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. Manifestations are categorized according to the CEAP classification of chronic venous disorders. 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. , most of which are available as nutritional supplements in the US, may help relieve symptoms such as pain and the sensation of heaviness.
- Venous insufficiency: disturbance in venous outflow; may be congenital (e.g., congenital absence of valves, ) or acquired (e.g., valvular injury secondary to deep vein thrombosis) 
- Chronic venous disease/disorders (CVD): a spectrum of disorders caused by venous dysfunction; ranges from telangiectasia to venous ulceration
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. 
Risk factors for CVD include the following: : 
- Pathophysiology of varicose veins: elevated venous pressure (see “Risk factors” above) → incompetence of venous valves (superficial or deep veins) → reflux of blood into superficial veins and back into the extremity → further elevation of venous pressure → formation of varicose veins
- Pathophysiology of CVI: varicose veins → extravasation of protein and leukocytes → release of free radicals → damage to capillary basement membrane → leakage of plasma proteins → edema formation → ↓ oxygen supply → tissue hypoperfusion and hypoxia → inflammation and atrophy → possibly ulcer formation
Features of venous hypertension
Generalized or localized pain, lower extremity discomfort/cramping, and limb swelling
- Worsened by heat
- Worse while standing, relieved by walking and raising of legs
- Pruritus, tingling, and numbness
- Edema (may be unilateral) that starts in the ankle and may involve the calf later in the disease course (in about half of affected individuals)
- Yellow-brown or red-brown skin pigmentation of the medial ankle; later of the foot and possibly lower leg
- Paraplantar varicose veins
- Lipodermatosclerosis: Localized chronic inflammation and fibrosis of skin and subcutaneous tissues of lower leg 
Tourniquet tests for varicose veins
Bedside tourniquet tests may help determine the site of venous insufficiency, but imaging is required for diagnostic confirmation. 
Trendelenburg test: evaluates the function of superficial and perforating venous valves 
- Ask the patient to lie in a supine position and elevate their legs to 45° (to drain the superficial veins).
- Apply a tourniquet to the mid-thigh to compress the superficial veins (mainly the great saphenous vein).
- Ask the patient to stand.
- Normal: no filling of the superficial veins as blood flows from the superficial to the perforating veins
- Trendelenburg I positive : Stasis means that there is rapid filling from the deep to superficial venous system (insufficient perforating veins).
- Trendelenburg II positive : After tourniquet removal, there is rapid filling within the superficial venous system (insufficient superficial venous valves).
- Perthes test: assesses deep venous patency 
- CVD is classified using the CEAP classification system. 
- 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. 
|Clinical component of CEAP classification |
|CEAP class C0|| |
|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. 
- Assess patients according to .
Consider additional studies in consultation with vascular surgery if there is:
- Complicated disease
- Suspected suprainguinal venous obstruction 
- Diagnostic uncertainty
- Planned intervention
- Evaluate for concurrent peripheral arterial disease (PAD).
Venous duplex ultrasound 
- Indications: all patients with varicose veins or suspected CVI 
- Evidence of venous reflux 
- (acute or chronic) 
Additional studies 
Not routinely required; consider in complications, diagnostic uncertainty, or planned interventions.
- CBC and BMP: patients with venous ulcers 
- : patients with recurrent DVT, thrombosis at a young age, or thrombosis in an atypical site (see also “DVT diagnostics”) 
- Microbiology : patients with venous ulceration and signs of active infection (see “Complications of CVI”)
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. 
- Abdominal/pelvic US: Consider as initial study for suspected suprainguinal venous obstruction. 
- CT or MR venography: Consider if duplex US is inconclusive and before planned intervention for suprainguinal venous obstruction. 
- Invasive imaging (e.g., , intravascular ultrasound): Consider if CT/MRV is inconclusive or inadequate. 
- Edema: See “Differential diagnoses of peripheral edema.”
- Skin changes 
- Ulceration 
|Differential diagnosis of leg ulcers|
|Venous ulcer||Arterial ulcer|| Malum perforans |
|Location|| || |
|Mechanism|| || |
|Wound features|| || |
|Pain|| || || |
The differential diagnoses listed here are not exhaustive.
- All patients
- Symptomatic patients
- Initiate compression therapy.
- Consider phlebotonic supplements.
- Symptomatic varicose veins and/or edema (/): Consider interventional therapies.
