Chronic venous insufficiency.

Chronic venous insufficiency, characterized by the retrograde flow of blood in the lower extremity, is a common, debilitating disorder that is increasing in prevalence. An estimated 25 million people in the United States have varicose veins, 2 to 6 million have more advanced forms of chronic venous insufficiency (swelling, skin changes), and nearly 500,000 have painful venous ulcers. Although varicose veins are more likely to develop in women, men more commonly have venous ulcers. Regardless of gender, the disorder is associated with a significant reduction in quality of life. Although initiating events, such as deep vein thrombosis and muscle pump failure, may lead to chronic venous insufficiency, vein valve dysfunction appears to be the common final pathway in the development of this problem. Recent studies have determined that the basal state of veins valves is coaptation, with the prevention of retrograde flow. Failure of this mechanism results in increases in retrograde flow and distal venous pressure, which can begin to alter the structure and function of the downstream vein wall. The diagnosis is established by history, physical examination, and functional venous testing with duplex imaging or phlebography. Classification systems have been developed that stratify according to the severity of the disorder and help guide therapeutic endeavors. Treatment is directed toward controlling the retrograde flow of blood, venous pooling, and the complications associated with these pathophysiologic processes. When appropriate therapy is instituted, response is generally excellent.