Mædica - a Journal of Clinical Medicine

MAEDICA – a Journal of Clinical Medicine

2017; 12(1): 59-61

S TATE OF THE ART

Chronic Venous Insufficiency:

a Frequently Underdiagnosed
and Undertreated Pathology
Marilena SPIRIDONa, Dana CORDUNEANUb
a
Department of Cardiology, “St. Spiridon” Clinical Emergency Hospital, Iasi,
Romania
b
Department of Internal Medicine, “St. Spiridon” Clinical Emergency Hospital, Iasi,
Romania

ABSTRACT
The article describes the medical approach of a frequent pathology, chronic venous insufficiency.
Chronic venous insufficiency requires early diagnosis as well as an evaluation of the associated risk fac-
tors; also, patients need to understand the disease and its treatment, and to become compliant with all their
physician’s recommendations. Importantly, the physician should correctly evaluate the disease and decide
the best option for the patient.
These days, it is crucial that the patient benefits from optimal treatment choice in order to prevent com-
plications.
CVI is a potentially severe pathology that has been underdiagnosed and undertreated for a long time and
requires patience from the patient as well as care from the physician.

BACKGROUND mally occurs during exercise, resulting in venous

hypertension. In addition, poor function or failure

C
hronic venous insufficiency (CVI) is a of the calf muscle pump due to inactivity, immo-
common but underdiagnosed cause bility or abnormal gait may contribute to venous
of leg pain and swelling, and it is fre- hypertension. Chronic venous hypertension
quently associated with varicose causes abnormalities in the capillaries within the
veins. It is a consequence of the dys- leg tissues that make them more permeable. This
function of the valve of the veins, associated with allows fluid, proteins and blood cells leak into the
an impaired circulation of blood in the leg veins (1). tissues. Venous hypertension may also be associ-
Valve failure may occur due to a weakening of ated with an increased inflammatory response,
the valves as a result of varicose veins, or damage changes in the structure of the microvasculature
to the deep veins secondary to venous thrombo- and reduced skin and tissue oxygenation (2). It
sis, trauma or venous obstruction. The failure of has been postulated that valvular dysfunction
the valves allows the blood to flow back down causing reflux was the initial pathological change
(reflux) into the section of vein below. This pre- in CVD. The existing evidence seems to favour
vents the reduction in venous pressure that nor- pre-existing weakness in the wall, which produces

Address for correspondence:

Dr Marilena Spiridon, MD
Phone: 0745 651 642
Mailing adress: marilena_spiridon@yahoo.com

Article received on the 28th of November 2016 and accepted for publication on the 11th of March 2017.

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CHRONIC VENOUS INSUFFICIENCY: A FREQUENTLY UNDERDIAGNOSED AND UNDERTREATED PATHOLOGY

dilation and causes secondary valvular incompe- CVI; stockings are non-invasive, safe and
tence (3). Overall, these effects cause changes in can be sufficient in treating uncomplica-
the skin and subcutaneous tissues such as oede- ted venous disease
ma, hyperpigmentation, lipodermatosclerosis, at- Compression therapy systems applied exter-
rophe blanche and varicose eczema, and contri- nally to the lower leg increase pressure of the skin
bute to a greater skin fragility, increasing the risk of and underlying structures to counteract the force
leg ulceration and delayed healing (2). of gravity. This can help to relieve the symptoms in
the lower limb by acting to the venous and lym-
Risk factors for CVI phatic systems to improve removal of fluid (blood
and lymph) from the limb (2).
• Family history Compression therapy has two mechanisms of
• Increasing age over 30 action: a static effect or resting pressure and a dy-
• One or more blood clots in superficial or namic effect due to the changing circumference
deep veins of the leg during walking. Applying external pres-
• Female gender; varicose veins occur sure will increase pressure in the limb; this will be
nearly as commonly in men distributed evenly, according to Pascal’s law. The
• Prolonged standing greater the pressure increase in the lower limb, he
• Heavy lifting greater the force that pushes the fluid out of the
• Multiple pregnancies limb (2).
• Limited physical activity Bandages with a high SSI – static stiffness index
• High blood pressure – (inelastic) are able to remain rigid due to their
• Obesity (1) lack of extensibility. This allows them to generate
intermittent high working pressures and low res-
Diagnosis of CVI ting pressures, improving both comfort and effec-
Clinical examination is the first step for diag- tiveness of calf muscle pump (2).
nosing CVI. The accuracy of the diagnosis can be Bandages with a low SSI provide constant
increased by using a hand-held instrument called pressure, maintaining a therapeutic level of com-
Doppler that allows the examiner to listen to the pression a rest, but with less marked changes in
blood flow. The most accurate exam is a venous pressure during exercise (2).
duplex ultrasound scan, that provides an accurate Compressive stockings are a required treat-
image of the vein, so that any blockage caused by ment component during travel in patients who
blood clots or improper vein valve function can
be detected. To exclude other causes of leg swel-
ling, an MRI or CAT scan can be used (1).

