What doctors wish patients knew about chronic venous insufficiency

For more than 30 million adults in the U.S., swollen legs, aching calves and skin changes are more than daily discomfort. These are signs of chronic venous insufficiency, a condition in which the veins in the legs cannot efficiently return blood to the heart—and one that has been in the headlines this year following the announcement that President Donald Trump has been diagnosed with it. 

Left untreated, chronic venous insufficiency can progress to painful ulcers and limit mobility, yet many patients delay care because symptoms may seem like a normal part of aging. Physicians emphasize that early recognition and treatment can improve quality of life and prevent complications.

The AMA’s What Doctors Wish Patients Knew™ series gives physicians a platform to share what they want patients to understand about today’s health care headlines. 

In this installment, Charles C. Leithead, MD, a vascular surgeon at Ochsner Health, discusses what patients should know about chronic venous insufficiency. 

Ochsner Health is part of the AMA Health System Member Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.

“Chronic venous insufficiency is the weakening of the vein valves that prevent blood from returning to the heart,” said Dr. Leithead. “That can lead to increased pressure in the legs due to damaged vein valves, which are not fully closing when they pump blood back to the heart.”

This increased pressure can result in swelling, spider veins, and varicose veins,” he added. “In the worst-case scenario, the skin becomes so pressurized that it can actually open into a sore or wound.”

“Due to vein-valve weakness, the blood is not fully returning to the heart,” Dr. Leithead explained. “This increasing pressure in the leg can cause varicose veins, which are bulging veins—branches of our superficial veins.”

Charles Leithead, MD

“Spider veins are often the first sign of venous insufficiency. When those small spider veins get overwhelmed with pressure, the branches or varicose veins develop,” he said. “So, the varicose veins are a cause of venous insufficiency.”

“Among the signs of chronic venous insufficiency are leg heaviness or pain at the end of the day, especially for those with prolonged standing or desk jobs,” Dr. Leithead said. “Swelling in the foot and ankle, as well as itching, which can be associated with restless leg syndrome, are also signs.”

“If you have spider veins, varicose veins or a long-term nonhealing wound—most commonly in the ankle area—those are also signs,” he added. “Discoloration, such as a dark purple in the lower leg or a bronze-golden skin tone, is another indicator.”

“You may have a higher risk if you have a family history of chronic venous insufficiency in one relative or one parent,” Dr. Leithead said. “If both parents have chronic venous insufficiency, you can have up to an 80% risk of developing it. One parent represents a 50% risk.”

Meanwhile, “women are at higher risk due to certain hormones, past pregnancies and blood clots,” he said. “Other risk factors include people who have had blood clots, those with prolonged standing or sitting at work, a sedentary lifestyle, a high-sodium diet and obesity.”

“Chronic venous insufficiency is diagnosed based on a patient’s history,” Dr. Leithead said. “A venous insufficiency ultrasound is also used to evaluate how quickly the valves can pump blood back to the heart and to assess for blood clots.”

“It is important to seek medical assistance when you have signs or symptoms,” he emphasized. “Even if it’s mild swelling or mild heaviness, it is important to be evaluated to prevent worsening symptoms, as well as spider or varicose veins.”

“While treatment for varicose veins is not always necessary, reducing pressure is crucial,” said Dr. Leithead. “Medical treatment includes medical-grade, graduated-compression stockings with about 20 to 30 millimeters of mercury. These should be worn in the morning and removed at night.” 

“Exercising throughout the week, pumping calf muscles with the stockings on, elevating the legs when sitting, lowering sodium intake and monitoring water intake,” he added, “can all help prevent the progression of varicose veins.”

Additionally, “varicose veins can bleed, develop clots, turn red, become infected and cause severe pain if they develop an inflammation called thrombophlebitis,” Dr. Leithead said. “It’s not prudent to treat every varicose vein, but it benefits the patient to prevent progression and the development of inflammation, clots or bleeding.”

“Medical therapy can be limited somewhat in a warmer climate or by certain wardrobes, but it is very effective,” Dr. Leithead said. “If the varicose veins hurt, burn or itch, heat can be applied with a warm compress or heating pad, and an anti-inflammatory medication can be taken as needed.”

“If medical therapy does not resolve symptoms or improve the patient’s quality of life, we can treat the weak vein valves with a minimally invasive procedure called laser ablation,” he said. “There’s little to no downtime—you walk in and walk out of the clinic.”

“We use the laser to close off the weak vein valves to prevent pressure from supplying the lower leg spider veins or varicose veins,” Dr. Leithead explained. “Once that pressure is treated or the laser ablation is completed, or if you have normal veins but still have spider veins and varicose veins, we can remove varicose veins with a procedure called a phlebectomy. 

“This involves small needle pokes in the office,” he added. “We can also inject spider veins with a Food and Drug Administration-approved medication.”

“If you do not treat chronic venous insufficiency, you can develop spider veins, which can become painful, and varicose veins can also become painful, bleed, or grow in size and number,” Dr. Leithead said. “You can also develop heaviness, pain and discoloration in the legs that prevent you from doing things you enjoy, decreasing your quality of life.”

“In the worst-case scenario, the discoloration in the legs can progress, skin integrity can decrease, and a wound can develop, which can become a risk for limb loss or infection,” he said. “Early treatment would prevent that progression, take care of the pressure, remove the varicose veins and eradicate the spider veins.”

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“Making appropriate lifestyle changes has a significant association with prevention because of the buildup of pressure throughout the day with gravity and sodium pulling down fluid in our legs,” Dr. Leithead said. “It’s not just the salt you put on your food, but also what’s already in the food.”

“We know the American diet has a very high level of sodium despite adding salt,” he said. “It’s important at the grocery store to look at the labels. Try to stay ideally under 1,500 milligrams of sodium per day, compounding your serving sizes throughout the day.”

“Certain foods have a high level of sodium such as canned foods and frozen foods,” Dr. Leithead said. “So, it's always best to eat fresh.”

“With chronic venous insufficiency, if you sit at your desk throughout the day, you can elevate your legs,” Dr. Leithead said. “Beyond that, it’s important to exercise weekly—usually about two to three times a week, breaking a sweat.”

“The amount of water we drink is also important,” he said. “We recommend 64 ounces of water a day. However, excessive water intake, unless for a medical condition or dehydration, could add extra fluid in the leg.”

“When you exercise, the calf compression helps pump or squeeze the veins in the calves and pump the fluid up the legs,” Dr. Leithead explained. “A lack of exercise or movement can build up pressure in the legs.”

“On long days, if you’re on your feet for work or travel, you can wear compression socks,” Dr. Leithead said. “It’s best to get a prescription because they have different pressures going up the leg, which helps pump the fluid out from the foot better than over-the-counter options.”

“Any compression is better than no compression,” he said. “The most common reason people wear them on flights is to prevent deep vein thrombosis, or a blood clot, from blood not circulating in the legs while sitting still. Whether it’s a flight, desk job or car ride, it’s important to get up and walk around every hour to an hour and a half to pump fluid out of the legs.”

“If you have any signs or symptoms of chronic venous insufficiency, it may not just be old age or arthritis,” Dr. Leithead said. “You may have weak vein valves, and there is a good solution to increase your quality of life.

“You should seek a vascular specialist who has training in vein treatments at a comprehensive vein clinic or vein center,” he added.