Venous Insufficiency, Chronic

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

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

Imaging Studies

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

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

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