Chapter 52. Venous Insufficiency

A 45-year-old woman presents to her physician's office with complaints of heaviness and fatigue in her legs (Figure 52-1). She does not experience the symptoms in the morning but they become more noticeable as the day progresses and with prolonged standing. When she stands for many hours, she develops swelling in both of her legs. The symptoms are concentrated over her medial calf where she has prominent tortuous veins. She first noted the veins approximately 20 years ago when she was pregnant. Initially, they did not cause her any discomfort but have progressively enlarged now and over the past 10 years have become increasingly painful. She recalls that her mother had similar veins in her legs.

Venous insufficiency, or improperly functioning valves in the venous system, can lead to variety of symptoms, including, but not limited to, heaviness and/or swelling in the legs with prolonged standing, leg fatigue or aching, bleeding from leg varices, skin changes, and ulcerations. The prevalence is higher in industrialized nations and ranges from 15% to 30% of the U.S. population.

Varicose veins, venous stasis

• Varies by definition and region, but generally venous insufficiency affects 27% of the population.1
• Prevalence estimates vary by some reports, indicating a prevalence of 10.4% to 23% in men and 29.5% to 39% in women.2,3
• More frequent in women as compared to men.
• Symptomatic in more than two-thirds of those affected.
• Varicose veins are notable only in half of patients with venous insufficiency.4

• Most frequently it is a result of valvular dysfunction.
• Valvular dysfunction may be primary or secondary (result of trauma, deep venous thrombosis [DVT], or May-Thurner syndrome).
• It may affect deep system (i.e., femoral veins), superficial system (i.e., saphenous vein), or both.
• The superficial system is involved in 88% of cases either alone or in conjunction with the deep system.
• Dysfunction leads to loss of compartmentalization of veins, leading to distention and increased pressure (Figures 52-1 and 52-2).
• Increased pressure in veins is transmitted to microvasculature leading to basement membrane thickening, increased capillary elongation, and visual skin changes (Figures 52-3 and 52-4).

• Family history.
• Deep venous thrombosis.
• Female gender.
• Estrogen increase (hormone replacement, pregnancy, oral contraceptive pills).
• Age.
• Obesity.
• Prolonged standing.

Symptoms

• Heaviness, fatigue, and edema; not present immediately in the morning; gets worse with prolonged standing or walking; relieved with elevation.

Typical Distribution

• Varicose veins can be present anywhere on the leg depending upon affected segments or branches; ulcers from venous disease tend to be near the medial malleoli (Figure 52-5).

Tests

• Duplex scanning to assess valve closure; normal valve closure takes 0.5 to 1.0 seconds.

• Arterial ulcers—Tend to be at toes, shin, and pressure points (heels or sides of feet).
• Diabetic ulcers—Occur at ambulatory pressure points, mostly at first metatarsal head.
• Malignancy (basal cell or squamous cell carcinoma).
• Chronic infectious diseases (osteomyelitis, leprosy).
• Vasculitides—Irregular border, black necrosis, erythema, or bluish or purplish discoloration of adjacent tissue.

• Graduated compression hose for superficial or deep system insufficiency: SOR C
  • 15 to 20 mm Hg—Minor reflux and minimal symptoms.
  • 20 to 30 mm Hg—Moderate to severe reflux and symptoms; moderate edema; postsurgical.
  • 30 to 40 mm Hg—Severe reflux and symptoms; severe edema.
• Compression for open ulcer.5 SOR B
• Compression hose treat symptoms, not underlying pathophysiology. Effective only when being worn.
• Surgical intervention is available either with endovenous ablation or with stripping and ligation if superficial system involved.
• If only deep system involvement, then compression hose is the mainstay of therapy. SOR C
• When superficial and deep systems are affected, treatment of superficial system leads to improvement of deep system reflux in one-third of the patients.
• A study randomizing patients to stripping and ligation versus compression therapy demonstrated an improved quality of life in the surgical arm.7 SOR A
• Endovenous therapy uses radiofrequency or laser energy to ablate vein. Because the vein is usually accessed with a needle under ultrasound guidance, an incision is avoided in most instances.
• Decreased postoperative pain and analgesic use in patients undergoing endovenous ablation compared to those undergoing stripping and ligation.8 SOR A
• Adjunctive phlebectomies or sclerotherapy for branch varicosities may be necessary with either operative approach.

Patients at risk for developing venous insufficiency (genetics, occupations with prolonged standing, etc.) may benefit from compression hose use.

Majority of patients with venous insufficiency live a full and complete life without significant sequelae. Those with only superficial involvement tend to have greater relief with treatment than those with superficial and deep or only deep system involvement. Most patients obtain relief from interventions such as compression hose or surgery.

• It depends on the treatment and severity of disease.
• Unna boots for ulceration need to be changed at least weekly.
• Compression hose needs to be replaced every 6 months.
• Following surgical intervention, follow-up depends upon intervention. Stripping and ligation require wound checks, whereas endovenous ablations require ultrasound monitoring.

Venous insufficiency is not merely a cosmetic concern. Longstanding disease can give rise to skin changes (Figures 52-3 and 52-4) and ulcers (Figure 52-5). Compliance with compression hose is necessary. Compression hose only treats symptoms, not the underlying disease process. Even after surgical intervention, new varicose veins may appear as the process is chronic.

Patient Resources

• MedlinePlus. Venous Insufficiency—http://www.nlm.nih.gov/medlineplus/ency/article/000203.htm.
• MedlinePlus. Varicose Veins—http://www.nlm.nih.gov/medlineplus/ency/article/001109.htm.
• MedlinePlus. Stasis Dermatitis and Ulcers—http://www.nlm.nih.gov/medlineplus/ency/article/000834.htm.

Provider Resources

• Medscape. Venous Insufficiency—http://emedicine.medscape.com/article/1085412.
• American College of Phlebology—http://www.phlebology.org/.