Chronic venous insufficiency

Chronic venous insufficiency, chronic venous insufficiency, CVI, varicose veins, varicosis.

Edema formation, and irreversible change in the veins, surrounding tissues and muscle fascia due to chronic. Reflux of venous blood.

• Women > men
• Prevalence: 15-50% affected depending on source

• Insufficiency of superficial, deep or transfascial veins
• May develop in connection with:
  • Primary varicose veins
  • Secondary varicose veins
  • Phlebothrombosis
  • Post-thrombotic syndrome
  • Extrinsic compression of the vein(s) (e.g., tumor, May-Thurner syndrome, obesity)

• The examination should always be performed standing up due to the hydrostatic pressure.

• Purpura jaune d'ocre: Due to increased hydrostatic pressure, erythrocyte extravasation occurs with consequent haemosiderin deposition, leading to hyperpigmentation on the lower legs.
• Hypodermatitis: Aseptic, acute inflammation of the cutaneous subcutaneous tissue. This is often painful and occurs with redness and tension (pseudoerysipelas). In the course, transition into dermatoliposclerosis.

• Dermatoliposclerosis: proteins leaking in the context of hydrostatic pressure lead to increased cutaneous and subcutaneous collagen synthesis and fibroblast stimulation.

• Atrophy blanche/ capillaritis alba: Porcelain-coloured scarring healing skin atrophy around the ankles or around an ulcer. There is an increased risk of ulceration.

• Clinical
• Phlebological examination: Exclusion of deep vein thrombosis and post-thrombotic changes, varicose vein assessment
• If necessary, measurement of the ankle-brachial index to rule out relevant arterial occlusive disease: especially in cases of ulcers (prevalence of mixed ulcers 15-20%), cardiovascular comorbidities, symptomatic PAD, absent foot pulses

Compression therapy: 

• Class I compression stockings (15-20 mmHg): C1S (symptomatic), C2
• Class II compression stockings (20-30 mmHg): C3-C5, post-thrombotic syndrome
• Class III compression stockings (30-40 mmHg): recurrent ulcers, severe post-traumatic edema, lymphedema (flat-knit compression stockings)
• Bandages (40-60 mmHg): C6, deep vein thrombosis
• Adaptive compression systems: Alternative, especially for stage C6
• Overlay compression stockings (e.g., Ulcer X): Alternative for fresh ulcers measuring <5 mm
• Contraindications: ABI < 0.6, severe heart failure NYHA III-IV, prosthetic arterial bypass in the compression area, allergy to compression material

Venoactive therapies (e.g., Daflon, Venoruton, Antistax): 

• Reduction of edema and symptoms (recommendation IIb)
• Adjuvant treatment of ulcers (recommendation IIa), especially if compression is contraindicated or not tolerated

Lifestyle measures

• Physical activity 
• Frequent elevation of the legs and cold water showers on the legs 
• Avoidance of weight gain, lack of exercise, prolonged standing/sitting, heat (e.g., sauna), sports with increased venous pressure (e.g., weightlifting)

Local therapy: Wound care, moisturizing

Vein intervention: 

• Aesthetic sclerotherapy (stage C1) – transcutaneous laser therapy
  • First, varicose vein assessment (recommendation grade IC), treatment of trunk vein insufficiency first (IC)
  • Compression therapy for symptoms (class I)
• Thermal procedures: first line of treatment for trunk vein insufficiency
  • Radiofrequency ablation (RFA) 
  • Endovenous laser therapy (EVLT): gold standard
• Non-thermal procedures: 
  • Ultrasound-guided foam sclerotherapy
  • Cyanoacrylate glue (not yet approved in Switzerland)
  • Mechanochemical ablation (MOCA) 
• Surgical treatment: 
  • Crossectomy, stripping 
  • Phlebectomy
• Indication for treatment: 
  • Stage C2S: Cost approval application required
  • Stage C3: First exclude other causes of edema
  • Stage C4: Recommendation grade IB
  • Stage C5: To reduce recurrence (IA)
  • Stage C6: Early endovenous ablation is recommended to accelerate wound healing (IB).

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