Impaired venous return due to venous valve incompetence and/or venous obstruction
Aetiology
Pathophysiology
Valve Incompetence
- Failure of venous valves → reflux
Venous Hypertension
- Blood pools in lower limbs
- Increased hydrostatic pressure
Microcirculatory Changes
- Capillary leakage → edema
- RBC breakdown → hemosiderin deposition
- Inflammation → fibrosis
Tissue Damage
- Chronic hypoxia → skin changes and ulcers
Clinical presentation
CVI results from venous hypertension due to valve incompetence, leading to:
- Venous pooling
- Edema
- Skin and tissue changes over time
Symptom Profile (Patient Complaints)
Leg Heaviness & Aching Pain
- Dull, aching discomfort
- Worse with:
- Prolonged standing
- End of the day
- Relieved by:
- Leg elevation
- Walking
Itching (Pruritus)
- Due to stasis dermatitis
- May lead to scratching → skin breakdown
Swelling (Edema)
- Gradual onset
- Worse in evening
- Improves overnight
Physical Examination Findings
Edema
- Pitting edema (early)
- Becomes non-pitting with fibrosis (late)
Skin Changes
Hyperpigmentation
- Brown discoloration
- Due to hemosiderin deposition
Stasis Dermatitis
- Eczema-like:
- Redness
- Scaling
- Itching
Lipodermatosclerosis
- Fibrosis of subcutaneous tissue
- “Inverted champagne bottle” appearance:
- Narrow ankle
- Swollen calf
Varicose Veins
- Dilated, tortuous superficial veins
- Often visible and palpable
Venous Ulcers
- Location:
- Medial malleolus (most common)
- Appearance:
- Shallow
- Irregular margins
- Exudative (wet)
- Surrounding skin:
- Hyperpigmented
- Inflamed
CEAP Classification
Clinical Classification (C)
Class | Clinical Features |
C0 | No visible or palpable signs |
C1 | Telangiectasia / reticular veins |
C2 | Varicose veins |
C3 | Edema |
C4a | Pigmentation or eczema |
C4b | Lipodermatosclerosis or atrophie blanche |
C5 | Healed venous ulcer |
C6 | Active venous ulcer |
Etiologic Classification (E)
Code | Cause |
Ec | Congenital |
Ep | Primary (idiopathic) |
Es | Secondary (post-thrombotic, e.g., after DVT) |
En | No venous cause identified |
Anatomic Classification (A)
Code | Veins involved |
As | Superficial veins |
Ad | Deep veins |
Ap | Perforator veins |
An | No venous location identified |
Pathophysiologic Classification (P)
Code | Mechanism |
Pr | Reflux |
Po | Obstruction |
Pr,o | Both reflux and obstruction |
Pn | No identifiable mechanism |
Investigations
Imaging
CT / MR Venography
Indications:
- Suspected pelvic/iliac obstruction
- Complex or recurrent disease
Photoplethysmography
Assesses:
- Venous refill time
- Severity of reflux
Management
Core Principle
- Reduce venous hypertension
- Improve venous return
- Prevent complications (ulcers, infection)
First-Line: Conservative Management
Compression Therapy
- Graduated compression stockings (20–40 mmHg)
- Improves venous return and reduces edema
⚠️ Always check ABI to exclude Peripheral Arterial Disease before use
Lifestyle Modification
- Leg elevation (above heart level)
- Regular exercise (walking)
- Avoid prolonged standing/sitting
- Weight reduction
Skin Care
- Emollients (prevent dryness)
- Topical steroids (for stasis dermatitis)
Pharmacological Therapy
- Venoactive drugs (e.g., flavonoids) → limited benefit
- Analgesics if needed
Ulcer Management
- Compression bandaging (mainstay)
- Wound care:
- Cleaning
- Dressings
- Treat infection if present
Interventional Management
Indications
- Symptomatic varicose veins
- Refractory symptoms
- Non-healing ulcers
Options
- Endovenous Therapy (Preferred)
- Laser ablation
- Radiofrequency ablation
- Sclerotherapy
- Injection to obliterate veins
- Surgical
- Vein stripping or ligation
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