## INTRODUCTION

ESSENTIALS OF DIAGNOSIS

• Symptoms including heaviness, aching, swelling, throbbing, or itching.

• Skin changes include hemosiderin staining, lipodermatosclerosis, and atrophie blanche.

• Varicose veins may range from telangiectasia to ropey varicosities.

• Edema, which may be soft and pitting or brawny and fibrotic, usually increases throughout the day with dependency and improves with elevation.

• Ultrasound imaging demonstrates venous reflux or chronic postthrombotic changes.

• Severe disease presents with ulceration typically located above the medial malleolus.

## GENERAL PRINCIPLES

Chronic venous disease (CVD) is a broad term that refers globally to anatomic or functional changes affecting the venous system that prompts an individual to seek medical attention. At one end of the spectrum, patients with CVD may present with no apparent clinical signs but report symptoms of heaviness, aching, or late-day leg fatigue. At the other end of the spectrum is chronic venous insufficiency (CVI). CVI refers to a more advanced form of CVD that is associated with apparent clinical signs such as trophic skin changes, edema, lymphedema, or venous stasis ulcers. From recent epidemiologic studies, the prevalence of CVD may be as high as 70% to 80% of the general population. When followed longitudinally, the incidence of CVD is approximately 1% to 2% annually. However, once an individual is affected, CVD progression is common and estimated at 30% to 50% over a 5-year period. CVI is costly; in the United States, approximately $2 to$3 billion is spent annually on CVI and related treatments.

Despite its high prevalence, CVD is underrecognized and clinically underappreciated. In part, this is due to the nonspecific nature of the presenting symptoms. Leg pain or aching, swelling, nocturnal cramping, and nonspecific complaints such as burning, itching, or throbbing may be attributed to many different etiologies. Frequently the disease is overlooked until it becomes more severe, presenting with advanced skin changes including venous stasis ulcers. CVD is more common in women than in men, with a ratio of approximately 3:1. Men tend to present with more advanced venous disease, whereas women are more likely to present with superficial venous disease such as spider veins and varicose veins. Risk factors for CVD and CVI include advancing age, obesity, pregnancy, history of lower extremity injury, and prolonged standing or dependency. Patients with limited mobility or a history of stroke or those who are using walking aids or ankle-foot orthoses will frequently have decreased calf muscle pump function and secondary CVI. It is important to ask about sleeping habits. Chair or recliner sleeping is common in older adults because of back or joint pain, limited mobility, cardiopulmonary disease, or poor sleep habits. Sleeping in a chair or recliner predisposes older adults to secondary venous hypertension, which can progress to CVD and even CVI.

## PATHOGENESIS

The venous system is made up of (1) deep veins within the subfascial, muscular compartment of the limbs; (2) superficial veins, which ...

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