Two of the most common ailments are peripheral arterial disease and chronic venous insufficiency. Millions of people worldwide live with these diseases.

Both diseases involve the blood vessels. But: do you know the key differences between PAD and CVI?

This post discusses signs, symptoms, and treatment options for both PAD and CVI. This is a great place to start educating yourself on these vein issues.

However, if you suspect you have arterial or venous insufficiency, talk to your healthcare provider. You’ll want to take control of your health before either PAD or CVI worsens. 

What is Peripheral Arterial Disease?

Patients with peripheral arterial disease, or PAD, have poor circulation in their lower legs. Plaque restricts blood flow, causing pain in the calf or thigh. This pain can make walking difficult.

Peripheral arterial disease is most commonly caused by fatty material in the arteries. Less common causes include injuries, radiation, or blood vessel inflammation(2).

PAD affects more than 200 million adults worldwide(1). Some risk factors for PAD include(3):

• Ethnicity
• Diabetes
• Obesity
• Smoking
• Hypertension
• Increased age
• Family history of PAD, heart disease, or stroke
• High blood levels of homocysteine
• High cholesterol levels

How Does Peripheral Arterial Disease Occur?

Peripheral arterial disease occurs when plaque slowly builds up inside the arteries and sticks to the walls(4). 

In the early stages, arteries continue to function. Arteries stretch to maintain the flow. However, as this plaque increases, the arteries cease to stretch. At this point, the plaque restricts blood flow.

This can cause ischemia – a reduction or restriction of blood flow – in the lower leg. You might also experience an embolus, such as a blood clot. 

When the artery is fully obstructed, blood flow can shift to smaller arteries. However, flow is limited due to their size.

Signs and Symptoms of Peripheral Arterial Disease

If you have PAD, you might experience pain in the lower legs that worsens while walking. Your legs may also feel crampy, heavy, or tired.

Patients with mild to moderate PAD may have little to no symptoms. This depends on where in the leg the PAD has occurred (if in a major artery or a minor one) or how active the patient is. 

Patients with severe peripheral arterial disease may experience pain even while resting. These patients are often bed-bound. They may complain of burning pain, especially on the soles of the feet, and most often at night. This can lead to fatigue.

Patients with severe pain usually relieve their symptoms by dangling their legs. This can cause edema, however.

Other side effects include paleness, a decrease in muscle, hair loss, cool skin, or palpitations. 

Peripheral Arterial Disease Diagnosis

To diagnose PAD, your doctor will perform a physical exam. They will take your blood pressure above your ankle and on both arms. (This is an ankle-brachial index, or ABI.)

They may order labs to check renal function and electrolyte levels. They may also perform Doppler exams to locate the site of the issue and its severity. They may order CT or MRA scans. An electrocardiogram (ECG/EKG) may be ordered to check for heart problems.

Treatments for Peripheral Arterial Disease

Patients with PAD should focus on lifestyle and mobility improvement. Doctors recommend a diet low in cholesterol and to avoid smoking. It is also important to manage certain conditions simultaneously, like diabetes or hypertension. This can help improve PAD symptoms(5).  

Your doctor may also prescribe medications like cilostazol to improve circulation. Pentoxifylline may also be prescribed to increase oxygen delivery.

Consult with a medical professional before taking these medications. Certain comorbidities may contraindicate the intake of these medications. 

Peripheral Arterial Disease Complications

Patients who do not make lifestyle changes are at risk of severe PAD. Peripheral arterial disease can progress to:

• Infections in the lower leg
• Ischemia or gangrene
• Stroke
• Blood clots
• Heart attack
• Erectile dysfunction
• Amputation 
• Chronic venous insufficiency

And speaking of…

What is Chronic Venous Insufficiency (CVI)?

Chronic venous insufficiency is a disease that causes edema in the lower legs, skin changes, and discomfort. Many patients also have venous ulcers, which can be painful, and become infected.

Chronic venous insufficiency affects 30 million people in the United States(6).

CVI can either be primary or secondary to deep vein thrombosis:

Primary chronic venous insufficiency means that the symptoms occur without a prior disease.

Secondary chronic venous insufficiency occurs as a result of deep vein thrombosis. DVT triggers an inflammatory response.

Modifiable risk factors of CVI include:

• Smoking
• Obesity
• Pregnancy
• Hypertension
• Hormonal birth control
• Prolonged standing
• Vein injury
• Deep vein thrombosis

Non-modifiable risk factors of CVI include being female or the May-Thurner syndrome. 

How Does Chronic Venous Insufficiency Occur?

Chronic venous insufficiency occurs due to reflux or obstruction of venous blood flow. This backward flow stems from a weakened, expanded, or oddly shaped valve. In almost all cases, CVI leads to venous hypertension.

