Chronic venous insufficiency: symptoms, causes and treatment

Guy's and St Thomas' lists these symptoms and says they vary from person to person. Pain, heaviness and swelling are often worse after sitting or standing for long periods, and activity such as walking usually helps. Severe untreated symptoms can lead to skin ulceration, particularly around the ankles.

• Long-term pain, aching and heaviness of the leg.

• Itching and pins and needles.

• Swelling (oedema) of the leg.

• Varicose veins.

• Patches of darker skin around the ankle and lower leg, which may be more difficult to see on brown or black skin.

• In severe cases, breaks in the skin (ulceration).

The Devon ICB referral guideline describes the clinical picture as a chronically swollen limb, often permanent and brawny, skin changes with pigmentation and hardness of the tissue under the skin (lipodermatosclerosis), a bursting pain in the limb on walking that settles with elevation or compression, and ulceration. Eczema-like skin changes may also be present.

The NHS says varicose veins themselves can cause pain, aching or heaviness, itching, colour changes or dry, scaly skin and swollen ankles or legs, with symptoms worse after standing for a long time and better when you rest with your legs up.

Leg veins carry blood back to the heart, helped by one-way valves. Guy's and St Thomas' describes chronic venous insufficiency as when the leg veins do not allow blood to flow back up to the heart as fast as it should. It says some of the symptoms of post-thrombotic syndrome also affect people who have not had a DVT, and these cases are called chronic venous insufficiency.

The Devon guideline makes a distinction: it describes chronic venous disease as abnormalities of the deep venous system, as opposed to the superficial veins of varicose veins, and says it is typically caused by DVT, sometimes called post-phlebitic syndrome. The two problems can occur together, and the NHS says varicose veins are common and not usually serious.

The Devon guideline lists management as compression therapy, usually a well-fitted class 2 below-knee stocking, and care of the skin by moisturising. It checks first that the arterial circulation is normal (by pulses, a Doppler signal or ankle brachial pressure index), because compression is not suitable with arterial blood flow problems. The NHS says the same about stockings for varicose veins.

The NHS advice for varicose veins gives lifestyle measures that apply sensibly to leg vein problems: keep to a healthy weight, put your legs up when possible, exercise regularly such as walking or running, avoid standing or sitting for long periods unless your feet are raised, use a moisturiser if skin is dry, flaky or itchy, try not to injure your legs, and stop smoking.

The NHS says varicose veins do not always need treatment. When they do, endothermal ablation is usually the first choice, with foam sclerotherapy if that is not suitable, and ligation and stripping surgery if simpler procedures are not suitable. Compression stockings are offered if procedures are not suitable.

These procedures treat the superficial veins, so they are not a cure for deep vein damage. A vascular specialist is the right person to advise which, if any, applies to you.

DVT is the cause most clearly described in these sources. Guy's and St Thomas' explains that a DVT blocks the vein, which affects blood flow from the leg back to the body. Despite treatment with anticoagulant medicines some blockage can remain, and the clot can also damage the valves. The risk of post-thrombotic syndrome is higher if you have had more than one DVT or if the first DVT was extensive and affected the veins of the pelvis and groin.

A clot may not cause any symptoms, so these problems can appear even if you were never diagnosed with a DVT. The Devon guideline lists features that raise suspicion: previous DVT, pulmonary embolism or significant limb trauma, risk factors for DVT including family history, and previous ulcers.

The Devon guideline describes assessment by history and examination of the legs and skin, with a check that arterial circulation is normal. Other causes of limb swelling are considered, such as lymphoedema, acute DVT and venous compression from a pelvic mass or anatomical abnormality, which is why a swollen leg should be assessed rather than assumed to be venous.

The NHS says a specialist will usually do a duplex ultrasound, a scan that checks blood flow, to plan treatment for varicose veins. Guy's and St Thomas' uses the Villalta score to measure severity of post-thrombotic symptoms, done by a clinical nurse specialist. If there is a sudden change in an affected leg, a doctor can check for a new DVT with blood tests and an ultrasound scan.

Guy's and St Thomas' says to ask for an urgent GP appointment or call 111 if you have a sudden increase of swelling or pain in your leg. The NHS says to see a GP if you have varicose veins and symptoms such as pain, itching or swelling, if you get a sore on your leg that has not healed after 2 weeks, or if they are getting worse, and to ask for an urgent GP appointment or NHS 111 help if varicose veins are bleeding.

The Devon guideline lists reasons for a GP to refer to a vascular specialist: symptoms that have become a persistent and significant disability, doubt about the diagnosis, chronic one-sided swelling without a history of DVT (where an ultrasound or CT scan should be considered) and ulceration.

On the NHS, assessment starts with your GP, with referral to a vascular service for the situations listed above. Compression and skin care can usually be started in primary care. Treatment to improve how veins look is not usually available on the NHS if they are not causing other problems, as the NHS says for varicose veins.

Private vascular clinics can offer duplex ultrasound and specialist opinions. Ask whether the deep or the superficial veins are involved, what a procedure is expected to achieve, and what ongoing compression and skin care will be needed.