Chronic Venous Insufficiency

When the veins in the legs struggle to return blood effectively

What is chronic venous insufficiency?

Chronic venous insufficiency (CVI) is a long-term condition in which the veins of the legs have difficulty returning blood back towards the heart efficiently.

Veins contain small one-way valves that help blood travel upwards against gravity. If these valves become damaged or stop closing properly, some blood can flow backwards and pool within the lower legs.

Over time this increases the pressure within the veins and surrounding tissues. This is sometimes called venous hypertension.

CVI can cause swelling, aching, varicose veins and characteristic changes to the skin around the lower legs and ankles.

What symptoms can occur?

Symptoms vary considerably between people.

You may notice:

  • Aching or uncomfortable legs

  • A feeling of heaviness or tiredness

  • Swollen feet or ankles

  • Symptoms becoming worse after standing for long periods

  • Symptoms improving when the legs are elevated

  • Itching

  • Varicose veins

  • Changes in skin colour

  • Dry, flaky or irritated skin

  • Tightening or hardening of the skin

  • Wounds around the lower leg or ankle

Swelling is commonly worse towards the end of the day or after prolonged standing.

What causes chronic venous insufficiency?

The problem usually develops when the valves within the leg veins no longer work effectively.

Risk may be increased by:

  • Varicose veins

  • Previous deep vein thrombosis (DVT)

  • Increasing age

  • Family history of venous disease

  • Pregnancy

  • Obesity

  • Reduced mobility

  • Previous leg injury or surgery

  • Spending long periods standing

A previous DVT is particularly important because a clot can damage the valves inside the deep veins and lead to long-term venous problems.

What changes can appear around the ankle?

This is where CVI becomes particularly relevant to foot and lower-limb assessment.

Long-term venous hypertension can produce several distinctive changes.

Ankle flare

A cluster of very small red, purple or blue veins may develop around the inside of the ankle or foot.

This is sometimes known as corona phlebectatica or an ankle flare.

A few isolated thread veins are very common and do not automatically mean you have significant venous disease. However, a prominent ankle flare alongside swelling, pigmentation or varicose veins can form part of the clinical picture of chronic venous insufficiency.

Brown pigmentation

Long-standing venous pressure can allow red blood cells to leak into the surrounding tissues.

As they break down, iron-containing pigment called haemosiderin can accumulate in the skin, producing brown or rusty pigmentation, particularly around the lower leg and ankle.

This pigmentation may persist even if the underlying venous problem is subsequently treated.

Venous eczema

Venous eczema, also called varicose, gravitational or stasis eczema, can develop because of persistently raised venous pressure.

The skin may become:

  • Itchy

  • Dry

  • Flaky

  • Scaly

  • Swollen

  • Crusted or blistered

On lighter skin it may appear red or brown. On darker skin it can appear darker brown, purple or grey.

Lipodermatosclerosis

Long-standing inflammation can cause the skin and tissues beneath it to become firm, tight and hardened.

This is known as lipodermatosclerosis.

In more advanced disease the lower leg can gradually become narrower near the ankle while remaining wider above, producing an appearance sometimes described as an inverted champagne bottle.

Atrophie blanche

Small areas of pale or white scar-like skin can occasionally develop, often surrounded by pigmentation or tiny visible vessels.

These are known as atrophie blanche and can be associated with more advanced chronic venous disease.

Can chronic venous insufficiency cause ulcers?

Yes.

Persistently high pressure within the veins can eventually make the skin fragile and interfere with normal healing.

A small knock or break in the skin may then develop into a venous leg ulcer.

Venous ulcers commonly develop in the lower part of the leg, particularly around the inside of the ankle.

A break in the skin below the knee that has not healed within 2 weeks should be medically assessed. NICE recommends referral to a vascular service for both active and healed venous leg ulcers.

Is chronic venous insufficiency the same as poor arterial circulation?

No.

This distinction is really important.

With arterial disease, the problem is getting enough oxygenated blood down to the leg and foot.

With venous insufficiency, blood reaches the leg but has difficulty travelling back upwards towards the heart.

The two conditions can also occur at the same time.

This is why someone can have obvious venous swelling or skin changes but still require an assessment of their arterial circulation before compression therapy is prescribed.

How is chronic venous insufficiency assessed?

Assessment may include:

  • Your symptoms and medical history

  • Examination of the legs and skin

  • Varicose veins

  • Swelling

  • Pigmentation and eczema

  • Previous DVT or ulceration

  • Arterial circulation assessment

  • Ankle Brachial Pressure Index (ABPI) where appropriate

If significant venous disease is suspected, a vascular service may perform a duplex ultrasound scan. This shows blood flow within the veins and can identify where valves are failing or blood is refluxing backwards. NICE recommends duplex ultrasound when assessing varicose veins for treatment.