For some patients, this valve issue is genetic. For others, it may be due to thrombosis, trauma, prolonged standing, or hormonal changes. 

Patients may experience pain, swelling, and even hyperpigmentation. They may also experience lipodermatosclerosis: when the skin thickens due to fat fibrosis. And, as the skin continues to weaken, ulcers may form. 

Signs and Symptoms of Chronic Venous Insufficiency

Patients with CVI may experience lower leg swelling, discomfort, pain, fatigue, and itching. Some may complain of cramping or throbbing feeling relieved by resting or elevating their legs. 

Unlike peripheral arterial disease, this pain is not associated with any activity. 

As the disease worsens, varicose veins may develop in the legs. Patients may also experience lesions, ulcers, hyperpigmentation, and dermal atrophy.

Chronic Venous Insufficiency Diagnosis

To diagnose CVI, your doctor will review your medical history. It is important to share other conditions you may have. Take note of diseases that you have, especially diabetes and hypertension. 

They will also perform a physical exam. 

They may order a duplex ultrasonography to help identify affected regions. Invasive venography may be done in stenosis patients(7). The doctor may take an ankle-brachial index. This is to rule out other causes like peripheral arterial disease. 

They may also order a blood test if the cause of the disease is unknown. 

Treatment for Chronic Venous Insufficiency

Patients with chronic venous insufficiency are treated based on disease severity.

Treatments for CVI aim to: 

• Reduce leg discomfort or pain
• Reduce swelling
• Stabilize or improve leg appearance
• Treat painful varicose veins 
• Heal ulcers and avoid infection

In early stages, patients may regularly elevate their legs, do calf exercises, and wear compression stockings.

Ulcers are treated with antibiotics and compression bandages. Compression bandages should be used with caution if PAD coexists. If ulcers do not heal, your doctor may recommend surgery.

Patients with superficial vein reflux may try radiofrequency ablation, vein stripping, or foam sclerotherapy.

Radiofrequency ablation, sclerotherapy, and endoscopic perforator surgery are recommended to treat perforator reflux.

Compression therapy is highly effective for managing CVI if a patient keeps at it. 

Chronic Venous Insufficiency Complications

CVI complications include:

• Venous ulcers
• Thrombophlebitis
• Blood Clots
• Bleeding
• Chronic pain
• Secondary lymphedema
• Deep vein thrombosis
• Pulmonary embolism

Deep vein thrombosis and pulmonary embolism are emergency cases. These should be treated as soon as possible.

The Differences Between PAD and CVI

Peripheral arterial disease and chronic venous insufficiency may seem similar. However, there are key differences between these two diseases. We’ve summed up these differences in the chart below:

Conclusion

If you have any of the symptoms described in this post, don’t wait to get help. Whether it’s PAD, CVI, or a different vein disease, getting a proper diagnosis is the first step toward a healthier you and improving your quality of life. 

Vein & Vascular Institute is here to provide solutions for PAD, CVI, and other vein diseases. Our team members are professional and patient-focused. We provide top-of-the-line care using the latest medical technology to provide treatment like radiofrequency ablation and sclerotherapy. 

Don’t wait one day longer to get your vein health under control. Book your consultation today!

References

1. Zemaitis MR, Boll JM, Dreyer MA. Peripheral Arterial Disease. [Updated 2020 Jul 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430745/
2. Simon F, Oberhuber A, Floros N, Düppers P, Schelzig H, Duran M. Pathophysiology of chronic limb ischemia. Gefasschirurgie. 2018;23(Suppl 1):13-18.
3. Jelani QU, Petrov M, Martinez SC, Holmvang L, Al-Shaibi K, Alasnag M. Peripheral Arterial Disease in Women: an Overview of Risk Factor Profile, Clinical Features, and Outcomes. Curr Atheroscler Rep. 2018 Jun 02;20(8):40
4. Kim HO, Kim W. Elucidation of the Diagnosis and Treatment of Peripheral Arterial Disease. Korean Circ J. 2018 Sep;48(9):826-827.
5. US Preventive Services Task Force. Curry SJ, Krist AH, Owens DK, Barry MJ, Caughey AB, Davidson KW, Doubeni CA, Epling JW, Kemper AR, Kubik M, Landefeld CS, Mangione CM, Silverstein M, Simon MA, Tseng CW, Wong JB. Screening for Peripheral Artery Disease and Cardiovascular Disease Risk Assessment With the Ankle-Brachial Index: US Preventive Services Task Force Recommendation Statement. JAMA. 2018 Jul 10;320(2):177-183. 
6. Patel SK, Surowiec SM. Venous Insufficiency. [Updated 2020 Aug 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430975/
7. Knupfer J, Reich-Schupke S, Stücker M. [Conservative management of varicosis and postthrombotic syndrome]. Hautarzt. 2018 May;69(5):413-424

Chronic Venous Insufficiency

30 million people in the United States live with chronic venous insufficiency. Around 150,000 new people are diagnosed every year(1).

