Chronic venous disease

Last updated: September 15, 2023

Summarytoggle arrow icon

Chronic venous disease (also referred to as chronic venous disorders) is an umbrella term for a variety of clinical manifestations caused by chronically increased venous pressure in the lower extremities. Depending on the severity of hemodynamic dysfunction, manifestations can include superficial dilated veins (including varicose veins), peripheral edema, skin changes (e.g., stasis dermatitis), and venous ulcers. Diagnosis is based on clinical features and duplex ultrasonography, which shows vascular reflux and/or obstruction. Advanced diagnostic studies, such as magnetic resonance venography (MRV), may be indicated for certain patients. Treatment is aimed at reducing underlying venous hypertension. Lifestyle changes and localized vascular compression therapy are indicated for all patients. Surgical intervention is additionally recommended for patients with advanced or refractory disease. Surgical procedures are typically minimally invasive (e.g., endovenous ablation), although vein removal or valvuloplasty may be required. Phlebotonic supplements, most of which are available as nutritional supplements in the US, may help relieve symptoms such as pain and the sensation of heaviness.

Definitiontoggle arrow icon

The terms CVD and CVI are sometimes used interchangeably in literature because the pathophysiology is similar. However, most guideline definitions limit the term CVI to more advanced disease. [2][3][4]

Epidemiologytoggle arrow icon

Epidemiological data refers to the US, unless otherwise specified.

Etiologytoggle arrow icon

Risk factors for CVD include the following: : [4]

  • Increasing age and female sex
  • Family history of venous disease
  • Ligamentous laxity
  • Sedentary lifestyle and prolonged standing
  • Obesity
  • Pregnancy
  • Smoking
  • Prior deep vein thrombosis (DVT) causing postthrombotic syndrome
  • Prior extremity trauma
  • Congenital abnormalities

Pathophysiologytoggle arrow icon

In healthy individuals, blood from the superficial veins of the leg passes through the perforating veins into the deep veins.

Clinical featurestoggle arrow icon

The following are all features of venous hypertension:

Tourniquet tests for varicose veins

Bedside tourniquet tests may help determine the site of venous insufficiency, but imaging is required for diagnostic confirmation. [2][4]

  • Trendelenburg test: evaluates the function of superficial and perforating venous valves [6]
  • Perthes test: assesses deep venous patency [6][8]

Classificationtoggle arrow icon

  • CVD is classified using the CEAP classification system. [9]
    • C: clinical signs, ranked in severity from C0–C6
    • E: etiology; may be congenital (Ec), primary (Ep), or secondary (Es) , or ranked as unidentified (En)
    • A: anatomy; involves the superficial veins (As), perforators (Ap), or deep veins (Ad), or is ranked as unidentified (An)
    • P: pathophysiology; caused by reflux (Pr), obstruction (Po), or both (Pr,o), or is ranked as unidentified (Pn)
  • The clinical component of CEAP is often used alone in primary care as it does not require venous studies. [10]
Clinical component of CEAP classification [9]
Clinical features
CEAP class C0
  • No visible or palpable signs of disease
CEAP class C1
CEAP class C2
CEAP class C3
CEAP class C4
CEAP class C5
CEAP class C6
CVI is equivalent to CEAP classes C3 and above. [2][3]

Diagnosticstoggle arrow icon


Venous duplex ultrasound [2][4]

Additional studies [2][3]

Not routinely required; consider in complications, diagnostic uncertainty, or planned interventions

Laboratory studies

Venous plethysmography (venous function test)

  • A noninvasive test used to assess venous blood flow and detect reflux and/or obstruction
  • Indications include quantification of reflux or obstruction if duplex US findings are unclear. [2][3][12]

Further imaging

Differential diagnosestoggle arrow icon

Differential diagnosis of leg ulcers
Venous ulcer Arterial ulcer Malum perforans
  • Gaiter region (above the ankle)
  • Vessel occlusion leads to tissue ischemia.
  • Diabetic microvasculopathy and neuropathy leads to impaired tissue sustenance.
Wound features
  • Punched-out appearance
  • No exudation
  • Mild
  • Severe
  • Absent
Additional features

The differential diagnoses listed here are not exhaustive.

Treatmenttoggle arrow icon

Approach [2][4][10]

Manage CVD in pregnancy with conservative measures only and reassess for persistent disease at 3–6 months after delivery. [3]

Lifestyle modifications [3][10][16]

  • Frequent elevation of the legs [11]
  • Daily exercise [4][13]
  • Change in footwear [17]
  • Avoidance of:
    • Long periods of standing and sitting
    • Hot temperatures [18]
  • Smoking cessation
  • Management of obesity
  • Emollients to prevent dry skin [19]

Consider referral to physical therapy to increase calf pump activity and help improve mobility. [3]

Venous compression therapy

Indications [2][3][20]

  • Primary treatment modality for:
    • Most patients with symptomatic mild venous disease (CEAP C1 or CEAP C2) or edema
    • Pregnant patients with any stage of CVD
  • Adjunct to interventional therapy: patients with skin changes or ulceration (CEAP C4–C6)

Contraindications [3]

Active ulceration is not a contraindication to compression bandages; consult wound care to help manage concurrent wounds with compression dressings.

