Chronic venous insufficiency

Chronic venous insufficiency CVI is a common disorder characterized by impaired blood flow through the venous system (veins) of the lower limbs (lower legs). Symptoms can include leg heaviness, discomfort and itching (pruritis) – and more severe signs such as swelling (oedema), a reddish/brown pigmentation and lipodermatosclerosis. Changes to skin, subcutaneous tissue and vascular tissue can be mild or severe. Varicose veins and leg ulcerations can result from CVI.

• Lipodermatosclerosis is a chronic inflammatory skin condition characterized by a hardening of the skin tissue on the surface and beneath (subcutaneous fibrosis).
• Pigmentation occurs due burst capilleries. Because the blood flowing back to the heart from the legs is slow, pressure in the legs increases and the tiny blood vessels (capillaries) burst turning the surrounding skin a reddish-brown colour. The skin becomes vulnerable and can easily become damage if bumped. Inflammation, tissue damage and ulcers can result from burst capillaries.

Causes of chronic venous insufficiency

Causes of CVI include incompetent venous valves, venous outflow obstruction and dysfunction of the calf muscle pumps.

Incompetent venous valves. Oxygenated blood is delivered from the heart by arteries to tissues in the body, and veins return deoxygenated blood back to the heart. When the valves in the veins become faulty, blood flows backwards and can “pool”.

Venous outflow obstruction.
This is caused by obstruction of the iliac vein and can be classified as primary - non-thrombotic iliac vein obstruction (NTIVO) or secondary – post thrombotic iliac vein obstruction (PTIVO). The iliac veins are those located in the pelvis

Dysfunction of the calf muscle pump. The calf muscle pump plays a major role in pushing venous blood from lower extremities back to the heart.  Its action offers blood-flow continuity and prevents venous and lymphatic oedema.  

These dysfunctions cause a stagnation of blood flow which increases the tension within the veins (venous hypertension).

Inflammation results from an increase in white blood cells (leukocytes) which migrate to surrounding tissue. Activation of leukocytes release proinflammatory cells, intercellular messengers (cytokines) and increases the production of collagen (the important protein which is the main component of the dermis of the skin) and fibrosis of subcutaneous fat (lipodermatosclerosis).

CVI can occur to any veins of the body including the superficial veins on the surface of the skin, the deep veins which run through muscles and the perforating veins which connect deep and superficial veins.

Why do people develop chronic venous insufficiency?

Why do valves weaken, obstruction occur or calf muscles become dysfunctional?

People who are most likely to develop CVI are those who:

• Are overweight
• Are female – due to oestrogen
• Are pregnant – due to oestrogen
• Are older
• Have a family history
• Have had an injury to the leg causing damage or blood clots

Other causes of CVI include:

• High blood pressure in the veins due to standing or sitting for long periods of time
• Smoking
• Insufficient exercise
• Deep vein thrombosis (blood clots deep in a vein of the calf or thigh)
• Inflammation and swelling in the vein close to the skin (phlebitis)

Pathophysiology

In the beginning symptoms of achy or tired legs.

Stage 1 - the development of spider veins.

Stage 2 - the development of varicose veins at least 3 millimetres in width.

Stage 3 - oedema (swelling) but no skin changes.

Stage 4 - changes to skin colour and/or texture.

Stage 5 – ulcer which heal.

Stage 6 - active ulcers.

Symptoms which may be due to CVI

Symptoms may be mild in the beginning but worsen over time interfering with quality of life. Inflammation or swelling, tenderness or pain, warm to the touch, burning and an itching sensation are common symptoms – others may include:

• Pain when walking which resolves on rest
• Uncomfortable feeling in calves – tightness
• Restless leg syndrome – urge to move legs
• Leg cramps causing pain
• Brown-coloured skin – often in the lower extremity of the leg
• Varicose veins
• Unresolving leg ulcers

A medical practitioner should be consulted to confirm diagnosis and establish possible cause of development. Medical treatment is based on the severity of symptoms.

Supporting the venous system

Avoid long periods of standing or sitting to prevent the formation of clots. Physical activity works helps blood flow through veins.

Exercise

Physical exercise may help strengthen the muscle pump in the calf of the leg and improve movement of the ankle joint. Water-based exercise has been shown to be an effective adjuvant therapy for lower limb lymphedema. Normally the lymphatic and venous systems balance each other, however in advanced stages of CVI, the excessive fluid makes it harder for the lymphatic system to drain, leading to oedema development. Regular exercise can help improve venous circulation.