- Skin changes or ulceration () –C6: Refer to vascular surgery for interventional therapies. 
- See also “Complications of CVI” for further information on the management of venous ulcers and stasis dermatitis.
Lifestyle modifications 
- Frequent elevation of the legs 
- Daily exercise 
- Change in footwear 
- Avoidance of:
- Long periods of standing and sitting
- Hot temperatures 
- Emollients to prevent dry skin 
Venous compression therapy
- Primary treatment modality for:
- Most patients with symptomatic mild venous disease ( or ) or edema
- Pregnant patients with any stage of CVD
- Adjunct to interventional therapy: patients with skin changes or ulceration () –C6
PAD with either:
- ABI < 0.6 (absolute) or < 0.8 (relative) 
- Absolute ankle pressure < 60 mm Hg 
- Prior peripheral arterial bypass grafting at the site of compression
- NYHA III and IV congestive heart failure
- Severe diabetic neuropathy or microangiopathy
- Allergy to compression bandage materials
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 
Graded compression stockings
- Options include below-the-knee, thigh-high, or waist-high products 
- Can be applied by patients themselves
- Should be worn long-term all day, every day; adherence is often poor. 
- Elasticity is lost over time; provide two pairs that should be alternated daily and replace after 6–9 months. 
- 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. 
- Adjustable compression garments 
- Inelastic material with straps that can be tightened to increase pressure
- Used as an alternative to compression stockings or bandages
- : for refractory edema or as a second-line option for venous ulcers 
Amount of pressure 
|Recommended pressure for compression dressings in CVD |
|Clinical condition||Pressure in mm Hg|
|Varicose veins|| |
|Edema or skin changes|| |
|Postthrombotic syndrome|| |
|Active venous ulceration|| |
- Symptomatic varicose veins (CEAP C2) with:
- Edema (CEAP C3): if other are excluded and conservative management has failed 
- Skin changes or ulceration (CEAP C4–6)
Management of venous reflux 
- Vein ablation therapies: minimally invasive; typically preferred
- Partial or complete removal of a vein
- Vein valvuloplasty: reconstruction of valves in the deep veins 
Management of venous obstruction 
- First-line: endovascular recanalization and stenting
- Alternative: surgical reconstruction
Phlebotonic supplements 
- Venoactive drugs that increase tone and/or decrease capillary permeability
- Consider as an adjunct therapy for patients with pain or edema secondary to CVD. 
- Examples include horse chestnut seed extract and micronized purified flavonoid fraction (e.g., diosmiplex). 
Stasis dermatitis 
- Definition: eczematous dermatitis of the lower extremities caused by chronic venous hypertension and inflammation
- Clinical features
- Perform . , including
- Consider skin biopsy if there is diagnostic uncertainty. 
- Differential diagnosis: see “Differential diagnosis of CVI.”
- Initiate referral for interventional treatment. , including compression therapy and
- Avoid harsh cleansers and regularly apply emollients (e.g., petroleum jelly).
- Advise patients to avoid scratching. 
- Identify and treat superimposed infections. 
- Consider the following:
Consider cellulitis.  only if there is strong suspicion for
Venous ulcers 
- Definition: an open skin lesion of the leg or foot in an area affected by venous hypertension 
- Etiology: usually caused by CVI with or without complications (e.g., untreated stasis dermatitis) 
- Clinical features 
- Perform ABI to rule out concurrent PAD.
- Work up as needed for important (e.g., with ).
- Obtain aerobic and anaerobic wound cultures for suspected infections.
Tissue biopsy is indicated for ulcers with any of the following :
- No signs of healing after being open continuously for 3 months or after 4–6 weeks of standard treatment
- Worsening despite treatment (e.g., worsening pain, increase in size)
- Atypical features
- Differential diagnosis: see “Differential diagnoses of CVI.” 
- Initiate referral for interventional treatment., including compression therapy and
- Consider pentoxifylline to promote healing. 
- Provide topical wound care.
- Start systemic antibiotics if there is evidence of infection (e.g., , )
- Consider ulcers. in large or refractory
- Prognosis: Recurrence rate is as high as 70%. 
To prevent recurrence, compression therapy should be continued after a venous ulcer is healed. 
- Complications of compression therapy
- Varicose vein hemorrhage
- Superficial thrombophlebitis 
We list the most important complications. The selection is not exhaustive.