Chronic Venous Insufficiency

CVI Intro & Pathophysiology - Vein Valve Vexations

• CVI: Syndrome of chronic impaired venous return, primarily from lower limbs, due to venous hypertension.
• Core Problem: Incompetent venous valves ("Vein Valve Vexations").
  • Primary CVI (~70-80%): Degenerative valvular reflux; inherent weakness of vein wall/valves.
  • Secondary CVI (~20-30%): Post-thrombotic syndrome (PTS) after DVT; or non-thrombotic iliac vein obstruction causing outflow obstruction.
• Pathophysiological Sequence:
  • Valve failure → retrograde blood flow (reflux).
  • Calf muscle pump dysfunction (failure to ↓ venous pressure during ambulation).
  • Sustained venous hypertension → capillary leakage, leukocyte trapping, inflammation, fibrin cuffing.
  • Manifests as: edema, skin changes (e.g., lipodermatosclerosis, stasis dermatitis/eczema), and ultimately venous ulcers.

⭐ Calf muscle pump failure is a key contributor to venous hypertension and CVI progression.

CVI Clinical Picture & CEAP - Leggy Load & Looks

• Symptoms (Leggy Load):
  • Ache, heaviness, cramps; worse with dependency, better with elevation.
  • Leg swelling, pruritus.
  • 📌 Mnemonic - ACHES: Aching, Cramps, Heaviness, Edema, Skin changes.
• Signs (Leggy Looks):
  • Telangiectasias (<1 mm), reticular veins (1-3 mm), varicose veins (>3 mm).
  • Edema (pitting).
  • Skin changes:
    • Pigmentation (hemosiderin).
    • Dermatitis/eczema.
    • LDS: induration, 'inverted champagne bottle'.
    • Atrophie blanche.
  • Venous ulcers (medial malleolus, shallow).

  ⭐ Corona phlebectatica (fan-shaped intradermal veins at ankle/foot) is an early sign of advanced CVI (CEAP C4).

• CEAP Classification:
  • Clinical (C0-C6, S/A):
    • C0: No signs.
    • C1: Telangiectasias/reticular.
    • C2: Varicose veins.
    • C3: Edema.
    • C4a: Pigmentation/eczema.
    • C4b: LDS/atrophie blanche.
    • C5: Healed ulcer.
    • C6: Active ulcer.
    • (S/A for symptoms)
  • E: Ec (Congenital), Ep (Primary), Es (Secondary).
  • A: As (Superficial), Ad (Deep), Ap (Perforator).
  • P: Pr (Reflux), Po (Obstruction), Pr,o (Both).

CVI Diagnosis & Workup - Vein Viewing Quest

• Clinical Evaluation:
  • Symptoms: Leg ache, swelling, heaviness.
  • Signs: Edema, varicose veins, skin changes (lipodermatosclerosis, ulceration).
• Duplex Ultrasound (DUS):
  • Primary diagnostic tool.
  • Identifies reflux & obstruction.

  ⭐ Duplex ultrasound is the gold standard for diagnosing CVI, identifying reflux >0.5s in superficial/perforator veins or >1s in deep veins.

• Ancillary Tests (selected cases):
  • Venography, Plethysmography (APG), Ambulatory Venous Pressure (AVP).

CVI Management Strategies - Flow Fixes & Fortifiers

• Foundation (All CEAP Stages): 📌 Mnemonic: LEGS
  • Leg elevation, Exercise (calf pump), Graduated compression, Skin care.
  • Compression: Key! Stockings (20-30 mmHg for C0-C2, 30-40 mmHg for C3-C6), multi-layer bandages.

    ⭐ Compression therapy (e.g., 30‑40 mmHg stockings) is the cornerstone of CVI management, especially for CEAP C3-C6 stages.

• Pharmacotherapy (Adjunctive):
  • Venoactive drugs (VADs; e.g., MPFF, diosmin): ↑venous tone, ↓capillary permeability, ↓edema.
  • Pentoxifylline: Aids ulcer healing (↑RBC flexibility). Sulodexide also used.
• Interventions (For reflux/symptoms; CEAP C2-C6):
  • Endovenous Ablation:
    • Thermal: Radiofrequency (RFA), Laser (EVLA) for axial reflux.
    • Non-Thermal Non-Tumescent (NTNT): Cyanoacrylate, MOCA.
  • Sclerotherapy: Foam/liquid for varicosities, tributaries.
  • Surgery: Ligation & stripping (less common), phlebectomy, SEPS (perforators).
• Venous Ulcer Care (CEAP C5-C6):
  • Debridement, dressings, sustained high compression, consider pentoxifylline/sulodexide.

High‑Yield Points - ⚡ Biggest Takeaways

• Valvular incompetence and calf muscle pump dysfunction cause venous hypertension.
• Key symptoms include leg aching/heaviness, edema, and skin changes (e.g., lipodermatosclerosis, hemosiderin staining).
• Venous ulcers are classically found near the medial malleolus.
• Duplex ultrasonography is the gold standard for diagnosis.
• Graduated compression therapy and leg elevation are mainstays of conservative treatment.
• The CEAP classification is crucial for staging severity.
• History of DVT is a significant predisposing factor.