🩹

Venous Insufficiency Hub

Chronic venous insufficiency (CVI) results from impaired venous return due to valvular incompetence or obstruction. This module covers the CEAP classification, duplex evaluation, conservative and interventional treatment, venous ulcer management, and distinguishing CVI from other causes of leg edema.

Cardiology APPsCardiology NursesMAsVascular Procedure Staff

← Home

🩹Venous Insufficiency

0/7

📋

Pre-Test — Venous Insufficiency

~2 min

Answer a few quick questions before starting to measure your learning gain.

📋

Overview

Learning Objectives

1.Define chronic venous insufficiency and explain its pathophysiology
2.Apply the CEAP classification system (C0–C6)
3.Distinguish venous ulcers from arterial ulcers
4.Identify compression therapy indications and contraindications
5.Understand duplex ultrasound findings in CVI
6.Review interventional options: thermal ablation, VenaSeal, sclerotherapy, phlebectomy
7.Recognize when DVT must be ruled out
8.Differentiate CVI edema from lymphedema, lipedema, and heart failure edema
9.Provide appropriate wound care education for venous ulcers
10.Communicate effectively with Spanish-speaking patients about venous disease

📚

APP Lesson: Venous Insufficiency Foundations

Audience: Cardiology APPs and nurses working with a physician who performs venous procedures.

What is Chronic Venous Insufficiency?

›Chronic venous insufficiency (CVI) is impaired venous return from the lower extremities due to valvular incompetence, obstruction, or both. The result is chronically elevated venous pressure (venous hypertension) that drives fluid into the interstitium and eventually causes skin damage and ulceration.
›The venous system of the leg has three components: the deep venous system (femoral, popliteal veins), the superficial system (great saphenous vein [GSV], small saphenous vein [SSV], and tributaries), and the perforating veins that connect the two systems.
›Normally, one-way valves prevent retrograde flow (reflux) during muscle relaxation. When valves fail — due to DVT, prolonged standing, hereditary factors, or pregnancy — blood pools in the veins, raising pressure and causing the downstream effects of CVI.

CEAP Classification

›CEAP (Clinical-Etiology-Anatomy-Pathophysiology) is the international standard classification for venous disease. The Clinical (C) component is used most practically at the bedside:
›C0 — No visible or palpable signs of venous disease
›C1 — Telangiectasias or reticular veins (spider veins, small dilated veins)
›C2 — Varicose veins (tortuous, dilated superficial veins ≥3mm)
›C3 — Edema (lower extremity edema attributable to CVI)
›C4a — Pigmentation (hemosiderin staining) or eczema
›C4b — Lipodermatosclerosis (skin induration, fibrous changes) or atrophie blanche (white scarring)
›C5 — Healed venous ulcer
›C6 — Active venous ulcer
›Add "s" for symptomatic, "a" for asymptomatic (e.g., C3s = symptomatic edema).

Pathophysiology

›Venous hypertension → capillary hypertension → capillary leak of fluid, red blood cells, and proteins into the interstitium.
›Red blood cell breakdown releases hemosiderin → hemosiderin staining (brown discoloration above the medial malleolus).
›Chronic inflammation and fibrin deposition → lipodermatosclerosis (the skin becomes hard, woody, and contracted).
›Progressive tissue damage → atrophie blanche (avascular white plaques) → venous ulceration.
›Venous ulcers are the end result of sustained venous hypertension. Unlike arterial ulcers, they can have adequate arterial inflow but simply cannot heal due to the hostile local environment of chronic inflammation, edema, and poor lymphatic drainage.
›The cornerstone of treatment for venous disease is reducing venous hypertension — this is why compression therapy is so critical.

Symptoms

›Leg heaviness, aching, or fatigue — worse with prolonged standing or sitting, improved by elevation
›Lower extremity edema — pitting, worsens throughout the day, improves overnight with leg elevation
›Varicose veins — visible tortuous dilated veins on the lower extremity
›Skin changes — hemosiderin staining (brown), lipodermatosclerosis (hardening), eczema, itching
›Venous ulcer — typically at the medial malleolus (gaiter area), shallow, irregular borders, moist base, surrounded by stained/fibrotic skin
›Night cramps — common in CVI patients
›Restless legs — may have venous component
›Key: symptoms worsen with dependency (standing, sitting) and improve with elevation — opposite of arterial disease.

