Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 12-15: Chronic Venous Insufficiency + Key Features Download Section PDF Listen +++ +++ 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 Download Section PDF Listen +++ +++ 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 Download Section PDF Listen +++ +++ Imaging Studies ++ Duplex ultrasonography to evaluate for superficial reflux and to assess degree of deep reflux and obstruction + Treatment Download Section PDF Listen +++ +++ 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 Download Section PDF Listen +++ +++ Prevention ++ Early management of acute DVT +++ Prognosis ++ Recurrences common, particularly if support stockings that have at least 20–30 mm Hg compression are not consistently worn Although surgical treatment for venous reflux can improve symptoms, controlling edema and the secondary skin changes usually require life-long compression therapy Using venous stents, treatment of chronic iliac deep vein stenosis or obstruction may improve venous ulcer healing and reduce the ulcer recurrence rate in severe cases +++ When to Refer ++ Patients with significant saphenous reflux should be evaluated for ablation Patients with ulcers should be monitored by an interdisciplinary wound care team so that these challenging wounds can receive aggressive care + References Download Section PDF Listen +++ + +Carradice D et al. A comparison of the effectiveness of treating those with and without the complications of superficial venous insufficiency. Ann Surg. 2014 Aug;260(2):396–401. [PubMed: 24424141] + +O'Donnell TF Jr et al. Management of venous leg ulcers: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg. 2014 Aug;60(2 Suppl):3S–59S. [PubMed: 24974070] + +Raffetto JD. Pathophysiology of chronic venous disease and venous ulcers. Surg Clin North Am. 2018 Apr;98(2):337–47. [PubMed: 29502775] + +Seager MJ et al. Editor's Choice—A systematic review of endovenous stenting in chronic venous disease secondary to iliac vein obstruction. Eur J Vasc Endovasc Surg. 2016 Jan;51(1):100–20. [PubMed: 26464055] + +Vedantham S et al; ATTRACT Trial Investigators. Pharmacomechanical catheter-directed thrombolysis for deep-vein thrombosis. N Engl J Med. 2017 Dec 7;377(23):2240–52. [PubMed: 29211671]