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Chronic venous disease

Last updated: August 5, 2021

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The most common chronic venous diseases are varicose veins (affecting approx. 23% of the US population) and chronic venous insufficiency (CVI), which affects 2–5% of the population. The condition is most often caused by increased venous pressure due to malfunctioning valves in the veins. Elevated venous pressure results in fluid accumulation in the lower extremities, leading to alterations in the skin and veins. Depending on the severity of hemodynamic changes, clinical manifestations may include superficial tortuous veins, edema, skin changes (e.g., stasis dermatitis), and ulcer formation. Diagnosis is established based on duplex ultrasonography. In complicated cases, magnetic resonance venography (MRV) may be performed as well. Treatment may be conservative (e.g., compression stockings) or involve ablation therapies (e.g., sclerotherapy, surgical excision).

  • Varicose veins: cylindrical extension and dilation of superficial veins (diameter > 3 mm) with development of knots and tortuous veins
  • Chronic venous insufficiency: increased venous pressure resulting in alterations of the skin and veins
  • Prevalence
    • CVI affects 2–6% of women and ∼ 2% of men. [1]
    • Varicose veins affect approx. 23% of individuals in the US. [2]
  • Sex: > (∼ 2:1)

Epidemiological data refers to the US, unless otherwise specified.

Risk factors for chronic venous disease

  • Increasing age and female sex
  • Family history of venous disease
  • Ligamentous laxity
  • Sedentary lifestyle and prolonged standing
  • Obesity
  • Pregnancy
  • Smoking
  • Prior thrombosis; (postthrombotic syndrome)
  • Prior extremity trauma
  • Congenital abnormalities

In healthy individuals, blood from the superficial leg veins passes through the perforating veins into the deep veins.

  • Chief complaints
    • Generalized or localized pain, lower extremity discomfort/cramping, and limb swelling
      • Worsened by heat
      • Worse while standing, relieved by walking and raising of legs
    • Pruritus, tingling, and numbness
  • Skin findings
  • Physical examination

Varicose veins and chronic venous insufficiency are diagnosed based on history and clinical findings. Imaging is only used when a clinical diagnosis of CVI cannot be established and/or conservative management has failed.

General treatment principles

  • Elimination of the reflux pathways (via conservative, interventional, or surgical treatment options) → long-term normalization of hemodynamics prevention/slowing of CVI progression

Conservative measures [4]

Definite treatment [4]

  • Indications
    • Symptomatic venous disease with correctable cause of reflux
    • In case of complications such as bleeding, ulcers, or recurrent superficial thrombophlebitis (also see “Complications” below)
  • Technique: vein ablation therapies
    • Interventional:
    • Open surgery with partial or complete removal of a vein: only for veins that are not accessible by interventional techniques

Venous ulcers [5]

Differential diagnosis of foot ulcers

Differential diagnosis of lower leg ulcers
Venous ulcer Arterial ulcer Malum perforans
(neuropathic ulcer)
Location
  • Gaiter region (above the ankle)
Mechanism
  • Diabetic microvasculopathy and neuropathy → impaired tissue sustenance
Wound features
  • Punched-out appearance
  • No exudation
Pain
  • Mild
  • Severe
  • Absent
Additional features

Further complications

We list the most important complications. The selection is not exhaustive.

  1. Ferri FF. Ferri's Clinical Advisor 2017. Elsevier ; 2016 : p. 1345-1346
  2. Al Shammeri O, AlHamdan N, Al-Hothaly B, Midhet F, Hussain M, Al-Mohaimeed A. Chronic Venous Insufficiency: prevalence and effect of compression stockings.. Int J Health Sci. 2014; 8 (3): p.231-6. doi: 10.12816/0023975 . | Open in Read by QxMD
  3. Piazza G. Varicose Veins. Circulation. 2014; 130 (7): p.582-587. doi: 10.1161/circulationaha.113.008331 . | Open in Read by QxMD
  4. Alguire PC, Scovell S, Eidt JF, Mills JR, Collins KA. Overview and management of lower extremity chronic venous disease. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/overview-and-management-of-lower-extremity-chronic-venous-disease?source=machineLearning&search=chronic%20venous%20insufficiency&selectedTitle=1~150§ionRank=1&anchor=H26#H1.Last updated: July 27, 2016. Accessed: December 7, 2016.
  5. Leg ulcers (and disorders of venous insufficiency). http://www.pcds.org.uk/clinical-guidance/leg-ulcers. Updated: October 17, 2016. Accessed: March 8, 2017.
  6. PRACTICE GUIDELINES - Superficial Venous Disease.
  7. Herold G. Internal Medicine. Herold G ; 2014
  8. Arterial Ulcers. http://www.woundsource.com/patientcondition/arterial-ulcers. Updated: March 8, 2017. Accessed: March 8, 2017.