Chronic venous insufficiency
Chronic venous insufficiency (CVI) is a medical condition in which blood pools in the veins, straining the walls of the vein. The most common cause of CVI is superficial venous reflux which is a treatable condition. As functional venous valves are required to provide for efficient blood return from the lower extremities, this condition typically affects the legs. If the impaired vein function causes significant symptoms, such as swelling and ulcer formation, it is referred to as chronic venous disease. It is sometimes called "chronic peripheral venous insufficiency" and should not be confused with post-thrombotic syndrome  in which the deep veins have been damaged by previous deep vein thrombosis. Most cases of CVI can be improved with treatments to the superficial venous system or stenting the deep system. Varicose veins for example can now be treated by local anesthetic endovenous surgery. Rates of CVI are higher in women than in men. Other risk factors include genetics, smoking, obesity, pregnancy, and prolonged standing. Signs and symptoms. Signs and symptoms of CVI in the leg include the following: CVI in the leg may cause the following: Causes. The most common cause of chronic venous insufficiency is reflux of  the venous valves of superficial veins. This may in turn be caused by several conditions: Deep and superficial vein thrombosis may in turn be caused by thrombophilia, which is an increased propensity of forming blood clots. Arteriovenous fistula (an abnormal connection or passageway between an artery and a vein) may cause chronic venous insufficiency even with working vein valves. Diagnosis. History and examination by a clinician for characteristic signs and symptoms are sufficient in many cases in ruling out systemic causes of venous hypertension such as hypervolemia and heart failure. A duplex ultrasound (doppler ultrasonography and b-mode) can detect  venous obstruction or valvular incompetence as the cause, and is used for planning venous ablation procedures, but it is not necessary in suspected venous insufficiency where surgical intervention is not indicated. Insufficiency within a venous segment is defined as reflux of more than 0.5 seconds with distal compression. Invasive venography can be used in patients who may require surgery or have suspicion of venous stenosis. Other modalities that may be employed are: ankle-brachial index to exclude arterial pathology, air or photoplethysmography, intravascular ultrasound, and ambulatory venous pressures, which provides a global assessment of venous competence. Venous plethysmography can assess  for reflux and muscle pump dysfunction but the test is laborious and rarely done. The venous filling time after the patient is asked to stand up from a seated position also is used to assess for CVI. Rapid filling of the legs less than 20 seconds is abnormal. Classification. CEAP classification is based on Clinical, Etiological (causal), Anatomical, and Pathophysiological factors. According to Widmer Classification for assessment of chronic venous insufficiency (CVI), diagnosis of chronic venous insufficiency is clearly differentiated from varicose veins. It has been developed to guide decision-making in chronic venous insufficiency evaluation and treatment. The CEAP  classification for CVI is as follows: Management. Conservative. Conservative treatment of CVI in the leg involves symptomatic treatment and efforts to prevent the condition from getting worse instead of effecting a cure. This may include Surgical. Surgical treatment of CVI attempts a cure by physically changing the veins with incompetent valves. Surgical treatments for CVI include the following: Venous insufficiency conservative, hemodynamic and ambulatory treatment (CHIVA method) is an ultrasound guided, minimally invasive surgery strategic for the treatment of varicose veins, performed under local anaesthetic. Prognosis. CVI is not a benign disorder and, with its progression, can lead to morbidity . Venous ulcers are common and very difficult to treat. Chronic venous ulcers are painful and debilitating. Even with treatment, recurrences are common if venous hypertension persists. Nearly 60% develop phlebitis which often progresses to deep vein thrombosis in more than 50% of patients. The venous insufficiency can also lead to severe hemorrhage. Surgery for CVI remains unsatisfactory despite the availability of numerous procedures.