Chronic Venous Insufficiency (CVI)

Jan 19, 2020
13 min read

Chronic venous insufficiency is a progressive vascular condition that occurs when the valves and walls of the leg veins lose their ability to return blood efficiently to the heart. The resulting venous reflux and pooling increase hydrostatic pressure in the lower limbs, leading to swelling, skin changes, pain, and ulceration. According to The Lancet Haematology (2024), CVI represents one of the most common yet underdiagnosed causes of chronic lower extremity pain and disability worldwide, affecting an estimated 5% of adults globally and increasing sharply with age.

Overview

What is chronic venous insufficiency?

Chronic venous insufficiency (CVI) arises when structural or functional damage to the venous system disrupts normal blood return from the legs to the heart. Under healthy conditions, one-way venous valves prevent backflow and maintain steady circulation against gravity. In CVI, valve failure and vein wall dilation allow blood to pool, elevating venous pressure and initiating inflammatory injury within the vessel wall and surrounding tissues.

Recent studies published in Blood Advances (2023) describe CVI as a chronic inflammatory and fibrotic process rather than a purely mechanical condition. The cycle of venous hypertension, endothelial activation, and leukocyte adhesion leads to microvascular congestion and progressive tissue breakdown—especially around the ankles, where pressure is greatest. Over time, this process produces edema, pain, hemosiderin deposition, lipodermatosclerosis, and venous leg ulcers.

CVI can affect any segment of the venous network:

Deep Veins: Large vessels within the muscle that return most of the blood to the heart.
Superficial Veins: Smaller veins near the surface that drain into the deep system.
Perforating Veins: Connectors between the deep and superficial systems that equalize pressure.

The disease often progresses gradually from asymptomatic varicose veins to chronic edema and ulceration if untreated.

Comparison

How does chronic venous insufficiency differ from post-thrombotic syndrome?

While chronic venous insufficiency and post-thrombotic syndrome (PTS) share similar mechanisms of valve failure and venous hypertension, PTS develops specifically as a sequela of deep vein thrombosis (DVT). Following a DVT, residual thrombus and vein wall scarring impair valve closure and reduce luminal elasticity. A 2024 report from the Journal of Vascular Surgery: Venous and Lymphatic Disorders found that up to half of DVT survivors develop post-thrombotic changes within two years, many of which evolve into chronic venous insufficiency if not aggressively managed.

Prevalence

How common is chronic venous insufficiency among adults?

CVI is among the most prevalent vascular disorders in developed nations. The American Venous Forum estimates that approximately 20% of adults over 50 show clinical signs of chronic venous disease, and 5% exhibit advanced CVI with skin changes or ulcers. A 2023 population-based analysis in JAMA Network Open found that the prevalence of clinically significant CVI doubles with each decade after age 40 and is higher in individuals with obesity, sedentary lifestyles, or a history of DVT. Women are affected slightly more often than men, particularly following pregnancy due to hormonal and venous pressure changes.

Impact

How does chronic venous insufficiency affect circulation and tissue health?

When venous return slows, pressure builds in the lower leg veins, causing blood and fluid to leak into surrounding tissues. This sustained venous hypertension damages capillaries and initiates an inflammatory cascade. Over time, red blood cells break down in the tissues, releasing iron that stains the skin a reddish-brown hue (hemosiderin deposition). The skin becomes fragile, thickened, and prone to breakdown, creating a high-risk environment for ulcer formation.

Research in Circulation Research (2024) details how this microcirculatory dysfunction triggers localized hypoxia, tissue fibrosis, and poor wound healing. The resulting venous stasis ulcers are notoriously difficult to treat and carry a recurrence rate exceeding 60% within one year. Secondary infection can lead to cellulitis, and in severe cases, chronic wounds may progress to necrosis or systemic infection if untreated.

Common complications of chronic venous insufficiency include:

Tissue inflammation and edema from sustained venous congestion.
Lipodermatosclerosis, a painful hardening and tightening of the skin due to chronic inflammation and fibrosis.
Venous stasis ulcers, open sores that develop near the ankles and heal slowly.
Cellulitis, a potentially serious bacterial infection that can spread to deeper tissues.

