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Key Features

Essentials of Diagnosis

  • History of prior deep venous thrombosis (DVT) or leg injury

  • Edema, (brawny) skin hyperpigmentation, subcutaneous lipodermosclerosis in the lower leg

  • Large ulcerations at or above the medial ankle are common (venous ulcers)

General Considerations

  • Causes

    • Changes secondary to acute deep venous thrombophlebitis

    • Leg trauma

    • Superficial venous reflux and varicose veins

    • Congenital or neoplastic obstruction of the pelvic veins

    • Congenital or acquired arteriovenous fistula

  • Obesity is a complicating factor

  • Edema caused by the post-thrombotic syndrome results in

    • Fibrosis of subcutaneous tissue and skin

    • Pigmentation of skin

    • Ulceration

Clinical Findings

Symptoms and Signs

  • Progressive pitting edema of the leg (particularly the lower leg)

  • Itching

  • Dull discomfort made worse by periods of standing

  • Pain if an ulceration is present

  • Thin, shiny skin at ankle

  • Brownish pigmentation often develops

  • Subcutaneous tissues become thick and fibrous if condition is long-standing

  • Ulcerations, usually just above the ankle, on medial or anterior aspect of the leg

  • Varicosities may appear that are associated with incompetent perforating veins

Differential Diagnosis

  • Heart failure

  • Chronic kidney disease

  • Decompensated liver disease

  • Medications can cause edema (eg, calcium channel blockers, nonsteroidal anti-inflammatory agents, thiazolidinediones)

  • Lymphedema

  • Primary varicose veins

  • Other causes of chronic leg ulcers

    • Neuropathic ulcers usually from diabetes mellitus

    • Arterial insufficiency

    • Autoimmune diseases (Felty syndrome)

    • Sickle cell anemia

    • Erythema induratum

    • Fungal infections

Diagnosis

Imaging Studies

  • Duplex ultrasonography to evaluate for superficial reflux and to assess degree of deep reflux and obstruction

Treatment

Medications

  • Anticoagulants to manage acute DVT

Surgery

  • Percutaneous thermal ablation (radiofrequency or laser) used to treat incompetent (refluxing) perforator veins that feed the area of ulceration

Therapeutic Procedures

  • A semi-rigid gauze boot made with Unna paste

    • Applied to the leg after swelling has been reduced by a period of elevation

    • Must be changed every 2–3 days, depending on amount of drainage from ulcer

  • The pumping action of the calf muscles on the blood flow out of the lower extremity is enhanced by a circumferential nonelastic bandage on the ankle and lower leg

  • Measures to control the tendency toward edema

    • Use of fitted, graduated compression stockings (20–30 mm Hg pressure or higher) worn from the foot to just below the knee during the day and evening

    • Avoidance of long periods of sitting or standing

    • Intermittent elevation of the legs during the day and elevation of the legs at night

    • Pneumatic compression of the leg in refractory cases

Outcome

Prevention

  • Early management of acute DVT

Prognosis

  • Recurrences common, particularly if support stockings that have at least 20–30 ...

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