What can I do to help my circulation?

The calf muscles act as an important muscle pump.

Each time you walk and move your ankle, the calf muscles squeeze the deeper veins and help propel blood upwards.

This means that regular movement can be extremely beneficial.

Helpful measures may include:

  • Walking regularly

  • Moving your ankles and calves if sitting for long periods

  • Avoiding long periods standing completely still

  • Elevating the legs when resting

  • Maintaining a healthy weight

  • Caring for dry or fragile skin

  • Avoiding injury to the lower legs

For people with venous eczema, NHS advice includes keeping active, elevating the legs and regularly using appropriate emollients to protect the skin.

What about compression stockings?

Compression is one of the most effective tools for managing many forms of venous disease and oedema — but it needs to be appropriate for the individual.

Graduated compression is strongest around the ankle and reduces progressively further up the leg. This helps encourage blood and fluid to move upwards.

However, arterial circulation needs to be considered before significant compression is applied.

An ABPI or other appropriate vascular assessment may therefore be required, particularly when arterial disease is suspected. Compression can be unsafe where arterial blood flow is significantly reduced.

This is why strong medical compression should not simply be bought because someone's ankles are swollen.

Does compression cure faulty veins?

No.

Compression can control symptoms such as swelling and improve venous return while it is being worn, but it does not physically repair a faulty valve.

Where significant superficial venous reflux or symptomatic varicose veins are present, treatment of the underlying veins may be appropriate.

NICE recommends vascular referral for people with symptomatic varicose veins and those with skin pigmentation or eczema thought to result from chronic venous insufficiency.

Can the underlying veins be treated?

Yes.

Where assessment identifies suitable venous disease, specialist treatments can include:

  • Endothermal ablation, using heat to close an incompetent vein

  • Ultrasound-guided foam sclerotherapy

  • Surgery in selected cases

NICE recommends endothermal ablation first for suitable truncal reflux, followed by foam sclerotherapy when endothermal treatment is unsuitable, and surgery when neither is suitable.

Treating the underlying venous problem can help reduce venous hypertension and associated complications, although established pigmentation or skin changes may not disappear completely.

When should I seek medical advice?

It is worth discussing your legs with a healthcare professional if you develop:

  • Persistent ankle or lower-leg swelling

  • Troublesome varicose veins

  • Increasing pain, aching, heaviness or itching

  • New brown pigmentation around the ankle

  • Venous eczema

  • Hardening or tightening of the lower-leg skin

  • Recurrent superficial thrombophlebitis

  • A wound that is slow to heal

  • A previous venous ulcer

NICE recommends referral to a vascular service for symptomatic varicose veins, venous skin changes, superficial vein thrombosis associated with suspected venous incompetence, and active or healed venous ulcers.

When is it urgent?

Chronic venous insufficiency itself usually develops gradually.

However, seek urgent medical assessment if:

  • One leg suddenly becomes much more swollen

  • The leg becomes acutely hot, painful or red/discoloured

  • A vein becomes suddenly hard and painful

  • You develop rapidly spreading inflammation

  • A wound shows signs of significant infection

These symptoms may suggest conditions such as DVT, superficial thrombophlebitis or cellulitis rather than stable chronic venous disease.

Bleeding varicose veins

A varicose vein can occasionally bleed significantly, particularly where the overlying skin has become thin.

If this happens:

  1. Lie down.

  2. Raise the leg above the level of your heart.

  3. Apply firm, continuous pressure directly over the bleeding area.

  4. Seek urgent medical assistance if bleeding does not stop or is substantial.

NICE states that bleeding varicose veins require immediate referral to a vascular service because of the risk of further bleeding.

Chronic venous insufficiency and your podiatry assessment

At Blackfords Footcare, examination of the feet and lower legs may identify signs suggestive of chronic venous disease, including:

  • Oedema

  • Varicose or prominent superficial veins

  • Ankle flare

  • Haemosiderin pigmentation

  • Venous eczema

  • Skin thickening or lipodermatosclerosis

  • Previous or current ulceration

We can also assess the arterial circulation of the lower limbs where clinically appropriate, which is particularly important if compression therapy is being considered.

Where findings suggest clinically significant chronic venous insufficiency, we can explain what has been identified and recommend appropriate onward assessment through your GP or vascular service.

We can also help protect the feet from some of the secondary problems that become more important when the lower limb is swollen or the skin is vulnerable, including pressure, fissuring, fungal infection, nail trauma and footwear-related skin damage.

Changes such as persistent ankle swelling, brown pigmentation and venous eczema are not simply cosmetic changes associated with ageing — they can be signs of underlying chronic venous disease.