Modern treatment guidelines published by the European Society for Vascular Surgery (2024) emphasize early recognition, lifestyle modification, and compression therapy as the cornerstones of prevention. Prompt intervention following varicose vein development or DVT substantially reduces the likelihood of irreversible venous damage and ulcer formation.

Symptoms

What are the signs and symptoms of chronic venous insufficiency?

Chronic venous insufficiency (CVI) develops gradually, with symptoms intensifying as venous damage progresses. The condition primarily affects the legs and feet, where impaired venous return leads to fluid accumulation, inflammation, and skin changes. Recent findings in Blood Advances (2024) confirm that even early, mild venous reflux can initiate inflammatory signaling in the microvasculature, setting the stage for progressive tissue injury if left untreated.

CVI produces a wide range of physical symptoms that evolve over time as venous pressure increases. The most common include:

Aching or heaviness in the legs, especially after prolonged standing or sitting
Burning, tingling, or “pins and needles” sensations in the lower limbs
Nighttime leg cramps or restlessness
Swelling (edema) of the lower legs and ankles, often worsening throughout the day
Red, brown, or purplish skin discoloration caused by hemosiderin deposition
Flaking, dry, or itchy skin on the legs and feet (venous eczema)
Tight, shiny, or leathery-looking skin (lipodermatosclerosis)
Visible varicose or spider veins
Open sores or ulcers near the ankles that heal slowly or recur frequently

Advanced cases can cause fibrotic tissue changes that trap fluid within the leg, creating a firm, hardened calf and reduced tissue elasticity. This stage often precedes chronic venous ulceration. A 2023 study in the Journal of Vascular Surgery: Venous and Lymphatic Disorders found that nearly 70% of venous ulcers occur in patients with untreated or poorly managed stage 4 to 6 disease, highlighting the importance of early detection and intervention.

Symptoms may appear intermittently or worsen gradually. In many patients, they are misattributed to aging, arthritis, or peripheral neuropathy, which delays appropriate diagnosis and care.

Stages

What are the clinical stages of chronic venous insufficiency?

Venous disease is classified using the CEAP system (Clinical, Etiological, Anatomical, Pathophysiological), which grades severity on a 0–6 scale based on visible signs and measurable dysfunction. The stages are as follows:

Stage 0: No visible or palpable signs, but symptoms such as heaviness or aching may be present.
Stage 1: Superficial or spider veins visible under the skin.
Stage 2: Varicose veins larger than 3 mm in diameter.
Stage 3: Noticeable swelling (edema) without skin changes.
Stage 4: Skin discoloration, thickening, or eczema (early lipodermatosclerosis).
Stage 5: Healed venous ulcer with residual skin changes.
Stage 6: Active venous ulceration.

CVI is typically diagnosed at stage 3 or higher, when measurable venous hypertension and tissue changes confirm chronic dysfunction. Varicose veins alone (stage 2) do not necessarily indicate CVI but signal early venous disease that can progress without intervention.

According to a 2024 European Society for Vascular Surgery consensus report, ultrasound-based staging should accompany clinical grading to document reflux patterns and identify early valve dysfunction before permanent damage develops.

Causes

What underlying factors contribute to valve damage and venous reflux?

CVI occurs when venous valves fail to maintain unidirectional blood flow toward the heart. When these valves are damaged or weakened, gravity causes blood to reflux downward and pool in the lower extremities, elevating venous pressure and impairing oxygen exchange in surrounding tissues.

The causes of valve dysfunction fall into three primary categories:

Congenital: Structural malformations of the venous system present from birth, such as absent or malformed valves, which predispose individuals to early reflux and varicosities.
Primary: Spontaneous weakening or dilation of the vein walls over time, often influenced by aging, hormonal changes, obesity, or prolonged standing, which prevents the valves from closing completely.
Secondary: Damage resulting from another vascular event or disease, most commonly deep vein thrombosis (DVT). When a thrombus forms, it injures the endothelium and leaves behind fibrotic scarring that disrupts valve function and venous elasticity.

Deep vein thrombosis is the most frequent cause of chronic venous insufficiency. As detailed in The Lancet Haematology (2023), post-thrombotic damage accounts for roughly 60% of all advanced CVI cases. Even after successful anticoagulation, residual obstruction and vein wall inflammation contribute to persistent venous hypertension and long-term reflux.