Differential Diagnosis: Distinguishing CVI from Other Leg Edema

›Heart failure edema: Bilateral, pitting, associated with dyspnea, orthopnea, weight gain, elevated JVP — responds to diuretics. BNP elevated.
›Lymphedema: Non-pitting edema; involves the foot (Stemmer sign positive — cannot pinch dorsal foot skin); progresses to fibrosis; associated with prior surgery, radiation, or cancer.
›Lipedema: Bilateral, symmetric fatty deposition from waist to ankles; does NOT involve the feet; predominantly in women; painful; does not respond to elevation or compression (unlike CVI).
›DVT: Acute unilateral swelling, pain, warmth, erythema; rule out with duplex ultrasound and/or D-dimer.
›Lymphedema vs CVI: Lymphedema involves the foot (Stemmer sign); CVI typically spares the foot until late stages.
›Arterial vs venous ulcer: Critical distinction — see cheat sheet.
›Kidney disease / hypoalbuminemia: Bilateral pitting edema without venous skin changes; check albumin, renal function, UA.

Duplex Ultrasound in CVI

›Duplex ultrasound is the primary non-invasive test to evaluate venous anatomy and physiology.
›What it evaluates:
› Reflux: Retrograde flow >0.5 seconds in the GSV, SSV, or deep veins with compression and release = significant reflux/incompetence
› DVT: Compressibility of veins; non-compressible = DVT
› Anatomy: Identifies which segments of GSV or SSV are incompetent
›GSV reflux is the most common finding driving superficial venous disease. If the GSV trunk from the saphenofemoral junction (SFJ) has reflux, it is the primary target for ablation.
›Deep venous reflux (femoral, popliteal) is more severe and may indicate post-thrombotic syndrome or primary deep venous insufficiency.
›May-Thurner syndrome: Left iliac vein compression by the right iliac artery — causes left-sided edema and DVT; treated with iliac vein stenting.

Conservative Therapy

›Compression therapy — the cornerstone of CVI management:
› 20–30 mmHg: mild-moderate CVI, spider veins, prevention
› 30–40 mmHg: moderate-severe CVI, venous ulcers (when ABI adequate), post-procedural
› Contraindicated when ABI <0.6 (inadequate arterial perfusion — compression will worsen ischemia)
› Caution when ABI 0.6–0.8 — lower compression may be used with vascular monitoring
›Leg elevation: Elevate legs above heart level for 30 minutes, 3–4 times per day. Dramatically reduces venous pressure and edema.
›Exercise: Calf muscle pump activation through walking and ankle exercises improves venous return.
›Weight management: Obesity is a major risk factor and driver of CVI progression.
›Skin care: Moisturize dry skin, avoid trauma, protect fragile skin from injury.
›Diuretics: NOT first-line for CVI edema — compression is far more effective. Diuretics may be used short-term for severe edema or in patients with coexisting HF.
›Venotonics (e.g., horse chestnut seed extract, micronized purified flavonoid fraction): Some evidence for symptom relief; not universally recommended.

Interventional Treatments

›Thermal ablation (radiofrequency ablation [RFA] or endovenous laser therapy [EVLT]): First-line treatment for great saphenous vein (GSV) or small saphenous vein (SSV) incompetence. A catheter is inserted into the vein and thermal energy closes the vein. Performed under local anesthesia with tumescent infiltration.
›VenaSeal (cyanoacrylate closure): Adhesive injected into the GSV to close it — no heat, no tumescent anesthesia, minimal bruising. Emerging alternative to thermal ablation.
›Phlebectomy (ambulatory phlebectomy): Removal of varicose vein tributaries through small punctures. Often combined with GSV ablation.
›Sclerotherapy: Liquid or foam sclerosant injected into spider veins or small varicosities to close them. Used for C1–C2 disease and residual veins after ablation.
›Iliac vein stenting: Used for May-Thurner syndrome or other iliac vein obstruction causing severe CVI or DVT.
›Timing relative to venous ulcer: Ablation is typically performed after ulcer healing — compression heals the ulcer, then ablation addresses the underlying reflux to prevent recurrence. In refractory ulcers, earlier intervention may be considered.

Venous Ulcer Care

›Venous ulcers are the most severe manifestation of CVI (CEAP C6). They are responsible for significant morbidity, reduced quality of life, and healthcare costs.
›Compression is the cornerstone of venous ulcer healing — adequate compression reduces venous hypertension and dramatically improves healing rates.
›Before applying compression, verify adequate arterial perfusion: ABI ≥0.6 required for safe compression.
›Wound dressings: Moist wound healing environment — hydrocolloid, foam dressings, or non-adherent absorbent dressings. Avoid cytotoxic agents (iodine, hydrogen peroxide) on open wounds.
›Debridement: Remove necrotic/fibrinous tissue to stimulate healing — enzymatic, autolytic, or sharp debridement per wound care specialist.
›Infection: Venous ulcers are colonized but not always infected. Signs of clinical infection (erythema, warmth, purulence, fever, increasing pain) require antibiotic treatment. Swab infected wounds; empiric coverage for skin flora.
›Cellulitis with venous ulcer: Antibiotics targeting staph/strep; evaluate for underlying osteomyelitis if wound probes to bone.
›Edema control: Elevation and compression must be maintained to support healing.
›Referral to wound care specialist for recalcitrant ulcers.