Treatment of CVI
The treatment of CVI consists of both medical
and surgical approaches and involves additional
conservative therapeutic methods, as illustrated in
Figure 1:
• diet and lifestyle
• avoidance of prolonged standing or sitting
• structured exercise such as walking or
strengthen calf muscles may improve calf
muscle function
• elevation of the feet above the tights when
sitting and above the heart when lying
down, three to four times a day, to reduce
swelling (1)
• compression stocking use – a very impor-
tant part of the conservative treatment in FIGURE 1. Algorhythm for diagnosing and treating CVI (6)

60 Maedica A Journal of Clinical Medicine, Volume 12 No.1 2017

 CHRONIC VENOUS INSUFFICIENCY: A FREQUENTLY UNDERDIAGNOSED AND UNDERTREATED PATHOLOGY

Category Pressure storing the endothelial glycocalix structures. Sev-

Mild <20 mmHg
eral studies have also demonstrated the anti-in-
flammatory properties of sulodexide (5).
Moderate ≥20-40 mmHg
Studies on drug interactions with sulodexide
Strong ≥40-60 mmHg have shown that its oral administration in cardio-
Very strong ≥60 mmHg vascular disease, metabolic disorders and in pre-
TABLE 1. Categorisation of compression bandage vention and treatment of thrombosis does not in-
systems (2) terfere with the pharmacological interactions of
other routinely used agents (5).
require surgical interventions and in those with The efficacy of sulodexide has been shown in
advanced CVI (>C4 disease). In patients with re- several clinical trials in patients with peripheral
solution of symptoms under compliant compres- vascular disease, peripheral arterial occlusive di-
sive stocking use, surveillance at every 6 months is sease, coronary disease, cerebral vascular is-
recommended. If the patient develops break- chemia, myocardial infarction, post-thrombotic
through symptoms or if physical examination find- syndrome, intermittent claudication and vascular
ings deteriorate, the patient must be counselled complications of diabetics (5).
for intervention (4).
Surgical treatment
Pharmaceutical treatment
It is reserved for patients whose symptoms re-
Sulodexide is an agent with polypharmaco- main uncontrolled or worsen despite initial con-
logical actions which targets several sites involved servative treatment, and may consist of ligation
in the pathogenesis of CVD. The chemical com- with stripping, simple ligation and division, sclero-
position of sulodexide consists of 80% fast-moving therapy, stab evulsion, radiofrequency ablation,
heparine and 20% dermatan sulphate (5). endovenous laser therapy. q
The pharmacological effects of sulodexide dif-
fer substantially from other glycosaminoglycans CONCLUSION
and are mainly characterized by a prolonged half-
life, profibrinolytic properties and reduced effects
on both the coagulation cascade and bleeding pa-
rameters. The dual thrombin inhibitory action via
T hese days, it is very important that the patient
benefits from optimal choice of treatment in
order to prevent complications.
both antithrombin and heparin cofactor II gives CVI is a potentially severe pathology that has
sulodexide its potent antithrombotic effect with a been underdiagnosed and treated for a long time
low hemorrhagic profile (5). and that requires patience from the patient and
Sulodexide has endothelial protective effects care from the physician. q
by inducing the over expression of growth factors
that are important in the protection and repair of Conflict of interests: none declared.
several organs. It is capable of maintaining and re- Financial support: none declared.

R#$#%#&'#*
1. What is Chronic Venous Insufficiency ulcers. Wounds International. 2013. Venous Insufficiency. Supplement of
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chronic-venous-insufficiency-flyer.pdf Disease: Rationale, Results and Pharmacological profile of sulodexide.
2. Principles of compression in venous Unanswered Question. International Angiology. 2014;33:229-235.
disease: a practitioner’s guide to Eur J Vasc Surg 2011;41:117-125. 6. h!p://circ.ahajournals.org/
treatment and prevention of venous leg 4. Jennifer Heller. Treatment of Chronic content/130/4/333.

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