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Chronic Venous Insufficiency
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CVI is a long-term problem in which one-way valves in the leg veins stop working properly, letting blood slip backwards and pool in your legs. Vein disease is common, though the advanced stages are less so. The main symptoms are heavy, aching legs and swelling that are worse after standing, and skin changes or leg ulcers can follow. Compression stockings may help most people, once a trained clinician has checked the blood supply to your legs. Warning signs are listed in the 'When to see a podiatrist' section.
What is it?
Chronic venous insufficiency (CVI) is a long-term condition of the leg veins. Inside these veins are valves, which are one-way flaps. Normally they keep blood moving up towards your heart. In CVI the valves or vein walls are weak or damaged, so the valves no longer stop blood flowing backwards. Blood collects in your legs instead.
It is sometimes called chronic venous disease. CVI is the more advanced end of vein disease. It means the problem has caused swelling (also called oedema, a build-up of fluid), skin changes or open sores called venous leg ulcers. Over time it can bring heaviness and discomfort in the legs.
Who does it affect?
Advanced vein disease is much less common than mild disease. On the CEAP scale (C0 to C6, how advanced vein disease is), about 8 per cent have swelling (C3), 4 per cent skin changes (C4), 1 per cent a healed ulcer (C5) and 0.42 per cent an open ulcer (C6). These figures are for vein disease overall, not only CVI.
Venous leg ulcers affect an estimated 0.32 per cent of people and are the most common long-lasting lower leg wound.
Vein disease is more likely if you are a woman, older, carrying extra weight or on your feet for long periods. Family history, past pregnancies and Caucasian ethnicity are linked.
Signs and symptoms
Typical symptoms include heavy, aching or cramping legs, swelling, itching and throbbing. Many people also notice throbbing, itching and swelling in the lower legs. Some feel a dull pain, burning, tired legs or restless legs. In older adults, heaviness and aching or cramping pain may affect about half of people with the condition.
The discomfort is usually worse after standing for a long time. It generally eases when you raise your legs.
The skin can change too. It may turn brown and get thicker. Some people get venous eczema (also called varicose eczema), which describes skin changes caused by the vein problem, such as the skin turning brown and getting thicker. You may also see swollen, widened veins (varicose veins) on your legs.
In more advanced cases the skin can break down and form an open sore (a venous leg ulcer) on the lower leg.
What causes it?
Your calf muscles work like a pump. Pressure stays high instead of dropping when you move. This is a major reason skin can break down and form an ulcer.
Valves can weaken with age, and blood then pools in the lower legs. They can also be damaged by a past blood clot (deep vein thrombosis), inflamed veins, a leg injury, arthritis, extra weight or pregnancy.
A poorly working pump is a key part of CVI and causes venous leg ulcers. Sitting a lot, long standing, muscle, tendon, nerve or joint problems, and extra weight can weaken it. A weak pump goes with slower healing and larger ulcers.
How is it diagnosed?
Your podiatrist will ask about your symptoms, including whether your legs feel worse after standing and better when raised. They will look at both legs for swelling, varicose veins, changes in skin colour or texture, and ulcers.
They will place your legs on the CEAP scale. CVI means a class of C3 or higher. They may also use the Venous Clinical Severity Score, which grades severity and shows how well treatment is working.
They will also feel the pulses in your foot and ankle and measure the ABPI (ankle-brachial pressure index, a blood pressure check at the ankle). Stockings squeeze the leg, which can be harmful if the blood supply is poor, so this check comes before any compression. With a leg ulcer, a reading above 0.8 generally rules out a significant artery problem.
Treatment
Compression is the usual first treatment. Stockings or bandages squeeze your leg to help your calf muscle pump.
Looking after it at home
Walk regularly, move your calves, and take breaks from long standing or sitting. It isn't yet clear if this prevents CVI.
Take stockings off at the end of the day. Wash and dry them, check your skin, and make sure they fit with no bunching.
Stop and take them off if pain, numbness or toe colour change gets worse. If a vein bleeds, raise your leg and press firmly. For a new wound, or one not improving, see the 'When to see a podiatrist' section.
Treatment from your podiatrist
Stockings are often the first step, and most people improve without much discomfort. The usual pressure is 30 to 40 mmHg at the ankle when there is no artery disease.