Chances are that someone you know has this condition – or that someone may even be you!

Chronic venous insufficiency may be known for its symptoms: leg swelling, skin changes, and discomfort. But chronic venous insufficiency can be a sign of something worse down the road. It’s important to familiarize yourself with this condition.

Let’s learn how to identify chronic venous insufficiency: the causes, signs, symptoms, and treatment options.

How does chronic venous insufficiency start?

Chronic venous insufficiency is classified as either primary or secondary:

Patients with primary chronic venous insufficiency may be born with the condition. They might have abnormal vein walls or less elastin, which means their veins don’t stretch as well as others. In any case, these issues are out of one’s control and do not stem from another condition.

Secondary chronic venous insufficiency is, well, secondary to another condition. And it often develops because the patient already has deep vein thrombosis.

Deep vein thrombosis, or DVT, is a disease where blood clots form in the veins, usually in the legs(3). DVT triggers inflammation, causing damage to vein walls. This causes secondary chronic venous insufficiency.

Someone may have an increased risk of developing CVI if they are female, obese, or pregnant. Smoking also increases risk. Prolonged standing and having May-Thurner syndrome do as well(1).

The veins bring blood back to the heart, pushing blood upwards from the legs. To do this, the muscles of the calves and the valves of the veins work together.

However, chronic venous insufficiency patients may experience leaks or obstruction in the veins. This results in a pressure increase in the lower extremities. Blood flow, vein blockages, valves, and calf muscles all impact pressure.

When CVI is secondary to DVT, repeated vein wall injury from DVT causes the veins to scar. These scars narrow the blood passageway, increasing venous pressure. 

Chronic Venous Insufficiency Symptoms

Patients with CVI experience pain, leg discomfort, ankle and leg swelling, or itching. They may also feel “prickling,” cramping, or heaviness in the lower limbs after standing too long(4).

In severe cases, ulcers, pigmentation, thickening, and wound healing delays are possible. Ulcers near the ankles may especially have trouble healing.

Diagnosis of Chronic Venous Insufficiency

To diagnose chronic venous insufficiency, the doctor might ask if:

• You’ve ever been pregnant
• You have a family history of CVI
• Your job job involves heavy lifting or prolonged standing

They will also review your full medical history. They’ll look for conditions like obesity and hypertension. The doctor will also examine your legs, noting size, texture, and color. 

If they suspect CVI, you might receive more testing. One example is the venous duplex ultrasound scan. This is one of the best way to locate problematic veins(6)

Venous plethysmography is another noninvasive test. This uses infrared light to determine the amount of blood pumped during exercise. The physician can measure the amount of leakage, obstruction, or muscle use.

Your physician might request magnetic resonance venography or CT venography. This test is much more invasive and is for more complex CVI cases (7).

Your doctor may also rule out other conditions with MRI or CT scans.

Chronic Venous Insufficiency Classification

Clinical, Etiology, Anatomic, and Pathophysiology (CEAP) classification helps physicians consistently identify and treat vein disease(8):

• Clinical (C) classification divides vein disease into categories of severity based on symptoms.
• Etiologic (E) helps describe the disease’s cause.
• Anatomic (A) identifies which veins are insufficient.
• Pathophysiological (P) helps identify how the disease impacts the body. (Examples include reflux, thrombosis, or obstruction.)

Doctors also classify CVI with Venous Clinical Severity Scoring, or VCSS. VCSS uses different attributes to identify disease severity: absent, mild, moderate, or severe. This is often used in assessing the patient’s response to treatment(8).

Table 1.CEAP Classification. (8)

Chronic Venous Insufficiency Treatments

CEAP classification and VCSS will identify CVI severity. From there, the doctor will recommend treatment.

The goal of treatment is to improve circulation and prevent further vein damage. Treatments might also focus on reducing swelling, healing venous ulcers, and managing pain.

Treatments include: 

Lifestyle changes

Smoking causes several health problems, including vein issues. Smoking restricts the blood flow in our lower limbs. Nicotine also impacts vein elasticity. Stopping a smoking habit can greatly improve your vein health.

Eating a balanced diet is also crucial. Extra weight on your body can add extra stress on your legs, worsening symptoms.

Blood flow improvements

Elevating your legs can help improve blood flow. Try sitting with the legs raised above the thighs or lying down with the legs above your heart. This also reduces leg swelling.

