Chronic Venous Insufficiency in Obese Individuals: Focus on the Priority of Bariatric vs. Venous Surgery: A Systematic Review

Background: Chronic Venous Insufficiency (CVI) is a progressive disorder characterized by venous valve dysfunction, venous hypertension, and impaired venous return. Obesity exacerbates CVI progression through mechanical compression, systemic inflammation, endothelial dysfunction, and lymphatic impairment. Given the rising global prevalence of obesity, CVI is increasingly prevalent and challenging to manage. This systematic review aims to: (1) assess obesity's impact on CVI pathophysiology and progression, (2) evaluate diagnostic and treatment challenges in obese individuals, and (3) analyze the clinical prioritization between bariatric surgery and venous surgery in obese patients with CVI. Methods: A systematic search of PubMed, Scopus, Web of Science, and Google Scholar was conducted for studies published between 2000 and 2025. Eligible publications included randomized controlled trials (RCTs), observational studies, meta-analyses, and cohort studies. Search terms included: obesity, body mass index (BMI), chronic venous insufficiency, venous ulcer, varicose vein, deep vein thrombosis (DVT), bariatric surgery, endovenous laser ablation (EVLA), iliac vein stenting (IVS), mechanochemical ablation (MOCA), and sclerotherapy. Results: Obesity contributes to CVI through increased intra-abdominal pressure, venous reflux, inflammatory mediators, and calf muscle dysfunction. Evidence supports bariatric surgery as a first-line strategy in morbidly obese individuals, improving venous hypertension, and long-term vascular outcomes. Venous interventions including endovenous thermal ablation (ETA) and sclerotherapy, demonstrate improved effective post weight loss due to lower perioperative risks and better outcomes. Conclusion: In morbidly obese patients with CVI, bariatric surgery may be prioritized to address underlying venous hypertension. However, in acute complications (e.g., active ulcers, thrombosis), venous interventions may be prioritized. An integrated, multidisciplinary approach optimizing both weight reduction and vascular treatment improves long-term outcomes.