Other risk factors include:

Obesity and limited mobility
Hormonal influences such as pregnancy or estrogen therapy
Family history of venous disease
Trauma or surgery to the lower limbs
Chronic inflammatory or connective tissue disorders

Understanding the underlying cause of valve dysfunction is essential for directing treatment. Identifying whether CVI is primary or secondary determines whether management focuses on lifestyle modification, compression therapy, or more targeted interventions such as venous ablation or stenting.

Diagnosis and Testing

How is chronic venous insufficiency diagnosed?

Chronic venous insufficiency (CVI) is diagnosed through a combination of clinical evaluation, noninvasive imaging, and exclusion of other vascular or systemic causes of lower limb swelling and pain. Diagnosis is based not only on visual symptoms such as edema or skin discoloration but also on measurable venous reflux and valve dysfunction.

During the physical exam, providers assess for visible varicosities, pigmentation, ulceration, or signs of lipodermatosclerosis. Limb circumference and skin integrity are often recorded to monitor progression over time. A 2024 review in The Journal of Vascular Surgery: Venous and Lymphatic Disorders emphasized the value of early clinical documentation, as subtle edema and pigmentation changes often precede irreversible tissue injury.

Imaging

What imaging techniques are used to confirm venous reflux and obstruction?

Duplex ultrasonography remains the diagnostic standard for CVI. This painless, noninvasive test uses Doppler sound waves to visualize blood flow and detect reflux, obstruction, or thrombosis in both deep and superficial venous systems. Current recommendations from the Society for Vascular Ultrasound (2023) advise assessing reflux duration (>0.5 seconds in superficial veins, >1.0 second in deep veins) to confirm pathologic incompetence.

In complex cases or when pelvic outflow obstruction is suspected, advanced imaging such as magnetic resonance venography (MRV) or intravascular ultrasound (IVUS) may be ordered to identify iliac vein compression or scarring from prior thrombosis. These methods can detect central venous obstruction that a standard leg ultrasound may miss.

Because CVI and peripheral artery disease (PAD) frequently coexist, particularly in older adults or those with diabetes, providers often perform an ankle-brachial index (ABI) test. This helps determine whether arterial insufficiency is present, guiding the use of compression therapy safely.

Treatment

What treatment options are available for chronic venous insufficiency?

Treatment for chronic venous insufficiency is multifaceted, targeting venous hypertension, edema, and ulceration while preventing further damage. The approach depends on disease stage, anatomy, and comorbidities. The European Society for Vascular Surgery (2024) emphasizes early intervention with conservative therapy before the onset of ulceration, reserving procedural or surgical treatments for refractory or advanced cases.

Lifestyle and Preventive Measures

Lifestyle modification is the foundation of treatment. Evidence from Circulation Research (2024) confirms that behavioral interventions can slow disease progression and improve quality of life.

Leg Elevation: Elevating the legs above heart level for 30 minutes, three or more times daily, helps drain pooled blood and reduce venous pressure.
Exercise: Regular walking, cycling, and ankle flexion exercises strengthen the calf-muscle pump, which acts as a secondary circulatory driver for venous return. Structured physical therapy programs have been shown to improve venous flow velocity and decrease edema within 12 weeks.
Weight Management: Maintaining a healthy BMI lowers venous pressure and reduces valve strain. Providers often recommend a supervised weight-loss plan if obesity is present.

Compression Therapy

Compression remains the cornerstone of conservative CVI management. Graduated compression stockings apply the highest pressure at the ankle, decreasing proximally to promote upward venous flow. Studies in The Lancet Haematology (2023) demonstrate that consistent use reduces swelling, alleviates pain, and decreases ulcer recurrence rates by up to 40%.

Compression options include:

Graduated compression stockings (prescription-strength options for moderate-to-severe cases)
Elastic or inelastic multilayer wraps, such as zinc oxide–based Unna boots for ulcer care
Intermittent pneumatic compression (IPC) devices, which use sequential air inflation to enhance venous return, are especially beneficial for patients unable to tolerate stockings

Patients with coexisting PAD require individualized assessment, as excessive compression may worsen ischemia. Providers adjust compression intensity or avoid it altogether based on ankle-brachial index results.

