Lower extremity venous valve incompetence or obstruction producing edema, hyperpigmentation, varicosities, and venous stasis ulcers over the medial malleolus.
Also known as: CVI, chronic venous insufficiency, venous stasis, venous ulcer, varicose veins
Overview
Chronic dysfunction of the lower extremity venous system due to valvular incompetence, obstruction, or muscle pump failure, producing ambulatory venous hypertension. Manifestations range from telangiectasias and varicose veins to skin pigmentation, lipodermatosclerosis, and venous leg ulcers. Severity is graded by the CEAP classification (Clinical, Etiologic, Anatomic, Pathophysiologic).
Epidemiology
Affects ~25% of adults in the US to some degree; lower extremity varicose veins are present in ~20-30% of women and ~10-20% of men. Venous ulcers affect ~1% of the population and account for ~70% of all leg ulcers. Cost burden is substantial due to chronic care and recurrence.
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Prior deep vein thrombosis (post-thrombotic syndrome)
Pregnancy (mechanical compression and hormonal changes)
Sedentary lifestyle, immobility
Smoking
Pelvic mass or pelvic congestion syndrome
Pathophysiology
Failure of one-way venous valves in the superficial, perforating, or deep venous system allows retrograde blood flow (reflux) on standing or with calf muscle contraction. The resulting sustained ambulatory venous hypertension causes capillary leak of fluid, plasma proteins, and red blood cells into the dermis. Hemosiderin deposition produces characteristic brown pigmentation; chronic inflammation drives lipodermatosclerosis (fibrotic, woody induration). Skin breakdown produces venous ulcers, classically over the medial malleolus (gaiter area).
Clinical presentation
Symptoms
Lower extremity heaviness, aching, throbbing, or cramping — worse with prolonged standing, improved with elevation
Itching, burning, restless legs
Visible varicose veins or telangiectasias
Recurrent skin breakdown / ulceration, usually over the medial malleolus
Often bilateral but often asymmetric
Signs / physical exam
Pitting edema, worse at end of day, improving overnight
Hemosiderin deposition: brown pigmentation in the gaiter distribution (medial ankle and lower calf)
Lipodermatosclerosis: woody, fibrotic 'inverted champagne bottle' deformity of the lower calf
Atrophie blanche: porcelain-white atrophic patches with surrounding telangiectasias
Venous ulcers: shallow, irregular, exudative, granulating base, located over the medial malleolus
Pulses are typically preserved unless concurrent arterial disease
Varicose veins: dilated tortuous superficial veins, often along the great or small saphenous distribution
Classic findings
Shallow, exudative ulcer over the medial malleolus with surrounding brown pigmentation and lipodermatosclerosis — venous stasis ulcer.
Differential diagnosis
Arterial insufficiency (PAD) — Cool, pale extremity; absent or diminished pulses; ABI <0.9; ulcers over pressure points (toes, lateral malleolus), punched-out and painful; intermittent claudication
Lymphedema — Painless, firm, non-pitting in chronic stages; toes and dorsum of foot involved (positive Stemmer sign); minimal skin changes early; lymphoscintigraphy if confirmation needed
Cellulitis — Acute erythema, warmth, fever, leukocytosis — often misdiagnosed as venous insufficiency and vice versa; bilateral 'cellulitis' should prompt reconsideration
Stasis dermatitis — Pruritic, scaly, erythematous patches in the same gaiter distribution; can mimic cellulitis; often coexists with CVI
Diagnostic workup
Diagnostic criteria
CEAP classification: C0 (no visible signs) → C1 (telangiectasias) → C2 (varicose veins) → C3 (edema) → C4a (pigmentation/eczema) → C4b (lipodermatosclerosis/atrophie blanche) → C5 (healed ulcer) → C6 (active ulcer). The classification also includes etiology, anatomic site, and pathophysiologic mechanism.
