For chronic venous insufficiency (CVI), what are possible treatments and which doctor should I see?

Doctor's Answers 1

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Dr Joel Foo

General Practitioner

To simplify medical terms, chronic venous insufficiency refers to a wide spectrum of longstanding problems with the veins (often confused with the arteries which are vessels that bring blood to the legs from the heart).

The insufficiency refers to a state of reflux whereby blood is stagnant within the vein as it fails to flow back up the legs towards the heart. This most commonly occurs in the lower limbs due to effect of gravity.

We may be most familiar with:

(i) spider/reticular veins in up to 80% of the population or even

(ii) varicose veins (abnormal permanently dilated subcutaneous veins) in 20-60% of the population.

These are often unsightly and cause issues with cosmesis so most women choose to wear stockings or Long skirts in order to hide the colour changes or bulging areas.

For purposes of discussion, it is important to know that there are two sets of venous drainage systems in our legs, Doctors call it the deep versus superficial venous system. I often use the analogy of two rivers flowing into a bigger sea. The deeper veins carry the majority of the blood from the legs back to the heart, but the reflux of the veins are more common in the superficial system since the deeper veins are surrounded by muscle that acts to squeeze the veins like a pump.

The risk factors for vein reflux include:

  • advanced age
  • family history of vein problems
  • prolonged standing
  • being overweight
  • smoking
  • prior blockage of the veins
  • and most commonly, pregnancy

All the above occurs when the venous wall and/or valves are not working effectively, making it difficult for blood to return back to the heart from the legs and causing blood to collect in this legs.

This is different from what Doctors consider as “blockage” in the blood vessels of the legs, which is a much more serious medical condition even though chronic venous insufficiency is a risk factor for deep vein thrombosis .

What is less known, however, is that chronic venous insufficiency has more advanced stages, which can have detrimental effects on our health if not treated.

In more advanced stages, patients suffer from swelling of the legs (typically worse in the night after a Long day of standing), discoloration of the skin (darkening) and at worst forms skin wounds and ulcers which are extremely difficult to heal.

It is however important to remember that NOT ALL ulcers in the legs are due to vein problems and you should seek your doctor who will then rule out other causes (e.g. problems with the artery, nerves or even skin cancers could cause ulcers).

The diagnosis as to the severity of the venous insufficiency is made based on clinical (history of typical symptoms such as leg pain, fatigue or heaviness along with examination findings of the above), and occasionally the doctor may order ultrasound of the veins to confirm reflux and the location of the reflux.

The correct specialties to approach depends on what stage of the disease a patient is suffering from.

The following are general health tips to improve circulation to your legs:

  • Exercise regularly, sports that strengthen your leg muscles

  • Elevate your legs whenever possible

  • Take a break from prolonged sitting – stand to walk every 30 minutes

  • Avoid soaking in hot baths for Long periods of time

  • Wearing compression stockings if you anticipate that your work requires Long periods of standing. The types and tightness of stockings prescribed depends on how tolerant a patient is to wearing the stockings. It would be ideal to wear the stockings from the moment you wake and stand till you are back home resting. Many people wear stockings at night when they are sleeping which makes the treatment less useful because the function of the stockings is to counter against the gravitational pull of the blood within the veins.

  1. To treat spider veins : these are generally asymptomatic and most of the treatment done would be cosmetic in nature to achieve unblemished skin in your legs. seek help from a dermatologist or a vascular surgeon. Options for treatment generally include injection sclerotherapy (small injections to obliterate the veins) or laser therapy to destroy the veins without affecting the skin

  2. Another common problem that venous insufficiencies tend to manifest would be in the form of stasis dermatitis (as above). These are ugly darkish -reddish spots that are typically itchy in the background of skins suffering from chronic venous insufficiencies. For this you should seek the review of a dermatologist who may then work with a vascular surgeon to treat the incompetent veins and the skin.

  3. To treat varicose veins : seek help from a vascular surgeon.
    Strategies to treat varicosities include newer techniques such as Endo venous laser therapy and radio frequency ablation. Depending on the site and expertise of the surgeon older techniques include stab avulsions and vein stripping maybe suggested.

  4. If you have more advanced stages of venous insufficiency such as venous ulcers, you should seek the referral of a vascular surgeon, who will work together with wound Nurses/podiatrists to apply special multiple layered compression bandages to aid healing of the ulcer.

The treatment of chronic venous insufficiencies takes time and multiple treatment sessions maybe required to diagnose and initiate treatment. I typically follow up my patients for years on end (reviews dependent on severity of disease) to ensure they have good lifestyle measures that do not worsen their venous insufficiencies.

For further queries, feel free to seek help from your nearby family clinics, and the doctors there should be able to advise you on the appropriate escalation to different specialists.

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