Venous Insufficiency, Chronic

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

• Venous ulcers: Large ulcerations at or above the medial ankle

General Considerations

• Chronic venous insufficiency is a severe manifestation of venous hypertension

• Chronic venous insufficiency develops because

  • Valve leaflets do not coapt since they are thickened and scarred (post-thrombotic syndrome) or in a dilated vein and are functionally inadequate

  • Proximal venous obstruction due to chronic thrombus or scarring compounds the problem

• Deleterious secondary changes occur from the resulting edema

• Causes of chronic venous insufficiency

  • Prior deep venous thrombophlebitis (75% of cases)

  • Leg trauma or surgery

  • Superficial venous reflux

  • Congenital or neoplastic obstruction of the pelvic veins

  • Congenital or acquired arteriovenous fistula

• Obesity is a complicating factor

• Stigmata of chronic venous insufficiency include

  • Fibrosis of subcutaneous tissue and skin

  • Pigmentation of skin (hemosiderin taken up by the dermal macrophages)

  • 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

• Cellulitis

  • Often difficult to distinguish from the hemosiderin pigmentation

  • May be diagnosed by blanching erythema with pain

Differential Diagnosis

• Heart failure

• Chronic kidney disease

• Decompensated liver disease

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

• Lymphedema

• Lipedema

• 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

• Measures to control edema formation

  • 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 are mainstays of treatment and usually sufficient

  • Additional measures include

    • Avoidance of long periods of sitting or standing

    • Intermittent elevation of the leg during the day and elevation of the leg at night above the level of the heart

    • Pneumatic compression of the leg in refractory cases

• Treatment of ulceration

  • Healing of ulcer will not occur unless edema is controlled and compression applied

    • Circumferential nonelastic bandage on the lower leg for the edema

    • Home compression therapy with a pneumatic ...