Avoid compression therapy in significant PAD.

Types of compression [2][3]

  • Graded compression stockings
    • Options include below-the-knee, thigh-high, or waist-high products [21]
    • Can be applied by patients themselves
    • Should be worn long-term all day, every day; adherence is often poor. [22]
    • Elasticity is lost over time; provide two pairs that should be alternated daily and replace after 6–9 months. [4]
  • Elastic or inelastic bandages (e.g., Unna boots)
    • Application of bandages requires trained staff.
    • Multicomponent elastic bandages are the most effective form of compression therapy for venous ulcers. [11]
  • Adjustable compression garments [3]
    • Inelastic material with straps that can be tightened to increase pressure
    • Used as an alternative to compression stockings or bandages
  • Intermittent pneumatic compression device: for refractory edema or as a second-line option for venous ulcers [3][11]

Some individuals (e.g., with obesity or limited mobility) may have difficulty applying compression garments and thus require a donning device or assistance. [13]

Amount of pressure [4]

Recommended pressure for compression dressings in CVD [2][3][11]
Clinical condition Pressure in mm Hg
Varicose veins
  • 15–30
Edema or skin changes
  • 20–40
Postthrombotic syndrome
  • 30–40 [3][11]
Active venous ulceration
  • 40–60 [3]

Interventional procedures

Indications [2][3][23]


Management of venous reflux [2][3][23]

Before ablating or stripping superficial veins, confirm the deep veins are patent using duplex US.

Management of venous obstruction [3][23]

  • First-line: endovascular recanalization and stenting
  • Alternative: surgical reconstruction

Phlebotonic supplements [2][10][25]

  • Venoactive drugs that increase tone and/or decrease capillary permeability
  • Consider as an adjunct therapy for patients with pain or edema secondary to CVD. [2][3]
  • Examples include horse chestnut seed extract and micronized purified flavonoid fraction (e.g., diosmiplex). [26]

Phlebotonics may improve some symptoms of CVI, but there is a paucity of evidence on the efficacy and safety of long-term use. [10]

Complicationstoggle arrow icon

Stasis dermatitis [13][27]

Treatment of stasis dermatitis includes addressing the underlying CVI.

Consider antibiotic therapy for skin and soft tissue infections only if there is strong suspicion for cellulitis. [13][27][30]

Venous ulcers [11][14][31]

To prevent recurrence, compression therapy should be continued after a venous ulcer is healed. [11]

Other complications

We list the most important complications. The selection is not exhaustive.

