Chronic Venous Insufficiency

Abstract

Chronic venous disease is often overlooked by primary and cardiovascular care providers because of an underappreciation of the magnitude and impact of the problem. The importance of chronic venous disease is related to the number of people with the disease and the socioeconomic impact of its more severe manifestations. Unfortunately, the literature concerning the prevalence and incidence of chronic venous disease has varied greatly because of differences in the methods of evaluation, criteria for definition, and the geographic regions analyzed. The most common manifestations of chronic venous disease are dilated cutaneous veins, such as telangiectases and reticular veins, and varicose veins. The term chronic venous insufficiency (CVI) describes a condition that affects the venous system of the lower extremities with venous hypertension causing various pathologies including pain, swelling, edema, skin changes, and ulcerations. Although the term CVI is often used to exclude uncomplicated varicose veins, varicose veins have incompetent valves with increased venous pressure leading to progressive dilation and tortuosity. We will use the term CVI to represent the full spectrum of manifestations of chronic venous disease. Varicose veins have an estimated prevalence between 5% to 30% in the adult population, with a female to male predominance of 3 to 1, although a more recent study supports a higher male prevalence.1 The Edinburgh Vein Study screened 1566 subjects with duplex ultrasound for reflux finding CVI in 9.4% of men and 6.6% of women, after age adjustment, which rose significantly with age (21.2% in men 50 years old, and 12.0% in women 50 years old).2 The San Valentino Vascular Screening Project found among the 30 000 subjects evaluated by clinical assessment and duplex ultrasound a prevalence of 7% for varicose veins and 0.86% for “symptomatic” CVI.3 As in previous studies, CVI was more common with increasing age, but there was no significant sex difference. The rate of varicose vein development may be estimated from the Framingham Heart Study, which found an annual incidence of 2.6% in women and 1.9% in men.4 Risk factors found to be associated with CVI include age, sex, a family history of varicose veins, obesity, pregnancy, phlebitis, and previous leg injury.5,6 There also may be environmental or behavioral factors associated with CVI such as prolonged standing and perhaps a sitting posture at work.6,7 Varicose veins have a significant impact on healthcare resources, with millions of people seeking medical attention for their cosmetic appearance annually. Although often minimized, the cosmetic consequences may adversely affect an individual’s quality of life and are associated with other manifestations. The more serious consequences of CVI such as venous ulcers have an estimated prevalence of 0.3%, although active or healed ulcers are seen in 1% of the adult population.8 It has been estimated that 2.5 million people have CVI in the United States, and of those, 20% develop venous ulcers.9 The overall prognosis of venous ulcers is poor, with delayed healing and recurrent ulceration being common.10 More than 50% of venous ulcers require prolonged therapy lasting 1 year.5 The socioeconomic impact of venous ulceration is dramatic, resulting in an impaired ability to engage in social and occupational activities, thus reducing the quality of life and imposing financial constraints. Disability related to venous ulcers leads to loss of productive work hours, estimated at 2 million workdays/year, and may cause early retirement, which is found in up to 12.5% of workers with venous ulcers.11 The financial burden of venous ulcer disease on the healthcare system is readily apparent: An estimated $1 billion is spent annually on the treatment of chronic wounds in the United States, or up to 2% of the total healthcare budget in all Western countries, and recent estimates place the cost of venous ulcer care at $3 billion annually.12,13 Given the prevalence and socioeconomic impact of chronic venous disease, an understanding of the clinical manifestations, diagnostic modalities, and therapeutic options is warranted. This article reviews the clinical aspects of CVI with a focus on the diagnostic and therapeutic options.