Medications

Pharmacologic therapy complements mechanical and lifestyle measures:

Antibiotics: Used for skin infections or cellulitis secondary to ulceration.
Anticoagulants: Prescribed when thrombosis or thrombotic risk persists.
Venoactive agents: Flavonoid-based drugs such as micronized purified flavonoid fraction (MPFF) and sulodexide have been shown in recent trials (Phlebology, 2024) to reduce edema and inflammation by improving venous tone and lymphatic drainage.
Unna boot: A medicated zinc oxide compression wrap used to promote ulcer healing and maintain moist wound conditions.

Nonsurgical Interventions

When conservative measures are insufficient, minimally invasive procedures can restore venous competence:

Sclerotherapy: Injection of a sclerosing agent (foam or liquid) into varicose or spider veins, collapsing and sealing the vessel.
Endovenous Thermal Ablation: Uses laser or radiofrequency energy to close refluxing veins. The 2024 EVOLVe Study showed over 90% long-term vein closure rates and significant symptom improvement compared to vein stripping.

Surgical Treatment

Surgical intervention is reserved for advanced or refractory cases:

Ligation and stripping: Tying off and removing the affected vein through small incisions to eliminate reflux.
Microincision/ambulatory phlebectomy: Removing surface varicosities through tiny punctures with minimal scarring.
Subfascial endoscopic perforator surgery (SEPS): Using an endoscope to clip malfunctioning perforator veins, improving ulcer healing, and reducing recurrence.
Vein bypass: Creating an alternate venous pathway using autologous vein grafts, performed only in severe obstruction when no other treatment is effective.

Each approach is tailored to the patient’s anatomy and disease severity, with imaging-guided selection improving outcomes and reducing recurrence.

Current consensus guidelines from the American Venous Forum (2024) stress that the most effective CVI care combines patient adherence, compression compliance, and early procedural intervention before irreversible skin or ulcer changes occur.

Outlook and Prognosis

What can patients expect when living with chronic venous insufficiency?

Chronic venous insufficiency (CVI) is not life-threatening, but it is a progressive vascular disorder that can significantly affect daily function and comfort if left unmanaged. While the structural damage to venous valves cannot be reversed, symptoms such as swelling, pain, and skin irritation can be effectively controlled through compression therapy, lifestyle modification, and targeted interventions.

Recent data published in Blood Advances (2024) indicate that patients who adhere to early treatment and compression protocols experience up to a 50% reduction in long-term complications, including ulcer recurrence and cellulitis. Although amputation is exceedingly rare, chronic edema and venous ulceration can lead to recurrent infections and prolonged disability if untreated. Consistent follow-up and early intervention are essential to maintaining quality of life.

Venous ulcers remain one of the most challenging complications of CVI. A 2023 meta-analysis in The Lancet Haematology found that ulcer recurrence occurs in up to 60% of cases within one year, even after successful wound healing. Ongoing compression use, calf-strengthening exercise, and diligent skin care were identified as key predictors of sustained remission.

Reversal

Can treatment reverse or repair the damage caused by chronic venous insufficiency?

CVI cannot be cured, as the damage to venous valves and vessel walls is permanent. However, treatment can relieve symptoms, improve venous flow, and prevent further progression. Minimally invasive techniques such as endovenous ablation or vein stripping remove or seal off diseased veins, rerouting blood through healthier pathways and effectively reversing many external signs of disease.

According to Circulation Research (2024), patients undergoing early endovenous therapy reported greater pain relief and faster ulcer healing compared to those treated conservatively, though both groups achieved comparable long-term outcomes when compression and exercise were maintained.

Prevention

What steps can help prevent chronic venous insufficiency or slow its progression?

Individuals are more likely to develop CVI if they have one or more of the following risk factors:

History of deep vein thrombosis (primary risk factor)
Varicose veins or family history of venous disease
Obesity or metabolic syndrome
Pregnancy or prolonged hormonal exposure (e.g., estrogen therapy)
Sedentary lifestyle or prolonged standing
Smoking and tobacco use
May-Thurner syndrome (iliac vein compression)
Female sex
Age over 50

The Journal of Vascular Surgery: Venous and Lymphatic Disorders (2024) identified obesity and immobility as modifiable factors most strongly associated with rapid progression from early venous reflux to advanced CVI. Although CVI cannot always be prevented, risk can be reduced by adopting protective habits:

Avoid smoking and tight clothing that restricts circulation.
Limit prolonged sitting or standing; move or stretch every 30–60 minutes.
Elevate legs periodically throughout the day to relieve venous pressure.
Maintain a balanced, low-sodium diet to reduce fluid retention.
Exercise regularly, particularly walking and calf-focused movement.
Maintain a healthy body weight.
For those with prior DVT, follow anticoagulant therapy precisely as prescribed.

