Understanding the venous system and implications of Chronic Venous Disease Venous Insufficiency

The Vascular System

The human vascular system is composed of three main parts: the arterial system, the venous system and the lymphatic system. While arteries carry oxygen to cells, veins carry deoxygenated blood back to the lungs and heart. Veins are elastic and unlike arteries, depend on one-way valves and muscle contractions to propel blood back toward the heart against the pull of gravity. Calf muscle contractions, such as when walking, are especially important in moving blood through the veins of the legs. This is called the “calf muscle pump.” Medical Compression Stockings (MCS) work in tandem with the calf muscle pump to improve circulation.

Calf muscle pump

The Calf Muscle Pump

In healthy veins…

  • When the calf muscle contracts, valves open and blood is propelled in one direction toward the heart.
  • When the calf muscle relaxes, valves approximate (tighten to close) and prevent blood from moving backwards in the vein.

Venous Insufficiency

Poor flow of blood through the veins, or venous insufficiency, can result in high venous pressure, engorging and stretching of the vein wall, and damage to the valves. When valves no longer tightly approximate, they fail to prevent pooling and backward movement of blood. Vein valves that fail are called “incompetent” and the backward regurgitation of blood is called “reflux.” This results in Chronic Venous Disease (CVD), and can cause distressing symptoms such as chronic swelling, pain, skin discoloration, open wounds and infections. Wearing MCS in combination with movement, such as walking, is an important intervention that can prevent or slow down the progression of CVD before it becomes this problematic.

Chronic Venous Disease

Chronic Venous Insufficiency, also known as Chronic Venous Disease (CVD), is a vascular disorder affecting more than 80% of the world’s population (Rabe, 2012). CVD conditions include spider veins, varicose veins, edema, skin changes and venous leg ulcers. CVD is progressive, therefore early detection and treatment are crucial in the management of the disease. If left untreated, CVD can cause serious complications. Wearing MCS and maintaining a healthy lifestyle are critical in the management of CVD.

Early Signs of CVD

  • Occupational and evening edema
  • General feeling of heaviness in the legs
  • Tired, achy legs
  • Spider veins
  • Varicose veins

Advanced Signs of CVD

  • Edema (swelling)
  • Skin changes, such as eczema and reddish brown pigmentation
  • Venous Leg Ulcer (VLU)
  • Pain

CVD Risk Factors

  • Family History (Heredity) – There is a greater chance of developing CVD if a family member had CVD
  • Age – Older age can cause wear and tear on the vein valves causing them to become incompetent
  • Pregnancy – Increased blood volume and additional weight from the growing baby can add extra pressure on the veins. Hormonal changes during pregnancy are also know to affect the veins
  • Obesity – Being overweight adds a lot of additional pressure on the venous system
  • Surgery/Trauma – This can cause physical damage to one or more veins. Limited movement post-surgery can also contribute to the development of CVD
  • Gender – Women are more likely to develop CVD. Hormonal changes during pregnancy, menstruation and menopause can all have an effect on the vein walls causing them to become more elastic and dilate.
  • Immobility – Standing or sitting for prolonged periods of time. Especially when traveling for 4 or more hours at a time
  • Smoking – Smoking affects blood circulation, which can increase your risk for CVD.
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CVD Progression

CVD is systematically categorized into a classification system called CEAP. The “C” in CEAP stands for the clinical presentation of a limb at a point in time.

C1: Spider Veins
Spider veins is one of the most common manifestations of CVD and is generally located in the thigh, legs, inner ankle and feet. Spider veins appear as a network of thin, red, blue or purple lines on the surface of the skin.

C2: Varicose Veins
Varicose veins are another common manifestation of CVD and are generally located in the thigh, legs, inner ankle and feet. They appear as twisted, enlarged or bulging veins, dark purple or blue in color. Often, varicose veins are not painful, however when there are symptoms, they may include:

  • Achy, tired or heavy feeling in legs
  • Burning or throbbing
  • Muscle cramping
  • Swelling in lower leg
  • Pain that is worse after sitting or standing for a period of time
  • Itching

C3: Edema
Edema (swelling) is caused by excess fluid trapped in the tissue of the body. Edema secondary to CVD slowly worsens throughout the day with prolonged sitting or standing and resolves overnight or with the legs elevated. Edema that persists is called chronic edema and results in chronic inflammation that can change the way the skin looks and feels, making it become progressively thicker or firmer (fibrotic). This is a sign that the delicate lymphatic system is damaged and these areas of skin are more susceptible to infection.