Your podiatrist checks your pulses and ABPI first, because stockings may worsen artery disease. Compression is generally safe with no signs of artery disease and an ABPI of 0.8 to 1.3. Bandages are avoided if the ABPI is below 0.5.
Stockings aren't suitable with suspected or proven artery disease, dermatitis, gangrene, a recent skin graft, an acute leg or foot infection or suspected skin cancer. They may not be suitable, or may need extra care, with nerve damage in the feet (neuropathy) or fragile skin. It isn't clear whether they should be avoided with a suspected acute leg clot (DVT). Your podiatrist will check the fit, show you how to wear them, and seek advice if unsure.
Other options
If the best compression can't be used, or the ulcer isn't healing despite it, a muscle pump activator (a way to boost the calf pump) can be added. Your podiatrist will review the ulcer regularly and, if it isn't healing, re-check the diagnosis and blood supply.
They may refer you after 12 weeks without healing, or sooner for an ABPI below 0.8 or above 1.3, an unusual ulcer pattern, or a skin problem or spot needing a closer look.
Recovery
CVI is a long-term condition, and in people with advanced CVI a poorly working calf muscle pump (the squeezing action of your calf muscles) is linked to a worse outlook. Compression stockings help most people, often without much discomfort. A poorly working pump goes with slower ulcer healing, larger ulcers and a worse outlook in people with advanced CVI. It isn't yet clear how often ulcers come back.
When to see a podiatrist
When to book
Book an appointment with your podiatrist if:
- your ulcer isn't getting smaller over several weeks of treatment
When to get help sooner
Call your local emergency number if:
- you have a foot wound, ulcer or infection and also feel very unwell, with confusion or slurred speech, severe shivering or muscle pain, severe breathlessness, mottled or discoloured skin, or little or no urine (possible sepsis)
- the skin over your infection turns dusky, purple or blistered, or the redness spreads very fast and the pain is much worse than the skin looks
- you suddenly become short of breath, have chest pain or cough up blood
- your leg or foot suddenly turns cold and pale, with pain or numbness, or you suddenly can't move it
- you have bleeding that won't stop when you press firmly on it
Get urgent medical assessment (see your GP today, or go to an urgent care clinic or the nearest emergency department) if:
- your calf or leg on one side becomes swollen and painful, especially if it is also warm or red
- redness from a wound, sore or infection is spreading into your foot or leg, or red streaks run up from it
- you have a foot wound, ulcer or infection, or a red, hot, swollen foot, and also have a fever, chills, a fast heartbeat or feel unwell
- your foot, or a patch of skin on your foot or leg, becomes red, hot, swollen and painful
- you have diabetes, poor circulation or reduced feeling in your feet and notice a new wound, sore, blister or colour change on your foot, or a sore that isn't healing
- you have constant pain in your foot or toes that is worse at night or when your legs are raised, and eases when you hang your leg down (this can be a sign of poor circulation)
- the skin on your toes or foot turns dark or black, or a wound turns black and smells bad: go straight away, without waiting for an appointment
- numbness or tingling in your foot or leg spreads quickly, or comes with new weakness
- a varicose vein on your leg has bled
See your GP soon if:
- a spot, mole or sore on the skin of your foot or leg is new, changing, bleeding or not healing
See your podiatrist or GP soon if:
- a wound or sore on your foot or leg hasn't started to heal after two weeks, or keeps coming back
Frequently asked questions
Are varicose veins the same as chronic venous insufficiency?
Not quite. Varicose veins are class C2 on the CEAP scale. CVI starts at C3 and runs to C6. It ranges from swelling and skin changes to healed and open leg ulcers.
Can I wear compression stockings if I have diabetes, poor circulation or heart failure?
It depends, so a trained professional checks first. With diabetes or nerve damage, extra caution is needed to protect your nerves. Heart failure alone doesn't rule stockings out, but they are advised against in severe heart failure and aren't routinely used in marked heart failure.
Does a past blood clot cause CVI?
It can. A past clot in a leg vein (deep vein thrombosis) is one of several things that can damage the valves. Leg injury, inflamed veins and pregnancy can too, so a clot isn't the only route.