3.2. Chronic Venous Insufficiency (CVI) / Varicose Veins

📄 Definition

Chronic Venous Insufficiency (CVI) occurs when the venous valves in the legs fail, leading to venous hypertension, pooling of blood, and impaired return to the heart.
Varicose veins are dilated, tortuous superficial veins, usually due to valve incompetence.

Causes – Mnemonic: VALVES

  • Valvular incompetence (most common – primary or post-thrombotic)

  • Ageing (reduced vein elasticity)

  • Lifestyle (prolonged standing, obesity, pregnancy)

  • Venous obstruction (e.g. DVT)

  • Endocrine changes (e.g. pregnancy, HRT)

  • Surgical damage or trauma to veins

📋 Clinical Features – Mnemonic: VEINS FAIL

  • Varicose veins – visible, dilated, twisted

  • Eczema – venous (itchy, scaly skin)

  • Induration – skin thickening and fibrosis (lipodermatosclerosis)

  • Non-healing ulcers – especially at the medial malleolus

  • Swelling – pitting oedema, worse with standing

  • Fatigue – aching, heavy legs

  • Atrophie blanche – white patches from skin infarction

  • Itching

  • Leg pigmentation – haemosiderin deposition

Investigations

🥇 First-Line

  • Clinical examination – inspect, palpate and perform calf squeeze

  • Duplex Doppler Ultrasound – confirms reflux and maps incompetent veins

🥈 Second-Line (if complications or surgery planned)

  • ABPI – if considering compression

  • Venous refilling time – research/tertiary settings

Management – Mnemonic: VEIN MAP

  • Venous Duplex scan – confirm diagnosis

  • Education – leg elevation, lifestyle, avoid prolonged standing

  • Initiate compression stockings (if ABPI > 0.8)

  • NSAIDs or paracetamol for discomfort

Interventional Options

  • Minimally invasive ablation (first-line per NICE) – e.g. laser, radiofrequency

  • Ablation or sclerotherapy – foam injection if unsuitable for laser

  • Phlebectomy – surgical removal of veins if above fails

⚠️ Complications

  • Chronic leg ulceration

  • Cellulitis

  • Lipodermatosclerosis

  • Venous eczema and hyperpigmentation

  • Superficial thrombophlebitis

  • Reduced quality of life

🔺 Last updated in line with NICE CG168 – Varicose veins: diagnosis and management

Published: July 2013 • Last updated: July 2020

  • PARA-aligned, reviewed February 2026


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