Referencestoggle arrow icon

  1. Sundaresan et al. Stasis Dermatitis: Pathophysiology, Evaluation, and Management. Am J Clin Dermatol. 2017; 18 (3): p.383-390.doi: 10.1007/s40257-016-0250-0 . | Open in Read by QxMD
  2. Rzepecki AK, Blasiak R. Stasis Dermatitis: Differentiation from Other Common Causes of Lower Leg Inflammation and Management Strategies. Curr Geriatr Rep. 2018; 7 (4): p.222-227.doi: 10.1007/s13670-018-0257-x . | Open in Read by QxMD
  3. Rinaldi G. The Itch-Scratch Cycle: A Review of the Mechanisms. Dermatology Practical & Conceptual. 2019; 9 (2): p.90-97.doi: 10.5826/dpc.0902a03 . | Open in Read by QxMD
  4. Thomas Hess C. Venous Dermatitis Checklist. Adv Skin Wound Care. 2011; 24 (2): p.96.doi: 10.1097/01.asw.0000394035.87647.38 . | Open in Read by QxMD
  5. Infectious Diseases Society of America: Five Things Physicians and Patients Should Question. Updated: February 23, 2015. Accessed: March 9, 2022.
  6. Marston et al. Wound healing society 2015 update on guidelines for venous ulcers. Wound Repair Regen. 2016; 24 (1): p.136-144.doi: 10.1111/wrr.12394 . | Open in Read by QxMD
  7. Millan et al. Venous Ulcers: Diagnosis and Treatment. Am Fam Physician. 2019; 100 (5): p.298-305.
  8. O’Donnell TF, Passman MA, Marston WA, et al. Management of venous leg ulcers: Clinical practice guidelines of the Society for Vascular Surgery® and the American Venous Forum. J Vasc Surg. 2014; 60 (2): p.3S-59S.doi: 10.1016/j.jvs.2014.04.049 . | Open in Read by QxMD
  9. Grey JE, Harding KG, Enoch S. Venous and arterial leg ulcers. BMJ. 2006; 332 (7537): p.347-350.doi: 10.1136/bmj.332.7537.347 . | Open in Read by QxMD
  10. Jull et al. Pentoxifylline for treating venous leg ulcers. Cochrane Database Syst Rev. 2012.doi: 10.1002/14651858.cd001733.pub3 . | Open in Read by QxMD
  11. Gloviczki P, Comerota AJ, Dalsing MC, et al. The care of patients with varicose veins and associated chronic venous diseases: Clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg. 2011; 53 (5): p.2S-48S.doi: 10.1016/j.jvs.2011.01.079 . | Open in Read by QxMD
  12. De Maeseneer MG, Kakkos SK, Aherne T, et al. European Society for Vascular Surgery (ESVS) 2022 Clinical Practice Guidelines on the Management of Chronic Venous Disease of the Lower Limbs. Eur J Vasc Endovasc Surg. 2022.doi: 10.1016/j.ejvs.2021.12.024 . | Open in Read by QxMD
  13. ACR Appropriateness Criteria on Management of Lower-Extremity Venous Insufficiency. Updated: January 1, 2012. Accessed: December 23, 2021.
  14. American Institute of Ultrasound in Medicine. AIUM Practice Parameter for the Performance of a Peripheral Venous Ultrasound Examination. Journal of Ultrasound in Medicine. 2020; 39 (5): p.E49-E56.doi: 10.1002/jum.15263 . | Open in Read by QxMD
  15. Lurie F, Passman M, Meisner M, et al. The 2020 update of the CEAP classification system and reporting standards. J Vasc Surg Venous Lymphat Disord. 2020; 8 (3): p.342-352.doi: 10.1016/j.jvsv.2019.12.075 . | Open in Read by QxMD
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  17. Townsend CM, Beauchamp RD, Evers BM, Mattox KL. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. Elsevier ; 2021
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  19. Al Shammeri O, AlHamdan N, Al-Hothaly B, Midhet F, Hussain M, Al-Mohaimeed A. Chronic Venous Insufficiency: prevalence and effect of compression stockings. Int J Health Sci. 2014; 8 (3): p.231-6.doi: 10.12816/0023975 . | Open in Read by QxMD
  20. Piazza G. Varicose Veins. Circulation. 2014; 130 (7): p.582-587.doi: 10.1161/circulationaha.113.008331 . | Open in Read by QxMD
  21. Leg ulcers (and disorders of venous insufficiency). Updated: October 17, 2016. Accessed: March 8, 2017.
  22. Kim J, Richards S, Kent PJ. Clinical examination of varicose veins--a validation study. Ann R Coll Surg Engl. 2000; 82 (3): p.171-5.
  23. Lanzer P, Topol EJ. Pan Vascular Medicine. Springer ; 2013
  24. $Practice guidelines - Superficial Venous Disease.
  25. Lerebourg L, L’Hermette M, Menez C, Coquart J. The effects of shoe type on lower limb venous status during gait or exercise: A systematic review. PLoS ONE. 2020; 15 (11): p.e0239787.doi: 10.1371/journal.pone.0239787 . | Open in Read by QxMD
  26. Caggiati A, De Maeseneer M, Cavezzi A, Mosti G, Morrison N. Rehabilitation of patients with venous diseases of the lower limbs: State of the art. Phlebology: The Journal of Venous Disease. 2018; 33 (10): p.663-671.doi: 10.1177/0268355518754463 . | Open in Read by QxMD
  27. Shai A, Halevy S. Direct triggers for ulceration in patients with venous insufficiency. Int J Dermatol. 2005; 44 (12): p.1006-1009.doi: 10.1111/j.1365-4632.2005.02317.x . | Open in Read by QxMD
  28. Lurie F, Lal BK, Antignani PL, et al. Compression therapy after invasive treatment of superficial veins of the lower extremities: Clinical practice guidelines of the American Venous Forum, Society for Vascular Surgery, American College of Phlebology, Society for Vascular Medicine, and International Union of Phlebology. J Vasc Surg Venous Lymphat Disord. 2019; 7 (1): p.17-28.doi: 10.1016/j.jvsv.2018.10.002 . | Open in Read by QxMD
  29. Rabe E, Partsch H, Hafner J, et al. Indications for medical compression stockings in venous and lymphatic disorders: An evidence-based consensus statement. Phlebology. 2017; 33 (3): p.163-184.doi: 10.1177/0268355516689631 . | Open in Read by QxMD
  30. Bar L, Brandis S, Marks D. Improving Adherence to Wearing Compression Stockings for Chronic Venous Insufficiency and Venous Leg Ulcers: A Scoping Review. Patient Prefer Adherence. 2021; Volume 15: p.2085-2102.doi: 10.2147/ppa.s323766 . | Open in Read by QxMD
  31. Karathanos C, Spanos K, Saleptsis V, Tsezou A, Kyriakou D, Giannoukas AD. Recurrence of superficial vein thrombosis in patients with varicose veins. Phlebology. 2016; 31 (7): p.489-495.doi: 10.1177/0268355515596475 . | Open in Read by QxMD
  32. Martinez-Zapata MJ, Vernooij RW, Uriona Tuma SM, et al. Phlebotonics for venous insufficiency. Cochrane Database Syst Rev. 2016; 4: p.CD003229.doi: 10.1002/14651858.CD003229.pub3 . | Open in Read by QxMD
  33. Pittler MH, Ernst E. Horse chestnut seed extract for chronic venous insufficiency. Cochrane Database Syst Rev. 2012.doi: 10.1002/14651858.cd003230.pub4 . | Open in Read by QxMD

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