form of CVI, because they reflect a greater amount of backward flow and pressure inside the veins. Varicose veins can be felt as bulging and twisting veins under the skin in the legs. Varicose veins do not always cause pain or other symptoms, but when you do start to notice changes in your legs that impact your daily life, it is important to seek treatment. Rarely, varicose veins can bleed at the skin or can become firm and painful due to blood clots. Both of these are indications for an ultrasound exam and vein treatment.
Leg symptoms from chronic venous insufficiency can include:
These symptoms will tend to get worse after long periods of standing or sitting, or later in the day after gravity has had more effect on the blood in your legs. If you are experiencing swelling, it tends to go away or improve greatly in the morning after first waking up, and much worse before going to bed at night. This is a classic sign of CVI, with symptoms presenting in this pattern. With another condition like arthritis or another type of inflammation, there would be a much different symptom pattern that would require a different diagnosis and treatment method. Your physician will be able to determine the likelihood that your symptoms are from vein disease based on a careful history and examination.
We recommend the following to preserve the health of your vein valves and prevent CVI:
- Wear compression stockings
- Maintain healthy body weight
- Prevent or manage conditions like diabetes, high blood pressure, kidney disease, and high cholesterol
- Do not smoke
The greatest way to manage chronic venous insufficiency is to wear compression stockings, which can be obtained on the internet or a medical supply store without a prescription. We do recommend that you get fitted for compression stockings to ensure that they are doing the most to help your CVI. If you are standing or sitting for long periods of time for work or during your daily activities, wearing compression stockings could help delay the onset of CVI. This is because the stockings push blood out of the superficial veins and relieve stress on the valves. Many people have a strong family history of CVI and their valves will eventually become leaky even with these preventative measures.
The other main part of preventing this condition is to maintain overall good health, which is beneficial to cardiovascular health. Healthy body weight plays a large role in this, because being overweight will put more pressure on your veins and will eventually damage the valves. Exercise can help to prevent CVI because calf muscles are helping to push blood out of the legs and back to the heart, working against gravity for proper vein function and reducing the stress on the valves.
The typical treatment plan for CVI includes:
- Endovenous Laser Therapy (EVLT)
All patients with suspected CVI will undergo an ultrasound exam to map out the veins with leaky valves and ensure that the deep veins are healthy and flowing normally. Most patients will then be required by their insurance company to perform a trial with compression stockings. This can last anywhere from six weeks to three months, based on the insurance company’s policies. After the compression stocking trial is completed, we will have a good idea of how you will do with the treatment. The purpose of compression stockings is to hold and compress the superficial veins in your legs and take the pressure off the valves. If you can tolerate and respond well to compression stockings, there is a great chance that you will have symptom relief by undergoing procedures to close the diseased veins permanently.
Endovenous Laser Therapy (EVLT) is a procedure used to close the large veins that are the greatest cause of CVI symptoms. In most cases this includes the greater saphenous vein (GSV) and sometimes the small saphenous vein (SSV). These veins are the “freeways” that are connected to the deep vein system and carry the blood. They are the major source of the problem, so EVLT always comes first during our treatment plan. Most patients experience marked improvement in their symptoms after the first treatment.
After closing the major veins using EVLT, we will close the smaller tributary veins using injections called Sclerotherapy. The injection is a foam soap-like chemical that irritates and closes the veins directly. Injections are performed under ultrasound guidance for tributaries coming off the greater and small saphenous veins. Visually guided injections can be performed afterwards to target the remaining spider vein on the skin.
We are often asked if there is pain during these procedures or during the recovery period. During the procedures, there are a few small pinches from the medicine we use to numb the area. The procedures do not require sedation, and you are able to resume your daily activities immediately. In the days following the procedure, there may be some soreness or tenderness to touch along the vein that we treated, but there should not be any pain that limits your daily activities. In fact we encourage people to walk regularly after each treatment in order to promote blood flow in the healthy veins.
Typical Outcomes After Treatment
Patient’s can expect to achieve relief of their daily symptoms and for varicose veins to disappear. Most of the spider veins will disappear as well but may require visually guided injections. Sometimes foot and ankle swelling persists after treatment, and there are various methods to help clear the fluid depending on other underlying medical conditions. In many cases a specialized massage boot can be used to clear fluid through the lymphatic system, which has become overburdened with years of CVI. Patients may also achieve reduction in swelling by taking diuretic medications or “water pills”, especially those with heart, liver or kidney disease.
The Vascular Institute of Virginia provides non-surgical treatments for chronic venous insufficiency, including spider veins and varicose veins. We have two outpatient medical centers located in Fredericksburg, VA and Woodbridge, VA. Please call our office at 703-763-5224 to schedule a consultation.