Chronic Venous Insufficiency

Chronic venous insufficiency is the clinical result of sustained venous hypertension in the lower limbs caused by valvular incompetence, outflow obstruction or calf muscle pump failure. It is common, affects up to one in three adults to some degree, and ranges from cosmetic varicosities to painful venous leg ulceration.

• Risk factors: age, female sex, pregnancy and multiparity, obesity, prolonged standing, family history, previous deep vein thrombosis (post-thrombotic syndrome), leg injury, sedentary lifestyle.
• Staging uses the CEAP classification: C0 no signs; C1 telangiectasia or reticular veins; C2 varicose veins; C3 oedema; C4 skin changes (pigmentation, eczema, lipodermatosclerosis, atrophie blanche); C5 healed ulcer; C6 active ulcer.
• Complications: venous eczema, cellulitis, bleeding from varicosities, superficial thrombophlebitis, deep vein thrombosis, ulcer, and malignant transformation in chronic ulcers (rare).

• Heaviness, aching, throbbing or cramping in the legs, worse at the end of the day and with standing, relieved by elevation and walking.
• Itching, restless legs, nocturnal cramps, swelling around the ankles.
• Visible varicose veins, telangiectasia, corona phlebectatica (ankle flare).
• Skin changes: haemosiderin pigmentation (brown staining), venous eczema, lipodermatosclerosis (hard, tapered "inverted champagne bottle" leg), atrophie blanche.
• Venous ulcers: shallow, irregular, usually near the medial malleolus, with a sloughy base and moderate to heavy exudate, surrounding eczema and warm, pitting oedema.
• Red flags: sudden unilateral swelling (deep vein thrombosis), cellulitis, rapidly enlarging or atypical ulcer (biopsy to exclude malignancy), absent foot pulses, pain out of proportion, signs of arterial disease.

• Clinical assessment of limbs standing, with CEAP grade.
• Measure ankle brachial pressure index before compression: values of 0.8 to 1.3 are suitable for full compression, 0.5 to 0.8 mean reduced compression only under specialist advice, below 0.5 contraindicates compression.
• Duplex ultrasound of the venous system (standing or reverse Trendelenburg) is the key investigation to confirm reflux (retrograde flow more than 0.5 seconds in superficial veins, over 1 second in femoral and popliteal veins) and exclude obstruction or thrombus.
• Bloods when atypical: full blood count, glucose or HbA1c, albumin, renal and liver function, thyroid function, urine protein.
• Swab only if clinical infection.
• Biopsy of non-healing ulcers over 3 months.
• Differentials: heart failure, nephrotic syndrome, lymphoedema, lipoedema, drug induced oedema (amlodipine, pregabalin, steroids), cellulitis, deep vein thrombosis, arterial ulcer, pressure ulcer, diabetic foot ulcer.

Conservative measures (all patients)

• Compression hosiery: class 1 (14 to 17 mmHg) for mild symptoms, class 2 (18 to 24 mmHg) for varicose veins with oedema or after treatment, class 3 (25 to 35 mmHg) for severe oedema, skin changes or healed ulcer. Fit in the morning, remove at bedtime, replace every 3 to 6 months.
• Elevation of legs above heart level for 30 minutes three to four times daily.
• Weight reduction, regular walking and calf exercises, avoiding prolonged standing or sitting.
• Skin care: emollients (for example liquid paraffin 50 percent with white soft paraffin 50 percent ointment, or aqueous cream substitute) twice daily; avoid sensitisers such as lanolin and topical antibiotics.
• Venous eczema: moderately potent topical corticosteroid (betamethasone valerate 0.1 percent ointment once or twice daily for up to 2 weeks).

Venous leg ulcer

• Debride loose slough, use non-adherent dressings (for example simple low adherent dressing with absorbent pad) with multilayer compression bandaging (35 to 40 mmHg at ankle) once ABPI is acceptable. Change one to two times weekly.
• Oral antibiotics only if infection is present (flucloxacillin 500 mg to 1 g orally four times daily for 5 to 7 days; clarithromycin 500 mg twice daily if penicillin allergic).
• Analgesia: paracetamol 1 g orally every 6 hours (maximum 4 g daily); avoid topical anaesthetics and NSAIDs where renal or cardiac risk.
• Oral pentoxifylline 400 mg three times daily for 6 months as an adjunct in resistant ulcers (specialist; caution with bleeding risk).
• Refer for vein intervention at the time of ulcer diagnosis, because early endovenous ablation of reflux improves healing and lowers recurrence.

Interventional treatment (vascular specialist)

• Endovenous thermal ablation (radiofrequency or laser), ultrasound guided foam sclerotherapy, cyanoacrylate closure, or surgical ligation and stripping for symptomatic varicose veins, skin changes or ulcers.
• Compression for 1 to 2 weeks after treatment.

Medicines for symptoms

• Micronised purified flavonoid fraction (diosmin 450 mg with hesperidin 50 mg) 1000 mg orally daily may reduce oedema and heaviness, in settings where available.
• Diuretics are not appropriate for venous oedema.

Special groups

• Pregnancy: compression and elevation; avoid sclerotherapy until after delivery and breastfeeding.
• Diabetes or arterial disease: compression only after specialist vascular assessment.
• Older adults and mobility impairment: community tissue viability or leg ulcer clinic support.

Follow up and referral

• Urgent referral for suspected deep vein thrombosis, cellulitis not improving within 48 hours, ulcer with malignant features, or bleeding varicose vein (apply direct pressure with leg elevated).
• Routine vascular referral for symptomatic varicose veins, skin changes, active or healed ulcer, or ulcer not healing in 2 weeks.