Diet

Enjoy a healthy heart diet such as the Mediterranean diet, the DASH diet (Dietary Approaches to Stop Hypertension)  or a diet which is low in saturated and trans fats, and high in vegetables and fruit.

Maintain a healthy weight

Carrying extra weight can put pressure on veins and obesity is a known risk factor for the development and progression of chronic venous disorders (CVDs). 

Manage chronic health disorders

Such as diabetes, hypertension and high cholesterol. These are conditions which can damage blood vessels. 

Lifestyle

• Quit smoking. Tobacco damages blood vessels.
• Avoid standing or sitting for long periods of time.
• Avoid crossing legs when sitting.
• Wear compression stockings recommended by your healthcare provider. These help with tired and achy legs and reduce swelling. The pressure applied helps with circulation and blood pooling in the legs reducing the risk of clot formation. 

Improving tone and integrity of veins

The following herbs and bioflavonoids offer antioxidant activity which may interrupt oxidant injury implicated in the pathogenesis of CVI.

• Hamamelis virginiana (Witch Hazel)
• Vitus vinifera extract (Grapeseed)
• Aesculus hippocastanum seed (Horse chestnut) 
• Centella asiatica (Gotu kola)
• Vaccinium myrtillus extract (bilberry)
• Pinus pinaster (Pycnogenol, pine bark extract)
• Bioflavonoids - rutin and quercetin

Reducing inflammation

Chronic inflammation is a contributing factor in the development of CVI. The following venotonic herbs offer anti- inflammatory action which may attenuate its progression.

• Aesculus hippocastanum seed (Horse chestnut)
• Ruscus aculeatus (Burcher’s broom)
• Vitus vinifera extract (Grapeseed)
• Vaccinium myrtillus extract (bilberry)
• Centella asiatica (Gotu kola)

Symptom relief

• Ruscus aculeatus (Burcher’s broom) as well as its anti-inflammatory and antioxidant action, it improves blood flow, may help reduce leg volume, ankle and leg girth, oedema and symptoms of heaviness.
• Centella asiatica (Gotu kola) added benefits in helping to calf circumference, oedema and leg heaviness.
• Pinus pinaster (Pycnogenol) reduces leg heaviness and subcutaneous oedema along with its antioxidant activity.
• Vitus vinifera extract (Grapeseed) antioxidant, anti-inflammatory, reducing calf circumference and lower limb volume and pain.

Resolving underlying causes of CVI can help with halting disease progression, however curing this disabling condition may not be possible. Support venous blood flow through exercise. Symptom relief can be helped through the use herbal medicine and bioflavonoids (may take up to three months).

References

1. Understanding Chronic Venous Disease: A Critical Overview of Its Pathophysiology and Medical Management https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8348673/
2. https://www.hopkinsmedicine.org/health/conditions-and-diseases/chronic-venous-insufficiency#
3. Lipodermatosclerosis | DermNet NZ
4. Rossi FH, Rodrigues TO, Izukawa NM, Kambara AM. Best practices in diagnosis and treatment of chronic iliac vein obstruction. J Vasc Bras. 2020;19:e20190134. https://doi.org/10.1590/1677-5449.190134
5. https://my.clevelandclinic.org/health/body/22542-external-iliac-vein#   
6. The Effects of Thermal Water Physical Exercise in Patients with Lower Limb Chronic Venous Insufficiency Monitored by Bioimpedance Analysis https://www.mdpi.com/2075-4418/10/11/889/htm
7. Sarris, Jerome and Wardle, Jon; 2014, Clinical Naturopathy 2e, Elsevier, NSW Australia
8. Pharmacological Review on Centella asiatica: A Potential Herbal Cure-all https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3116297/?report=reader
9. https://www.nccih.nih.gov/health/grape-seed-extract
10. [Physiotherapy potentials improve the calf muscle pump function in chronic venous insufficiency] https://pubmed.ncbi.nlm.nih.gov/25764786/
11. https://www.paroven.com.au/our-solution
12. Effect of obesity on chronic venous insufficiency treatment outcomes https://pubmed.ncbi.nlm.nih.gov/32335333/