Labs
Basic labs typically normal; targeted testing for differential considerations (BNP, albumin, urinalysis)
Wound cultures if signs of infection
Imaging
Venous duplex ultrasonography — first-line diagnostic test; assesses for reflux (>500 ms reversal in superficial / >1000 ms in deep veins) and obstruction
Ankle-brachial index (ABI) — essential before compression therapy or ulcer care; ABI <0.5 contraindicates standard compression, ABI 0.5-0.8 requires modified (light) compression
Photoplethysmography or air plethysmography for selected cases
MR or CT venography if iliocaval obstruction or pelvic congestion suspected
Diagnostic algorithm
Feature
Venous Ulcer
Arterial Ulcer
Location
Medial malleolus (gaiter area)
Lateral malleolus, toes, pressure points
Appearance
Shallow, irregular border, exudative, granulating base
Punched-out, deep, dry, pale or necrotic base
Pain
Mild-moderate, improved with elevation
Severe, worse with elevation; better when dependent
Surrounding skin
Hyperpigmentation, lipodermatosclerosis, eczema
Pale, cool, hairless, shiny atrophic skin
Pulses
Preserved (unless concurrent PAD)
Diminished or absent
ABI
Usually >0.9
<0.9, often <0.5
First-line therapy
Compression + wound care
Revascularization (endovascular or surgical)
Distinguishing venous from arterial leg ulcers — a high-yield bedside comparison.
Treatment
First-line
Compression therapy is the cornerstone — graduated compression stockings (knee-high, 20-30 mmHg for mild-moderate disease; 30-40 mmHg for severe disease and ulcer prevention); ensure ABI ≥0.8 before strong compression
Multilayer compression bandaging (e.g., four-layer Unna boot) for active ulcers — heals ~70% of venous ulcers within 6 months
Leg elevation above heart level for 30 minutes 3-4 times daily
Exercise to engage calf muscle pump (walking, ankle pumps)
Endovenous thermal ablation (radiofrequency or laser ablation) of the great or small saphenous vein for symptomatic reflux — first-line procedural treatment; superior to traditional surgical stripping (less pain, faster recovery, equivalent efficacy)
Foam or liquid sclerotherapy for residual or telangiectatic veins
Ambulatory phlebectomy (microincisional removal) for bulging varicosities
Iliac vein stenting for post-thrombotic obstruction or May-Thurner anatomy
Surgical ligation and stripping reserved for selected cases when endovenous approach is not feasible
Pentoxifylline or micronized purified flavonoid fraction (MPFF) as adjunct for refractory ulcers
Aspirin has limited evidence for ulcer healing acceleration
Complications
Recurrent venous ulceration and chronic wound care burden
Cellulitis from skin breakdown
Superficial venous thrombosis (often in tortuous varicosities)
Bleeding from ruptured varicose veins (can be substantial; treat with elevation, pressure, and definitive vein closure)
Lipodermatosclerosis with permanent skin and subcutaneous changes
Marjolin ulcer: rare squamous cell carcinoma in chronic venous ulcers (consider biopsy of non-healing ulcers)
PANCE pearls
Always check ABI before initiating compression therapy — strong compression on an ischemic limb can cause tissue necrosis.
Venous ulcers occur over the MEDIAL malleolus and are shallow, exudative, and painless to mildly painful. Arterial ulcers occur over the LATERAL malleolus and pressure points, are punched-out and painful.
Topical antibiotics are NOT routinely used for venous ulcers — they delay healing and cause sensitization. Wound care + compression is the foundation.
Endovenous ablation has replaced stripping as the gold standard for saphenous reflux due to lower morbidity and equivalent or superior outcomes.
Post-thrombotic syndrome (CVI after prior DVT) can be reduced by early ambulation and graduated compression after acute DVT, though evidence for routine compression to prevent PTS has been mixed (SOX trial).
References
SVS/AVF 2011 — Society for Vascular Surgery and American Venous Forum Clinical Practice Guidelines for the Care of Patients with Varicose Veins and Associated Venous Disease (Gloviczki et al., J Vasc Surg 2011)
ESVS 2022 — European Society for Vascular Surgery (ESVS) 2022 Clinical Practice Guidelines on the Management of Chronic Venous Disease
ESCHAR Trial — Randomized clinical trial of compression plus surgery versus compression alone in chronic venous ulceration (Barwell et al., Lancet 2004)
EVRA Trial — A Randomized Trial of Early Endovenous Ablation in Venous Ulceration (Gohel et al., NEJM 2018)
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