What is going wrong
In a healthy leg, calf muscles squeeze the deep veins with every step and a ladder of one-way valves keeps the blood moving upward. Chronic venous insufficiency is what happens when enough of those valves stop working: blood falls back down and pressure builds in the lower leg, hour after hour, day after day.
That pressure is the whole disease. It forces fluid out of the vessels into the surrounding tissue, which is the swelling. It pushes red blood cells into the skin, which break down and leave the brown staining around the ankle. Over years, it inflames and scars the tissue until the skin becomes tight and fragile — and fragile skin under constant pressure is skin that eventually opens.
Who gets it
It is common and under-diagnosed. The risk rises with age, with a family history of vein disease, after pregnancy, with a previous deep vein thrombosis, and with work that keeps you standing or sitting still for hours — teachers, nurses, hairdressers, drivers, anyone at a bench or a desk without moving.
People often attribute the symptoms to age, weight or being on their feet all day. Sometimes that is right. But swelling that is reliably worse at night and better by morning, in one leg more than the other, is a vein pattern and deserves a proper look.
The assessment
A duplex ultrasound examination, performed standing, is the only way to establish which veins are refluxing and how far the problem reaches. It takes around thirty minutes, involves nothing more invasive than gel and a probe, and produces the map that everything else depends on.
Dr. D’Alessio also examines the skin — colour, texture, the presence of healed or open ulceration — because the stage of skin change tells you how long the pressure has been there and how urgent the treatment is.
Treatment
Two things happen in parallel.
Compression goes on immediately. Graduated compression stockings at the right pressure counteract the hydrostatic load while everything else is arranged. They are not the cure, but they are the difference between a leg that is getting worse and a leg that is holding.
The refluxing vein is closed. Depending on which vein and what shape it is, that means radiofrequency ablation, Varithena® microfoam, or sclerotherapy for the smaller branches. Blood reroutes through the leg’s healthy veins, the pressure in the lower leg drops, and the tissue is finally given the conditions in which it can recover.
What improves, and when
Swelling and heaviness tend to improve first — often within weeks, because they are direct consequences of the pressure that has just been removed. Skin discolouration fades slowly and incompletely; staining that has been there for years may never fully clear, which is the honest answer and another argument for treating early. An ulcer that has been failing to heal frequently begins to close once the venous pressure feeding it is dealt with.