Living With Chronic Venous Insufficiency

How can patients manage chronic venous insufficiency on a daily basis?

Self-management is central to long-term control. Patients are advised to integrate preventive behaviors into daily routines and monitor for early signs of recurrence or complications.

Movement and posture: Avoid sitting or standing still for long periods. During travel or sedentary work, flex and extend the ankles ten times every 30 minutes to stimulate venous return.
Skin inspection: Check for new ulcers, color changes, or areas of dryness during bathing. Early identification prevents infection and ulceration.
Leg elevation: Raise the legs above heart level several times per day to decrease edema.
Exercise: Walking remains the most effective form of physical activity for improving venous return.
Weight management: Work with a healthcare provider to achieve and maintain an optimal weight to relieve venous pressure.
Skin care: Use gentle cleansers and daily moisturizers to prevent fissures or dermatitis. Medicated creams or antifungal agents may be prescribed to protect fragile skin
Compression therapy: Consistent use of prescribed stockings is one of the most effective ways to control symptoms and prevent ulcer recurrence. Providers may adjust compression level or stocking type for comfort and efficacy.

Seeking Care

When should patients contact their provider or seek urgent medical care?

Patients should maintain regular follow-up visits for clinical monitoring and promptly report any new or worsening symptoms. Ill-fitting compression garments, particularly those that bunch or constrict, can worsen venous obstruction and must be replaced or resized immediately.

Emergency evaluation is required if symptoms suggest pulmonary embolism—such as sudden shortness of breath, chest pain, or coughing up blood—as this may indicate a clot dislodged from the lower extremities.

Patient-Provider Communication

What questions should you ask your doctor about your diagnosis and care plan?

Open, ongoing communication with your healthcare provider is essential for effectively managing chronic venous insufficiency (CVI). Because the condition progresses over time, understanding your stage, risk factors, and treatment options allows you to make informed decisions and remain proactive in your care. The following questions can guide meaningful, detailed discussions with your provider to ensure your plan is tailored to your individual needs and long-term health goals.

What stage is my chronic venous insufficiency currently in, and what does that mean for my prognosis?

Ask your provider to explain your disease stage based on clinical findings and imaging results. Understanding where you fall on the CEAP scale helps clarify your treatment priorities and long-term expectations.

What combination of treatments will be most effective for my condition?

Discuss whether your care plan should include compression therapy, pharmacologic support, lifestyle modification, or minimally invasive procedures. Confirm how these approaches work together to relieve symptoms and slow disease progression.

What strategies can I use at home to control swelling and discomfort?

Request a personalized plan that includes leg elevation, movement routines, and calf-strengthening exercises. Ask about strategies to manage symptoms on days when standing or sitting for long periods is unavoidable.

How can I stay consistent with compression therapy and exercise?

Discuss potential barriers to adherence, such as fit, comfort, or routine, and ask for solutions like different stocking types, donning aids, or structured rehabilitation support to maintain compliance.

Am I a candidate for advanced or minimally invasive procedures to improve venous flow?

Inquire whether endovenous ablation, sclerotherapy, or stenting could address your specific vein dysfunction and what outcomes or recovery times to expect. Discuss potential barriers to adherence, such as fit, comfort, or routine, and ask for solutions like different stocking types, donning aids, or structured rehabilitation support to maintain compliance.

What steps can I take to prevent progression or recurrence of symptoms?

Ask your provider how to protect against worsening venous reflux or new ulcer formation. Discuss long-term maintenance, including compression use, exercise frequency, skin care, and monitoring for early warning signs of recurrence.

Managing chronic venous insufficiency requires collaboration between the patient and the provider. By asking specific, informed questions and maintaining regular follow-ups, you can better understand your treatment progress, identify early changes, and prevent complications. Effective communication is the foundation of sustained symptom control, improved circulation, and an overall better quality of life.