Signs and symptoms:

  • Swelling of the legs directly under your skin
  • Skin often appears shiny or stretched
  • When pressed for several seconds, skin will imprint (pitting edema)

Unresolved venous edema can lead to a more serious condition known as phlebolymphedema, a combination of venous hypertension and a failing of the lymphatic system. Once the lymphatic system is compromised, swelling generally does not resolve overnight.

C4: Skin Changes
Skin changes due to CVD often present as skin discoloration, known as hemosiderin staining. Lower legs may appear rusty or dark purple in color. This type of staining represents pressure so high in the venous system that red blood cells are forced out of the blood capillaries and into the skin tissues. The red blood cells release iron deposits, called hemosiderin, which stain the skin. If left untreated, CVD may lead to skin breakdown, infection and chronic inflammation. This often results in the formation of a Venous Leg Ulcer (VLU).

C5: Healed Venous Leg Ulcers
Healed VLUs are a serious manifestation of CVD. Healed VLUs start as painful, open wounds on the lower leg and ankle. These shallow wounds can become large and drain copious amounts of fluid. VLUs may take weeks or months to heal and are a heavy burden on patients. VLU treatments may include weekly visits to a wound care facility, wound debridement, wound dressing changes, compression bandaging, and can often severely impact a person’s quality of life.

C6: Active Venous Leg Ulcers
Active VLUs are another serious manifestation of CVD. Active VLUs present as painful, open wounds on the lower leg and ankle. These shallow wounds can become large and drain copious amounts of fluid. Active VLUs may take weeks or months to heal and are a heavy burden on patients. VLU treatments may include weekly visits to a wound care facility, wound debridement, wound dressing changes, compression bandaging, and can often severely impact a person’s quality of life.

Can I prevent CVD?

While there is no way to completely prevent CVD, it is possible to slow the progression by living a healthy lifestyle.

  • Move – Change positions as often as possible while sitting or standing for prolonged periods of time
  • Manage Weight – Being overweight can add a lot of extra pressure on the venous system
  • Exercise – Regular exercise increases blood flow
  • Eat a Healthy Diet – A balanced diet can prevent unhealthy weight gain, protecting against excess venous pressure
  • Elevate Legs – Leg elevation can relieve venous pressure buildup as well as relieve symptoms of CVD
  • Wear MCS   Make compression a daily part of your wardrobe
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Vein Procedures

CVD Treatment

  • Self-care – This includes regular exercise and wearing compression stockings
  • See a vein specialist – People often choose to visit a vascular or vein specialist because varicose or spider veins are of cosmetic concern. However, it is important to visit a specialist if you are experiencing mild or more advanced symptoms of CVD. Proactive management and early intervention with corrective vein procedures may deter serious complications of CVD.
  • Bjork R, Ehmann S. STRIDE professional guide to compression garment selection for the lower extremity. Journal of wound care. 2019 Jun 1;28(Sup6a):1-44.
  • https://www.mayoclinic.org/
  • Lurie F, Passman M, Meisner M, Dalsing M, Masuda E, Welch H, Bush RL, Blebea J, Carpentier PH, De Maeseneer M, Gasparis A. The 2020 update of the CEAP classification system and reporting standards. Journal of Vascular Surgery: Venous and Lymphatic Disorders. 2020 May 1;8(3):342-52.
  • O’Meara S, Cullum N, Nelson EA, Dumville JC. Compression for venous leg ulcers. Cochrane database of systematic reviews. 2012(11).
  • Rabe E, Guex JJ, Puskas A, Scuderi A, Fernandez FQ. Epidemiology of chronic venous disorders in geographically diverse populations: results from the Vein Consult Program. International angiology: a journal of the International Union of Angiology. 2012 Apr;31(2):105-15.
  • Rabe, Eberhard, et al. “Indications for medical compression stockings in venous and lymphatic disorders: An evidence-based consensus statement.” Phlebology (2017): 0268355516689631

What is Venous Insufficiency?