⚡

Clinical Cheat Sheet

CEAP Clinical Classification

•C0 — No visible signs
•C1 — Telangiectasias / spider veins
•C2 — Varicose veins (≥3mm)
•C3 — Edema
•C4a — Pigmentation / eczema
•C4b — Lipodermatosclerosis / atrophie blanche
•C5 — Healed venous ulcer
•C6 — Active venous ulcer

Compression Stocking Guide

•20–30 mmHg: mild CVI, prevention, spider veins
•30–40 mmHg: moderate-severe CVI, venous ulcers
•Contraindicated: ABI <0.6
•Caution: ABI 0.6–0.8 (use lower pressure)
•ALWAYS check ABI before prescribing compression in PAD-risk patients

Venous vs Arterial Ulcer

•VENOUS: Medial malleolus / gaiter area
•VENOUS: Shallow, irregular, moist base
•VENOUS: Surrounded by hemosiderin staining, fibrosis
•VENOUS: Pulses present; ABI usually adequate
•VENOUS: Worse with dependency, better with elevation
•ARTERIAL: Toes, heel, pressure points
•ARTERIAL: Deep, punched-out, necrotic/eschar base
•ARTERIAL: Minimal surrounding skin changes
•ARTERIAL: Absent/diminished pulses; low ABI
•ARTERIAL: Worse with elevation (rest pain), better with dependency

Red Flags — Act Now

•Acute unilateral swelling + pain → rule out DVT
•Rapidly expanding ulcer or spreading erythema
•Fever with leg ulcer → possible cellulitis / infected wound
•Bone visible in wound → possible osteomyelitis
•Sudden severe leg swelling + left side → consider May-Thurner
•ABI <0.6 → do NOT apply compression

✅

Nurse Assessment Checklist

Systematic assessment for patients with suspected or known chronic venous insufficiency.

Edema Assessment

Edema: unilateral or bilateral?
Pitting grade: 1+ (2mm), 2+ (4mm), 3+ (6mm), 4+ (8mm)
Extent: ankle / calf / knee / thigh
Worse at end of day? Improves overnight?
Duration: acute (days) vs chronic (weeks, months, years)
Associated with limb pain, warmth, erythema? (DVT risk)

Skin Assessment

Hemosiderin staining: brown discoloration above ankle
Lipodermatosclerosis: hardened, indurated skin
Varicose veins: location, severity
Telangiectasias / spider veins
Eczema or scaling skin
Atrophie blanche: white, avascular plaques
Ulcer present? Location, size (cm), depth, base, periwound
Signs of infection: erythema, warmth, purulence, odor, streaking

Compression Contraindication Check

History of PAD or peripheral vascular disease?
ABI documented? (Required before compression if PAD suspected)
ABI <0.6 → compression contraindicated — notify provider
ABI 0.6–0.8 → caution — lower compression class with monitoring
Uncontrolled heart failure? (Compression can shift fluid centrally)
Is patient able to apply stockings independently?

DVT Symptom Screening

Acute onset unilateral swelling?
Calf or thigh tenderness?
Warmth and erythema of the affected leg?
Recent surgery, travel, prolonged immobilization?
Prior history of DVT or PE?
If DVT suspected → notify provider for duplex ultrasound order

Patient Education

Explain importance of compression stocking adherence
Demonstrate correct stocking application if needed
Leg elevation instructions: above heart level, 3–4x/day
Wound care instructions if ulcer present
Activity: walking encouraged; prolonged standing/sitting to minimize
When to call: new wound, spreading redness, fever, sudden worsening swelling
Follow-up: importance of keeping vascular procedure appointments

📄

Patient Education Handout

What is Venous Insufficiency?

Venous insufficiency means the valves inside the veins in your legs are not working properly. Normally, these valves keep blood flowing upward toward your heart. When they fail, blood pools in the veins, raising pressure and causing your legs to swell, ache, and develop skin changes.
Common signs include: leg swelling that gets worse as the day goes on, varicose veins (enlarged twisted veins), skin darkening or hardening above the ankle, and sometimes open sores (ulcers).
Venous insufficiency is very common and manageable — compression stockings and lifestyle changes make a big difference.

Why Compression Stockings Matter

Compression stockings are the most important treatment for venous insufficiency.
They gently squeeze the veins in your leg, pushing blood upward and preventing it from pooling.
Wear them every day — put them on in the morning before getting out of bed when swelling is at its lowest.
Tips for putting them on: sit on the edge of the bed, roll the stocking down to the heel, insert your foot, and slowly unroll it up your leg.
Stocking applicator devices can help if they are difficult to put on.
Replace stockings every 3–6 months — they lose compression strength over time.

