Chronic Venous Insufficiency

Chronic venous insufficiency is an advanced stage of chronic venous disease in the legs. Normally, one-way valves inside the veins and the calf muscle pump push blood up to the heart. If the valves leak or a vein is blocked, blood pools in the legs and the pressure inside the veins stays high, even when you walk. This is called venous hypertension, and it is different from the high blood pressure measured on your arm.

From Swelling to Ulcers

High venous pressure over a long period causes fluid to seep into the tissues, so the ankles swell. Over time, red blood cells that leak out of small vessels leave a brownish color in the skin, and inflammation makes the skin thicken and harden. In severe stages, the skin becomes fragile and easily injured, and a slow-healing venous wound (venous ulcer) forms, usually above the inner ankle.

Doctors classify the stages using the CEAP system. Fine vessels in the skin (C1) and varicose veins (C2) are part of chronic venous disease, and varicose veins are covered on the Varicose Veins page. The term chronic venous insufficiency is used when there is already swelling (C3), skin changes (C4), a healed ulcer (C5), or an active ulcer (C6).

Underlying Causes

The majority of cases are caused by leaking valves in the superficial or deep veins, often together with varicose veins. Another cause is valve damage after a blood clot in a deep vein, covered on the Post-Thrombotic Syndrome page. Compression or narrowing of the pelvic veins can also obstruct flow from the legs, covered on the May-Thurner Syndrome page. Excess weight and calf muscles that are weak or rarely used also make the condition worse.

It Can Be Controlled

Chronic venous insufficiency is generally long-lasting, but its progression can be slowed and ulcers can be healed. The ESVS 2022 guidelines recommend compression, staying active, and skin care as the foundation of treatment. If a superficial vein is leaking, closing that vein with a catheter helps ulcers heal faster and reduces recurrence. The EVRA clinical trial in 2018 supports doing this procedure earlier in people with venous ulcers, together with compression. After an ulcer heals, compression and staying active are continued to prevent it from coming back.

Your doctor asks about your symptoms, any history of varicose veins, blood clots, or pregnancy, and your job, then examines both legs while you are standing. From this examination, the doctor determines the CEAP stage and looks for typical signs such as swelling, brownish skin, thickened skin, white scarred patches, or wounds.

Duplex ultrasound is the main test recommended by guidelines. It shows which veins have leaking valves, how long the backward flow lasts, and whether there is a blockage or leftover clot in the deep veins. Before starting strong compression or a procedure, the doctor checks arterial flow with the Ankle-Brachial Index (ABI), because narrowed arteries can occur at the same time and change the treatment options.

If narrowing of the pelvic veins is suspected, for example because of severe swelling in one leg or a history of clots in the thigh and pelvic veins, the doctor may order CT venography or MR venography. A wound that looks atypical or does not improve despite good care may be biopsied to rule out other causes.

Make an appointment with a doctor if ankle swelling does not go away after rest, the skin on your lower leg starts to change color or thicken, or a wound appears on your leg. Earlier treatment helps prevent ulcers and recurrence. Go to the emergency room right away if one leg suddenly becomes swollen and painful, or you suddenly become short of breath.

• Ankle swelling that persists or spreads
• Brownish, itchy, or scaly skin above the ankle
• Skin on the lower leg that hardens and feels painful
• A leg wound that does not improve within two weeks
• A wound that comes back after it had healed
• Spreading redness, warmth, or fever around a wound