Another way to improve blood flow is to do regular exercises. Rehabilitation through exercise is also available. CVI patients saw improvements in 5 months after regular calf muscle exercise(10).

Compression stockings are a standard treatment for helping to restore venous blood flow. Compression is greatest around the ankle. This pressure decreases as you move up the leg, aiding blood flow(9).

Medications

The US Food and Drug Administration has not approved any medications for CVI. Medications may be prescribed to treat side effects.

Your doctor may prescribe diuretics to reduce leg swelling. Horse chestnut seed extracts, French maritime pine bark extract, and flavonoids can also help(2).

Venoablation

Venoablation is a surgical treatment for severe chronic venous insufficiency. Venoablation treats veins that serve as reflux pathways(9). Treating these veins may help with ulcer healing and symptom improvement.

Sclerotherapy is one type of venoablation. The physician inserts a substance into a specific vein. This substance destroys the vein. This is often used in smaller widened veins rather than CVI.

Radiofrequency ablation, or RFA, is another technique. The doctor uses radio waves to produce an electrical current that heats the vein, closing it off(9).

The doctor will perform ultrasound mapping beforehand to ensure patient safety(11). 

Chronic Venous Insufficiency Complications

The most common CVI complications include:

• Chronic leg pain
• Swelling
• Non-healing leg ulcers are the most common CVI complications.

Other less severe complications include venous ulcerations and secondary lymphedema.

It is important to treat CVI to avoid worse outcomes. Examples include deep vein thrombosis or pulmonary embolism.

A pulmonary embolism is a blood clot that travels from the deep veins to the lungs. This blocks the passage of blood and causes rapid body deterioration or even death.

Seek medical treatment right away if you are experiencing symptoms that could be related to a pulmonary embolism.

Conclusion

Chronic venous insufficiency is nothing to make light of. Leaving CVI untreated can lead to disability down the road.

When CVI starts, it does not stop. It is a persistent condition. Pain, skin issues, and ulceration will progress. DVT and pulmonary embolism become more possible.

Early diagnosis will save you time and money – and may even save your life. 

If you’re ready to take charge of your vein health, the experts at Vein & Vascular Institute. Our team is here to provide solutions for chronic venous insufficiency. Our vein experts are professional and patient-focused, providing top-of-the-line care and modern treatments like radiofrequency ablation and sclerotherapy.

Take the first step toward a healthier you. Book your consultation today!

References:

1. De Popas, E., & Brown, M. (2018). Varicose Veins and Lower Extremity Venous Insufficiency. Seminars in interventional radiology, 35(1), 56–61. https://doi.org/10.1055/s-0038-1636522
2. Jameson, J. L., Kasper, D. L., Longo, D. L., Fauci, A. S., Hauser, S. L., &Loscalzo, J. (2018). Harrisons principles of internal medicine 20th edition. New York: McGraw-Hill Education.
3. Waheed, S. M., Kudaravalli, P., &Hotwagner D. T. (2020). Deep vein thrombosis. StatPearls.Treasure Island: StatPearls Publishing 
4. Spiridon, M., &Corduneanu, D. (2017). Chronic Venous Insufficiency: a Frequently Underdiagnosed and Undertreated Pathology. Maedica, 12(1), 59–61.
5. Bounds E. J., Sankar P., Kok S. J. (2020) D imer. StatPearls. Treasure Island: StatPearls Publishing
6. Necas M. (2010). Duplex ultrasound in the assessment of lower extremity venous insufficiency. Australasian journal of ultrasound in medicine, 13(4), 37–45. https://doi.org/10.1002/j.2205-0140.2010.tb00178
7. Tamura, K., & Nakahara, H. (2014). MR Venography for the Assessment of Deep Vein Thrombosis in Lower Extremities with Varicose Veins. Annals of vascular diseases, 7(4), 399–403. https://doi.org/10.3400/avd.oa.14-00068
8. Eberhardt, R. T., &Raffetto, J. D. (2014). Chronic venous insufficiency. Circulation: Clinical Summaries. 130:293–294. https://doi.org/10.1161/CIR.0000000000000083 
9. Weiss, R., Anariba, D. E. Z., Lanza, J., &Lessnau, K. D. (2018). Venous insufficiency. Retrieved from https://emedicine.medscape.com/article/1085412-treatment
10. Kahle B, Leng K. Efficacy of sclerotherapy in varicose veins: prospective, blinded, placebo-controlled study.Dermatol Surg. 2004; 30:723–728.
11. Ombrellino, M., &Kabnick, L. S. (2005). Varicose vein surgery. Seminars in interventional radiology, 22(3), 185–194. https://doi.org/10.1055/s-2005-921951