Elevating Your Legs

Elevate your legs above the level of your heart for 30 minutes, 3–4 times a day.
This reduces pressure in the veins and helps fluid drain from your legs.
Use pillows under your legs when lying down.
Even small amounts of elevation throughout the day help.

Wound and Ulcer Care at Home

If you have an open sore (ulcer) on your leg:
•Keep the wound clean with gentle washing
•Apply dressings as instructed by your care team
•Wear your compression stocking over the dressing (unless told otherwise)
•Keep your legs elevated as much as possible
•Do NOT use hydrogen peroxide or iodine on open wounds — these can damage healing tissue
•Check the wound daily — call if you see spreading redness, warmth, fever, or the wound looks worse

Activity and Lifestyle

Walking is good — it activates the calf muscle pump and pushes blood back toward the heart.
Avoid long periods of standing or sitting in one position.
When sitting, flex your ankles and wiggle your feet regularly.
If you are overweight, losing weight reduces the pressure on your veins significantly.

When to Call the Clinic

•New open wound or sore on your leg
•Wound that is not healing or is getting bigger
•Red, warm, or swollen skin around a wound
•Fever — this may mean infection
•Sudden severe swelling or pain in one leg (may be a blood clot)
•Difficulty wearing your compression stockings
•Questions about your upcoming procedure

This handout is for education only and does not replace medical advice from your healthcare team.

🗣️

Spanish / Communication Phrases

Interpreter Notice: These phrases are for basic communication and rapport only. Use a certified medical interpreter for diagnosis, treatment decisions, medication changes, consent, discharge instructions, and all complex clinical conversations.

Do your legs feel heavy or achy?

¿Siente las piernas pesadas o adoloridas?

Is the swelling worse at the end of the day?

¿La hinchazón empeora al final del día?

Do you wear compression stockings?

¿Usa medias de compresión?

You need to elevate your legs above your heart.

Necesita elevar las piernas por encima del nivel del corazón.

Do you have any open sores on your legs?

¿Tiene alguna llaga abierta en las piernas?

We are going to do an ultrasound of your legs.

Le vamos a hacer un ultrasonido en las piernas.

Compression stockings are very important for your condition.

Las medias de compresión son muy importantes para su condición.

Is the swelling in one leg or both?

¿La hinchazón es en una pierna o en las dos?

Have you ever had a blood clot in your leg?

¿Ha tenido alguna vez un coágulo de sangre en la pierna?

The procedure will help close the leaking vein.

El procedimiento ayudará a cerrar la vena que tiene problemas.

🩺

Sim Patient Case

Cardiology / Vascular ClinicInteractive

Patient

[EN] 55-year-old Spanish-speaking female with obesity and a 20-year history of varicose veins, now presenting with progressive left leg swelling, skin darkening above the ankle, and a 3cm open wound on the medial left lower leg for 6 weeks that has not healed despite topical antibiotics. [ES] Mujer de 55 años, hispanohablante, con obesidad y antecedente de 20 años de várices, que acude por hinchazón progresiva en la pierna izquierda, oscurecimiento de la piel sobre el tobillo y una herida abierta de 3 cm en la parte interna inferior de la pierna izquierda de 6 semanas de evolución que no ha sanado a pesar de los antibióticos tópicos.

Chief Complaint

[EN] "My left leg has been swollen for years but now I have this wound that won't close and the skin around it looks brown and hard." [ES] "Mi pierna izquierda ha estado hinchada por años pero ahora tengo una herida que no cierra y la piel alrededor se ve café y dura."

Vitals

136/84 mmHg

76 bpm

SpO2

97%

Temp

98.6°F

BMI

34.2 kg/m²

Goal

[EN] Interview the patient in Spanish, recognize venous ulcer and CEAP C6 classification, rule out DVT and arterial insufficiency, initiate compression therapy, plan wound care, and refer for venous ablation after ulcer healing. [ES] Entreviste a la paciente en español, reconozca la úlcera venosa y la clasificación CEAP C6, descarte TVP e insuficiencia arterial, inicie terapia de compresión, planifique el cuidado de la herida y refiera para ablación venosa después de la cicatrización de la úlcera.

🧠

Knowledge Check Quiz

✉️

Stay sharp — get new modules in your inbox

New clinical topics, tools, and bedside cheat sheets for the cardiology care team. No spam, unsubscribe anytime.

Disclaimer: This content is for educational purposes only. It is not medical advice, does not replace clinical judgment, and is not a substitute for institutional protocols or certified medical interpreters. No patient health information (PHI) should be entered into this application.